What is Hormone Replacement Therapy (HRT)?
HRT is medication containing the hormones that a woman's body stops producing after menopause. The aim of HRT, as its name would suggest, is to replace the hormone that the body ceases to produce during menopause, namely oestrogen.
Body identical HRT is the closest molecular structure to our body's hormones and is thought to be the safest (derived from the yam), not to be confused with Compounded Bioidentical HRT (BHRT), which is often not licenced or assessed for safety.
What are the types of HRT?
HRT may be oestrogen alone or Combined HRT, which is both Oestrogen and Progesterone.
There are three main routes, and each will be appropriate for different women:
Orally as a tablet
'Transdermal' (through the skin) in the form of an adhesive patch, a gel or spray
An implant injected beneath the skin provides a slow release of oestrogen over several months.
Many women will opt for 'transdermal' HRT which is a patch, gel or spray, as there is no risk of developing blood clots on these forms (small increased risk of blood clots on the HRT pill).
For vaginal and bladder symptoms, topical oestrogen can be taken as a small vaginal tablet, cream or vaginal ring inserted within the vagina to provide very "local" relief. Topical (vaginal) oestrgen is very safe, and not associated with the same risks as HRT (see below).
Can I take Oestrogen Replacement alone, or do I need Combined HRT (Oestrogen and Progesterone)?
Think of the womb lining as the lawn, Oestrogen will water the lawn causing the grass (womb lining) to grow, and Progesterone is the lawn mower (keeps the womb lining nice and thin to prevent womb cancer).
Oestrogen-alone HRT can stimulate the womb's lining (endometrium), leading to thickening and possibly cancer in the long term. Therefore, for women who have not had a hysterectomy, progesterone or a progestogen is needed to counteract the effects of oestrogen and protect the endometrium.
In women who have had a partial hysterectomy (with cervix intact), some womb lining (endometrium) may remain so that progestogen may be required with the oestrogen. Often a 3-month trial of combined HRT will be given to see if a bleed occurs, and if it doesn't, this signifies no endometrium remaining and no need for progesterone.
For women who are known to have endometriosis, a continuous combined HRT is recommended. Women who have had an endometrial ablation (an operation to remove the lining of the womb, which is often performed for very heavy periods) should also receive progestogen in case any part of the endometrium is left. Combined HRT is available as either a tablet or a patch.
Hormone Therapy- Is it right for you?
The newer forms of HRT that we now prescribe are very safe for the majority of women. It is indicated when your menopausal symptoms impact your home, work, social or sex life, and in women whom the benefits of HRT outweigh the risks (most women). The benefits of HRT will outweigh the risks for most women who have not had hormone-dependent cancer.
Many lifestyle factors can also improve the symptoms of menopause and are essential to do in conjunction with HRT. A healthy diet is an excellent way to stabilise blood sugars which helps with menopausal symptoms. Sleep and physical exercise affect symptoms positively.
Will I have a bleed/period on HRT?
If you do not have a womb, have had a progesterone-containing IUD (e.g. Mirena) inserted, or had an ablation, you are unlikely to bleed on HRT.
If you take combined HRT, how progestogen is taken along with the oestrogen determines whether the HRT will lead to bleeding. A bleed occurs in the days following this course by adding progestogen for 10 to 14 days a month, similar to that of a natural cycle. This form of HRT is called 'cyclical' or 'sequential HRT' and is advisable in peri-menopausal women and during the first year or two after menopause.
Forms of hormone replacement that give continuous progestogen with the oestrogen have been developed to avoid bleeding altogether. This method is called 'continuous combined HRT' and is thought to reduce the risk of endometrial cancer even more so than sequential HRT. You may use this type of HRT if you have had at least a year without periods and are thought to be postmenopausal.
When should I start Hormone Replacement Therapy (HRT)?
The safest time to start HRT is usually in Perimenopause (when still having periods), as the benefits of HRT are traditionally highest when started early. The benefits of HRT usually outweigh the risks if started within 10 years of stopping. But HRT can still be started later if deemed safe.
You can start HRT at any point in your cycle if you still have periods. It will typically take 3 months for your periods to regulate, sometimes up to 6 months, and it is not unusual to have irregular/more frequent periods.
What are the risks and benefits of HRT?
BENEFITS
Reduction of the symptoms of menopause with a resultant improvement in quality of life.
Prevention of osteoporosis.
Protection against heart disease in certain age groups. The risk of heart disease increases with age, and it is the leading cause of death for women. HRT has been shown to reduce women's risk of heart disease by 30-50% if started within 10 years of menopause.
Some studies suggest reducing the risk of developing type 2 diabetes, bowel cancer, dementia, and depression.
RISKS
Breast Cancer is complex, and many women worry about this concerning HRT. Essentially 1 in 7 women will experience breast cancer at some point in their lives. Taking HRT makes very little difference to this. If you take oestrogen-only HRT (only applicable if you have no uterus or a Mirena coil), you have a reduced risk of being diagnosed or dying from breast cancer. If you take a combination HRT, you have a slightly increased risk of being diagnosed with breast cancer but no increased risk of dying. In trials, obesity or drinking 2 glasses of wine a night posed a more significant risk factor than being on HRT regarding the risk of getting breast cancer.
Blood Clots – older studies have suggested an increased clotting link with older forms of oral HRT; this risk is not evident if newer formulations of HRT are taken through the skin.
What are the side effects of HRT?
Common Side effects of HRT in the first 3 months of starting HRT tend to improve with time (if not better within 3 months, a change in the type of HRT can help):
Breast tenderness
Change in skin/acne
Bloating, mood swings
Bleeding on HRT – Common in the first 4 – 6 months of any new HRT regime. It typically does not indicate anything abnormal and usually settles with time. If it persists for more than 4-6 months, then please discuss it with a doctor. We can tweak your hormone combination to improve things, and we may need to investigate to ensure nothing else is causing the bleeding.
If you get new bleeding once established on HRT for more than 6 months, discuss this with your doctor, as this usually needs investigating.
When will I feel the effects of HRT?
It usually takes several weeks before the beneficial effects of HRT are felt and 3 months for the full effect. Hot flushes and night sweats are generally the first symptoms to improve, with psychological symptoms of menopause often taking the longest time to resolve. If symptoms are still present after 3 months, your doctor may increase your dose of HRT of change or change it to a different form.
Final Thoughts
HRT has many benefits; in most women, those benefits outweigh the small risk of taking HRT. For women who have symptoms of menopause, HRT will usually increase their quality of life. Optimising a healthy diet and lifestyle works symbiotically with HRT to alleviate symptoms and ensure a woman remains in good health and feels best.
Guest Post by Dr Ferhat Uddin of Liberty Health Clinics
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