What Is Hormone Replacement Therapy?
Hormone replacement therapy (HRT) is a hormone treatment prescribed to women experiencing many of the symptoms related to the menopause. These include hot flushes, night sweats, mood swings, vaginal dryness, and low libido.
According to the BMJ about 1 million women in the UK use hormone replacement therapy to treat the symptoms of declining ovarian responsiveness as they enter the menopause1.
HRT works by replacing the hormones oestrogen and progesterone that decline as a woman transitions to the menopause. Taking HRT upon diagnosis of symptoms that are related to the menopause can help women better manage this phase in their life by reducing the physical and psychological symptoms of the menopause.
What Are The Benefits of HRT?
Menopause symptoms can have a serious impact on a woman's personal and professional life, as detailed in our study on menopause in the workplace.
HRT not only offers relief from menopause symptoms, but it also helps prevent diseases associated with declining hormone levels such as osteoporosis and cardiovascular disease.
According to the NICE guidelines2 the risk of fragility bone fractures is decreased in women taking HRT, and oestrogen-only HRT treatment is associated with no, or reduced risk of developing coronary heart disease.
Although the risk of developing osteoporosis and breaking a bone is low in women around menopausal age, HRT reduces the risk further as it increases the body’s level of oestrogen.
As the ovaries become less responsive the amount of oestrogen produced also declines. A lack of oestrogen causes the bones to become thinner, therefore increasing the risk of developing osteoporosis.
The benefit HRT on bone health lasts only as long as HRT is being taken but may last longer if HRT is taken for a longer period of time.
“As women are spending an extended part of their lives in the menopausal state, ensuring you empower yourself with up to date information to make informed decisions, will enable you to ensure maintaining quality of life during this phase of your life” Dr Nicky Keay, Chief Medical Officer at Forth
What Are The Risks?
There has been a lot of misleading information in the press on the increased risks of developing breast cancer due to HRT. However, according to a BMJ editorial published in 2019 on HRT and breast cancer1 the risks of developing breast cancer due to an unhealthy lifestyle - such as being overweight - poses a risk of developing breast cancer that is six times higher than that posed by taking combined HRT.
“…women should be counselled that other factors, including body weight and alcohol consumption, have a greater effect on breast cancer risk than HRT. For example, the extra risk of breast cancer associated with being overweight or obese is six times higher than the extra risk associated with combined HRT, according to NICE.”, the BMJ editorial ‘HRT and breast cancer risk’ published 11 Oct 2019
Other risk factors of taking HRT according to NICE2 include:
The risk of developing a venous thromboembolism is only increased for women taking oral HRT compared to the baseline populate risk. Transdermal preparations such as patches or gels given at a standard therapeutic dose do not increase the risk of blood clots. Women who are at a higher risk of developing blood clots including those with a BMI over 30kg/m2 should be prescribed patches or gels. Women with a family history of blood clots should be referred to a haematologist for assessment before considering HRT.
The risk of developing heart disease is not increased by taking HRT if started before the age of 60 and HRT does not affect your risk of dying from cardiovascular disease. As mentioned above, oestrogen-only HRT poses no, or reduced risk of developing coronary heart disease. The combined oestrogen and progesterone HRT is associated with little, or no risk in developing coronary heart disease.
According to NICE, having existing cardiovascular risk factors such as high cholesterol, should not prevent HRT being recommended2. HRT can still be taken as long as the risk factors associated with developing cardiovascular disease are managed e.g. diet, exercise, smoking etc.
As with blood clots, HRT tablets slightly raise the risk of stroke, but it is important to remember that the risk of stroke is very low in women under 60 years of age.
Type 2 Diabetes
Taking HRT does not increase your risk of developing type 2 diabetes or have a negative impact on your blood sugar control if you already have the condition. However, when talking with your healthcare provider about starting HRT you should take into account any health problems related to type 2 diabetes.
According to NICE, studies have been carried out that show for women of menopausal age who take oestrogen-only HRT there is little or no change in the risk of development breast cancer. The combined HRT treatment (oestrogen and progesterone) may increase breast cancer risk. As mentioned above, lifestyle factors such as being overweight pose a far higher risk than HRT.
Womb (endometrial) Cancer
Taking the oestrogen only HRT treatment can increase the risk of developing endometrial cancer in postmenopausal women who have not had a hysterectomy3.
The risks of taking HRT need to be viewed against the benefits of which for many women are considerable in helping them manage the symptoms of the menopause.
“Risk means different things to different women, and each woman must be given information in context and be supported to make an informed choice about her best treatment options.”, the BMJ editorial ‘HRT and breast cancer risk’ published 11 Oct 2019
It’s also important that women are treated as individuals when diagnosing and managing the menopause2. HRT dosage, regime and duration should be tailored to each woman’s individual circumstances and reviewed annually. Providing individualised care during this stage of a woman’s life is key to helping her manage her symptoms and have a happy menopause.
“The guideline emphasises that, for most women, HRT is a very effective treatment for several menopausal symptoms, for example hot flushing and also reduces the risk of osteoporotic fracture.”, Professor Mary Ann Lumsden, chair of NICE guideline development group and honorary consultant gynaecologist at Glasgow Royal Infirmary2.
Starting And Stopping HRT
When you first start to take HRT, your GP should arrange a 3-month follow up appointment to check on your progress and tolerability of the prescribed HRT treatment. After that, you should have a follow up each year unless there are clinical indicators for an earlier review. This will also help to ensure you are on the right dosage as you progress through the menopause.
It is common in women with a uterus to experience unscheduled vaginal bleeding within the first 3 months of treatment and if experience should be mentioned in the 3-month review. If unscheduled bleeding it experienced after the first 3 months this should be reported promptly to your GP.
When you are stopping HRT you can either reduce your dosage gradually or stop immediately. The benefit of stopping gradually is that it may limit the return of symptoms in the short-term, but in the long-term either approach makes no difference on the symptoms experienced.
How Long Can You Take HRT?
HRT can be taken for as long as needed, however, generally not recommended for an extended time.
What Are The Different Types Of HRT?
The two main hormones used in HRT are:
HRT usually involves taking both of these hormones (combined HRT) as taking oestrogen on its own can increase your risk of developing endometrial (womb) cancer. Taking progestogen alongside oestrogen minimises the risk of developing endometrial cancer.
Oestrogen-only HRT is only recommended for women who have had a hysterectomy.
How To Take HRT
HRT treatments come in different preparations depending on the type of treatment prescribed. The most common forms are transdermal preparations in the form of gels and skin patches and orally in the form of tablets. The Mirena coil is also used for progesterone treatment.
Other treatments such as creams and pessaries are provided in addition to HRT treatment to be applied locally, for example, in the case of alleviating vaginal dryness. These treatments do not relieve other symptoms such as hot flushes.
Where possible taking HRT treatment in the form of skin patches or gels (transdermal route) is advised to avoid the effect of oral tablets on the liver.
What Are The Different HRT Treatment Regimes?
There are two different types of HRT treatment regimes, these are sequential and continuous.
Sequential HRT is recommended for women taking both oestrogen and progesterone. It consists of taking oestrogen daily alongside progestogen for part of the calendar month. There are two approaches, monthly HRT and 3-monthly HRT. Withdrawal bleed may occur after progesterone component
Monthly HRT is where oestrogen is taken daily, and progesterone is taken alongside it for the last 14 days of each month.
3-monthly HRT is where oestrogen is taken daily, and progesterone is taken alongside it for around 14 days every 3 months.
Continuous combined HRT simply means taken oestrogen and progesterone together each day without a break. It is usually recommended for women who are postmenopausal. No withdrawal bleed should occur.
Oestrogen-only HRT for those women with hysterectomy is usually taken every day without a break.
What Are The Alternatives To HRT?
There are women who, either for medical reasons or personal choice, prefer not to take HRT. You can learn more about non-hormonal alternatives to HRT in our blog 'Natural Remedies For The Menopause (it should be noted that HRT is a natural treatment and is a hormonal treatment to menopause symptoms).
It’s important for women to learn about HRT treatments and how it can help them with their menopause symptoms. Being informed and prepared ahead of starting the menopause on what treatment is best for you will help you have a more informed discussion with your healthcare practitioner to help you get the treatment you need.