How many of you have already recoiled in horror at just the mention of hormone replacement therapy?
What if I told you that taking HRT has health benefits in certain age groups? For example, HRT can lower the risk of developing conditions including heart disease, osteoporosis, diabetes, depression and dementia in the future. Are you interested to learn more?
Firstly, I’m not a doctor. But I am a woman who has recently chosen to go on my own HRT journey. I’ve also been fortunate enough to have spoken to many women clients who have shared their menopause stories over the years. And I’ve discovered common themes:
a stigma attached to menopause which has made women feel old, washed up, past their prime, and invisible, and
confusion and concern about the reported risks associated with HRT.
For years, a combination of medical gender inequalities, hysterical reporting and outdated science has held women in menopausal limbo. Women have been suffering debilitating and life-changing symptoms in silence, combined with an increased future risk of cardiovascular disease, osteoporosis and dementia.
But why do we find ourselves in this situation?
Let’s take a closer look at menopause and HRT.
Menopause Symptoms
Menopause marks the end of menstruation, the last period. It’s a natural event that occurs because you stop ovulating, and your ovaries no longer produce oestrogen (one of the female sex hormones). It marks the end of your reproductive years, just as the first menstrual period during puberty marked the start.
Usually, oestrogen and progesterone production slow down between 45 and 55 years of age. This time is known as perimenopause. Your monthly cycle goes away (menopause), and so does your fertility. The lower levels of hormones cause a number of health issues within your body, and around 75% of women experience symptoms, including:
Brain and nervous system: you can experience a mixture of physical and emotional symptoms - hot flushes, night sweats, mood swings, memory loss, ‘brain fog’, irritability, anxiety and depression, insomnia and sleep disturbances, aches and pains, reduced sex drive
Urinary system: the lining of your urethra becomes dry, thin and less elastic leading to frequency, mild urinary incontinence and increased risk of urinary tract infections
Vagina: the same issues of dryness, thinning, and reduced elasticity affect your vaginal tissue causing inflammation, irritation, discomfort, vaginal dryness and pain during sex
Skin: you can experience abnormal sensations, such as ‘prickling’ or ‘crawling’ under the skin, dry skin (read our Menopause and the Skin blog article), hair loss or abnormal hair growth and dry and itchy eyes.
You can manage these symptoms and physical changes in various ways:
lifestyle changes like healthier eating
exercising regularly
reducing coffee, alcohol and spicy foods
stopping smoking
hormone replacement therapy (HRT).
Once you hit the two-year milestone of life without a period, you’ve successfully made it through menopause. But this milestone also marks the beginning of postmenopausal life, and things don’t just go back to the way they were.
Symptoms can linger for a long time. And the continued low oestrogen levels can lead to more severe health concerns. For example, your rate of bone loss speeds up, increasing your risk of low bone density, osteopenia and osteoporosis. You also have a higher chance of cardiovascular disease and heart attack, stroke or other heart-related issues. If you love coffee, sugar, salt, cigarettes or alcohol, your risks for bone and heart issues, diabetes and bowel cancer are even higher.
What is HRT?
HRT, also known as hormone therapy (HT) or menopausal hormone therapy (MHT), is a medication that replenishes the hormones that our bodies have stopped producing. Oestrogen, often progestogen and, in some cases, testosterone.
Hormone replacement therapy was first available in the 1940s. By the 1960s, the medical profession hailed HRT as revolutionary in managing menopause symptoms. HRT was prescribed to all menopausal women to alleviate symptoms such as hot flushes, night sweats, sleep disturbances, psychological and genito-urinary problems, and to prevent osteoporosis.
However, the reputation of HRT took a big hit following the publication of the results from two studies: The US-based Women’s Health Initiative (WHI) in 2002 and the Million Women Study in 2003.
The studies raised safety concerns over the extended use of HRT, indicating that it increased the risk of breast cancer and heart disease.
As we know, the results of the studies received wide publicity at the time, creating panic in many women, almost 80% of whom then abandoned their HRT overnight. In addition, doctors had to adhere to new prescribing guidelines. Many chose to stop prescribing HRT, and other doctors significantly restricted who received it.
Therefore, many women were denied the opportunity of improved quality of life during their menopausal years.
Let’s take a minute to unpick the WHI study
The WHI study set out to determine whether older women who started to take HRT could enjoy the same heart-health benefits that HRT gave to younger menopausal women. The combined HRT in the study contained a form of oestrogen and progesterone no longer used today, as there are now more effective and safer forms available.
The WHI study didn't include women who were recently menopausal, i.e. the usual target group for starting HRT between 45-55 years old. The average age of the women beginning HRT in the study was much older, at 63 years. And two-thirds of the women were between 60 and 79 years, with 25% over 70.
The results showed that the women in the study taking combined HRT had a 26% increase in the risk of breast cancer compared with those not taking HRT. However, that equated to only slightly higher than the risk of breast cancer from drinking one glass of wine a night, but less than the risk from drinking two glasses of wine a night.
In addition, the risk of breast cancer in the study was similar to the risk reported with obesity and low physical activity.
Later analysis of WHI data for the women between the ages of 50 and 59 in the study, i.e. the age group most likely to use and need HRT, shows clear benefits of HRT. These women had fewer cancers, fractures, and deaths than those not taking HRT.
It’s a shame that the findings from the studies weren’t explained in more detail at the time and that the media reporting had been objective rather than sensational. The impact it had was detrimental to so many women’s lives.
So, that was then. What about nowadays?
Modern HRT
Most women take combined HRT (a combination of oestrogen and progestogen). Taking oestrogen on its own can thicken the uterus lining and increase the risk of uterine cancer; taking a progestogen keeps the lining thin and reverses this risk.
Women who have had a hysterectomy (a surgical procedure to remove the uterus) may take oestrogen by itself.
The type of oestrogen most commonly used is 17-beta-estradiol, which has the same molecular structure as the oestrogen you produce in your body.
The safest type of replacement progestogen is called micronised progesterone. In the UK, you may see the brand Utrogestan.
If you have been taking HRT for a few months but are still experiencing symptoms such as fatigue, brain fog and lack of libido, you may be prescribed testosterone as well to help alleviate these symptoms.
Hormone replacement therapy may be prescribed as tablets, patches, gels and vaginal creams, pessaries or rings. Your treatment regimen will vary depending on the delivery method and the combination of hormones prescribed.
Your doctor or menopause specialist will be able to help you choose the most appropriate type, dose and duration of HRT for you. You may need to try a number of different options before finding the one that gives you the best results.
What are the benefits of HRT?
HRT reduces perimenopausal and menopausal symptoms and reduces the risk of various chronic conditions:
Menopause symptoms These will gradually improve, with maximum benefit felt within 36 months of starting HRT.
Diabetes Taking HRT around the time of menopause can reduce a woman’s risk of developing diabetes
Osteoporosis HRT in postmenopausal women (under the age of 60) can prevent further bone density loss, preserve bone integrity and reduce the risk of fractures. Long term use if often required.
Cardiovascular disease HRT around menopause has been shown to lower the risk of women developing heart problems, stroke or vascular dementia.
Bowel cancer HRT around menopause slightly reduces the risk of colorectal cancer (bowel cancer)
What are the risks from modern HRT?
While HRT reduces the risk of some debilitating diseases, it may increase the risk of others for some women. Current thinking and studies show that the balance of benefits of HRT has shifted and that generally, they outweigh the small risks. But it’s important to talk to your doctor about any concerns you may have.
Breast cancer and HRT
Recent studies show that women over 50 years of age who use combined HRT for less than five years have little or no increased risk of breast cancer. Women who have used combined HRT for more than five years have a slightly increased risk of a breast cancer diagnosis.
The WHI long-term study published in 2020 showed a significant reduction in breast cancer diagnosis and mortality in women using oestrogen-only HRT for up to 15 years of usage.
There is no evidence suggesting that a woman taking HRT with a family history of breast cancer will have a greater risk of developing breast cancer.
Oestrogen only and newer combined HRT medications carry fewer risks than traditional combined oestrogen and progestogen HRT.
Cardiovascular disease and HRT
Studies have shown that healthy women starting HRT from around the typical time of menopause have a reduced risk of heart disease and dying from a cardiovascular event. It is also true for women starting HRT within ten years of the menopause (or under 60 years of age).
Women over 60 have a small increased risk of developing heart disease or stroke with combined oral (tablet) HRT. Although the increase in risk is small, it is an important consideration when starting HRT.
Venous thrombosis and HRT
Venous thromboses are blood clots that form inside veins. Women under 50 years of age, and women aged 50 to 60, who have a genetic tendency to develop thrombosis, have an increased risk if they take combined oral HRT. Doctors would typically advise these women not to use HRT.
Some studies suggest a lower risk with non-oral therapy (patches, implants or gels) and newer progestogen types.
Endometrial cancer and HRT
The endometrium is the lining of the uterus. Oestrogen-only HRT increases the risk of endometrial cancer (for the reasons given above in the section on Modern HRT). Combined continuous oestrogen and progestogen treatment does not carry the same risk. And, of course, there is no risk if a woman has had a hysterectomy (her uterus removed).
Ovarian cancer and HRT
The increased risk of ovarian cancer is minimal and estimated to be one extra case per 10,000 HRT users per year.
Is HRT suitable for me?
Are you looking for relief from menopause symptoms?
Knowing the pros and cons of hormone replacement therapy (HRT) can help you decide whether it might be right for you.
It’s then essential to talk to your doctor about your circumstances as treatment options are not one-size-fits-all. Any decision about HRT should consider your age, medical history, genetic and treatment risk factors and personal preferences. It is usual for doctors to prescribe the lowest effective HRT dose, with the duration of use depending on the clinical reasons for you using HRT. If you or your doctor have doubts, perhaps speak to a menopause specialist.
Don't forget, if you're taking HRT, your doctor should reassess you every year.
Menopause can be a challenging time for many women, both physically and emotionally. Talking about it and sharing experiences can help you stay better informed about symptoms and help you manage them. And last but by no means least, seek support during menopause from your family and friends.
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