Weighing up the pros and cons of HRT? We discuss the benefits and risks, to help you decide whether it’s the right choice for you.
By Dr Deborah Lee (MB ChB, MFFP, MRCGP, DRCOG, Dip GUM, Dip Colp, LOC Med Ed)
When a woman enters the menopause (typically, but not always, between the ages of 45 and 55), the levels of the female hormones oestrogen and progesterone in her body drop considerably.
Hormone Replacement Therapy (HRT), as the name suggests, helps to rectify this deficiency, by delivering a low dose of natural oestrogen, chemically identical to the oestrogen your ovaries were making before you entered the menopause.
HRT is available for women who have gone through menopause, but it is of course a personal choice. Some women regard the menopause as a natural event and do not wish to medicalise it by taking any form of therapy. Others may feel differently. Each woman needs to weigh up the pros and cons, to decide whether HRT is the right choice for her.
Dr Deborah Lee, sexual and reproductive healthcare specialist at Dr Fox Online Pharmacy, offers her expert insight on HRT types, benefits and potential side-effects:
Menopausal symptoms and HRT
HRT is a treatment for menopausal symptoms, brought on by oestrogen deficiency. Oestrogen levels fall naturally as women age. The average age of menopause is 51, but in fact, oestrogen levels are already considerably lower in women in their 40s. However, around the time of the final period, oestrogen levels fall dramatically, which is when symptoms are at their worst. Menopausal symptoms include:
- Hot flushes
- Night sweats
- Menstrual bleeding problems during the perimenopausaltransition
- Mood disturbance
- Problems with memory and concentration
- Dry mouth, eyes, skin, hair and nails
- Vaginal dryness
- Loss of libido
- Increased frequency of urination
- Stiff, painful joints
- Hair loss
- Formication (a sensation of ‘crawling’ on the skin)
- Increase in unwanted body hair
- Change in body fat distribution Longer-term health risks after menopause
- In the longer term, after menopause women are also more at risk from cardiovascular disease, osteoporosis and Alzheimer’s disease.
Who is HRT suitable for?
The typical groups of women who take HRT include:
- Perimenopausal women with symptoms
The most common group of women who take HRT are those in the perimenopausal period – usually between the ages of 50 and 60 – who are taking it to control unpleasant symptoms, such as hot flushes and night sweats. HRT is very effective at getting rid of these symptoms and improving many more.
- Perimenopausal women without symptoms
Sometimes, women choose to take HRT even if they don’t have much in the way of symptoms. This may be because they have health conditions for which HRT is beneficial, for example, osteoporosis prevention and treatment. Sometimes, they may be interested in the positive effects of HRT on mood, to help them sleep, on their skin, hair and nails, or general well-being.
- Menopausal women
There is no upper age limit for HRT – some women are still taking it in their seventies and eighties.
- Women who have experienced premature menopause
A premature menopause is defined as menopause occurring before the age of 40 years (some say 45 years). The medical term is ‘premature ovarian insufficiency’ (POI). A spontaneous premature menopause affects five per cent of women in the UK aged under 45. In POI, the ovaries fail much earlier than usual. These younger women often have dramatic symptoms and it’s strongly recommended they take oestrogen until at least their 50th birthday.
- Women undergoing fertility treatment
Women going through IVF treatments are asked to take HRT oestrogen, to thicken the endometrium (womb lining) ready for embryo transplantation.
In general, HRT will lead to improvements in the vast majority of menopausal symptoms. But managing the menopause effectively is not all about HRT; you must also follow a healthy lifestyle, eat well, get plenty of exercise, manage your weight, stop smoking and control your alcohol intake.
Specific benefits of HRT, in terms of symptom control, include:
- Control of hot flushes
Medical studies have confirmed HRT is the most effective treatment for the control of hot flushes and night sweats.
- Control of menstrual bleeding problems
It’s important to make sure any unscheduled bleeding around the time of menopause is properly investigated, for example, bleeding between periods or bleeding after sex. However, HRT may help control menstrual bleeding.
- Improvement in mood
Oestrogen undoubtedly improves mood and some authorities argue it’s the best first-line option to treat depression. Anxiety is often also improved with the use of HRT.
- May improve short-term memory
In a 2017 study, oestrogen was shown to protect the memory from stress, to enable women to perform short-term tasks.
- May improve headaches
The treatment of migraines during menopause is challenging, although HRT may be helpful. It may reduce the frequency and severity of migraine attacks, because it stabilises oestrogen levels.
- Improvement in sleeping patterns
Sleep disorders, especially insomnia, are very common in perimenopausal women. HRT leads to improvements in sleep, although few studies have examined the reasons why in depth. Oestrogen has been shown to increase REM sleep cycles.
- Improvement in dry skin
Around the time of menopause, women often report dryness of skin, with a reduction in skin firmness and elasticity, and an increase in wrinkles. Oestrogen has been shown to have a positive effect on collagen, promotes skin growth, has antioxidant properties and also helps protect the skin from UV light.
- Improvements in vaginal dryness
Oestrogen increases the thickness and maturity of cells lining the vaginal area and improves the production of natural secretions.
- Improvement in libido
HRT undoubtedly does help improve low libido. It may do so by correcting many of the physical issues at menopause – relieving vaginal dryness, hot flushes, insomnia, depression and tiredness, for example. However, once oestrogen has been restored, women get an even better response to the use of testosterone. This can restore sexual desire and lead to improved frequency of sexual intercourse and an improvement in the ability to orgasm.
- Improvement in urinary issues
HRT can lead to substantial improvements in urinary symptoms. It often reduces the number of times you need to pass urine every day, improves the stream and control of urination, and leads to a reduced number of visits to the toilet overnight. Topical oestrogen can also reduce the number of urinary tract infections.
- May ease painful joints
HRT may have a protective role against the development of osteoarthritis and can reduce joint pain. This may be at least in part because it has a positive effect on cartilage, which lines the joint.
- May assist weight loss
HRT does not cause weight gain. In fact, in one study, after three months of combined HRT, users lost an average of 2kg compared with the control group. Moreover, the HRT group showed a demonstrable improvement in insulin response to a glucose load and experienced a favourable change in cholesterol.
- Protects against cardiovascular disease
Medical studies suggest women are protected from cardiovascular disease by their hormones. It’s only after menopause, when oestrogen levels are lowered, their risk begins to increase. Oestrogen has a positive effect to lower cholesterol and also has a role in maintaining the health of arterial walls. There are many studies that confirm the protective effects of oestrogen on cardiovascular disease.
- Protects against osteoporosis
HRT confers protection for the skeleton. It can be regarded as a first-line approach for the prevention and treatment of osteoporosis when taken early in the post-menopausal period. Oestrogen has been shown not only to conserve bone health, but also to help prevent fractures.
- May protect against Alzheimer’s disease
There has been much interest in the fact that women outnumber men with dementia two to one. In a 2018 study, researchers noted that post-menopausal women had the greatest rate of brain shrinkage in their memory centres and higher rates of Alzheimer’s plaques. They postulated that oestrogen deficiency is associated with this more rapid decline.
HRT different types
HRT comprises two hormones – oestrogen and progesterone. The oestrogen has the therapeutic effect to control menopausal symptoms. However, the progesterone is necessary for women who still have their uterus (women who have not had a hysterectomy).
This is because, without the progesterone, the endometrium (lining of the womb) can become over-stimulated. Taking both oestrogen and progesterone counteracts this risk. The oestrogen in HRT is a low-dose natural hormone, chemically identical to the oestrogen your ovaries were making before you went through menopause.
HRT is packaged in different ways, for safety and convenience. The different types are:
- Combined HRT: HRT containing both oestrogen and progesterone.
- Oestrogen-only HRT: if you’ve had a hysterectomy, you do not need to take progesterone.
- Cyclical HRT: HRT in which oestrogen is taken for the whole cycle, and progesterone is taken with it for the last 12 to 14 days. Cyclical HRT usually induces a withdrawal bleed at the start of each new pack. This means you still have a monthly bleed.
- Continuous Combined HRT: HRT in which oestrogen and progesterone are taken together every day of the packet. The packs are taken continuously with no break. This means there is no bleeding.
How do you take HRT?
There are more than 50 different HRT brands, and you often need to try a few to find out which is best for you. HRT can be administered in different ways. All different types work effectively and no one method is better than any other. It’s often down to convenience and personal preference which one you choose:
✔️ Oral tablets: swallowed by mouth, once a day.
✔️ Transdermal HRT: patches that are stuck onto the skin. Some are changed twice a week, others once a week.
✔️ Gel: rubbed into the skin, usually once or twice a day.
✔️ HRT implants: pellets inserted into the abdominal wall or buttock, usually every six months.
✔️ Topical HRT: creams or pessaries inserted into the vagina (these only treat vaginal symptoms and will not reduce hot flushes, for example). Usually, these are inserted at night.
✔️ The levonorgestrel intrauterine system (LNG-IUS): the ‘hormone coil’, otherwise called the Mirena IUS. This is a convenient, safe and reliable way to provide progesterone in HRT. Once inserted, the IUS can stay in place for five years, if used as part of an HRT regime.
HRT short-term side-effects
When taking HRT, both oestrogen and progesterone can cause side effects. The most common include:
- Breast discomfort
- Irregular bleeding
- Loss of libido
- Skin rashes
- Weight changes – increase or decrease
Most of these side-effects are mild and will pass with time, so if you get any, try to persevere, as with time they may well improve. There are tips and tricks for dealing with side effects, so if they don’t settle, talk it over with your doctor.
HRT potential long-term risks
There are long-term risks associated with any medication, and HRT is no exception. Links between the use of HRT and an increased risk of breast cancer, heart disease and stroke have made headlines over the past 20 years.
The 2002 Woman’s Health Initiative (WHI) and the 2003 Million Women Study (MWS) were two very large clinical research trials. After they were published, numerous claims were made about the risks of taking HRT. As a result, prescriptions for HRT in the UK have fallen by 50 per cent.
The latest statistical analysis, as evidenced from these studies, demonstrates that if HRT is started in healthy women between the ages of 50 and 59 years, and used for 10 years:
- Heart disease risk is not increased. In fact, HRT may confer protection.
- Risk of stroke is not increased.
- The increased risk of breast cancer is four extra cases per 1000 women after five years of use (this is a significantly lower risk than the risk of smoking, alcohol and obesity).
- No increase in the risk of ovarian cancer.
- A slight increase in the risk of endometrial cancer. The risk is more or less counteracted by always taking progesterone if you have not had a hysterectomy.
Who should not take HRT?
There are a few medical conditions for which HRT could pose a severe health risk. If you suffer with any of the following conditions, HRT should not be prescribed:
- Current or recent deep vein thrombosis
- Past or recent stroke
- Past or current diagnosis of breast cancer or endometrial cancer
- Severe liver disease
Is HRT safe?
The British Menopause Society reviewed the evidence in 2008 and concluded that HRT is safe. It concluded that five years of HRT, taken to control menopausal symptoms between the ages of 50 and 60, is likely to convey benefit, not harm.
The National Institute of Clinical Excellence (NICE) published clinical guidelines on HRT prescribing in 2015. Having reviewed the evidence, NICE concluded that HRT should be offered to women with menopausal symptoms.
Some women prefer to avoid hormonal treatments. For others, HRT is not an option – for example, it’s not recommended for women who have had breast cancer within the past five years or those who carry a breast cancer gene. This means there are groups of women for whom non-hormonal treatments play an important role. These are either herbal remedies, prescribed medical products or non-medical therapies.
- Herbal remedies
Herbal options include isoflavones and soya products, for example, Red Clover; Black Cohosh; and St John’s Wort. Do not assume herbal remedies are necessarily risk-free. Many have not been thoroughly tested and there is not always evidence for the risks and benefits of use. They can also interact with other medications. Therefore, it’s important to discuss herbal options with your doctor before starting to take them.
- Cognitive behavioural therapy (CBT)
There is a large interplay between depression, stress, anxiety and menopausal symptoms. By understanding the physiology of menopause and the specific stressors, CBT can really help. This non-medical therapy involves education, breathing exercises and coping techniques. Women who have had CBT for menopausal symptoms have found it highly beneficial. You may be able to be referred by your GP.
- Prescribed medical products
Some medications have been shown to reduce the frequency and severity of hot flushes. These include Selective Serotonin Reuptake Inhibitors, usually prescribed as antidepressants; Clonidine, most often used to treat high blood pressure; and Gabapentin, used to treat epilepsy, chronic pain and restless leg syndrome. Speak with your doctor about whether these options may be a good fit for you.
- Complementary therapies
In a 2019 review published in the Journal of Evidence-Based Integrative Medicine, the authors reviewed the evidence for the current range of alternative and complementary menopause therapies. These include CBT, mindfulness, biofeedback and relaxation, yoga and aromatherapy. Many women obtain great benefit from the use of these therapies.