Hormone Replacement for Women
HRT remains the most effective solution for the relief of menopausal symptoms and is also effective for the prevention of osteoporosis. It may in certain age groups provide protection against heart disease.
You should discuss both the benefits and the risks of HRT with a doctor on an individual basis. The types of HRT available are listed below.
HRT Today: Key Points
HRT is taken to alleviate the symptoms of menopause. It has a role in the prevention of osteoporosis but long-term use is often required. The dose and duration of HRT use should be determined on an individual basis after discussing the risks and benefits. No arbitrary limit should be set on the duration of use. HRT users are assessed by a doctor at least once a year.
If women start HRT around the time of menopause the risk is very small and there appear to be cardiovascular and bone protective benefits. It is not usually appropriate for women over 60 to be starting HRT but as the WHI study shows, women initiating it over 60 years do not seem to be at increased risk of cardiovascular events or mortality.
Many women seek advice on the effects of HRT on sexual activity and desire. Case studies indicate that the estrogen in HRT can help maintain or return sex drive. It will also help other menopausal symptoms such as vaginal dryness and pain with intercourse. If vaginal symptoms are the only problem, then the use of local vaginal estrogen or dehydroepiandrostenedione (DHEA) may be preferable.
What are bioidentical hormones used for HRT?
Bio-identical hormones are hormone preparations that are identical molecules to those produced by the body. However, in practice, the term is used for preparations made by compounding chemists which are claimed to be safer than traditional hormones used in hormone replacement therapy (HRT). In fact, some traditional HRT preparations are actually bio-identical, using oestradiol 17-beta which is the natural human estrogen, or using micronized progesterone capsules which is the natural human progesterone.
It should be obvious that any product which is a bio-identical hormone will carry the same benefits and risks as the HRT products produced by pharmaceutical companies and properly licensed for use. The bio-identical hormones are often compounded following salivary hormone measurements and are therefore claimed to be customized.
Types of HRT
There are more than 50 types of HRT available: HRT can be given orally (tablets), transdermally (through the skin); subcutaneously (a long-lasting implant); or vaginally.
Cyclical HRT mimics the normal menstrual cycle. Estrogen is taken every day and progestogen for 12 to 14 days. At the end of each cycle of progestogen, there is some bleeding as the body “withdraws” from the hormone and the womb lining (endometrium) is shed. Progestogen regulates bleeding and protects the endometrium from harmful pre-cancerous changes.
Estrogen-alone HRT is normally prescribed to women who have had their womb removed (hysterectomy). The benefits of all HRTs are derived from estrogen; progestogen is only necessary to protect the womb lining.
In continuous combined therapy HRT (CCT) combinations of estrogen and progestogen are prescribed continuously to achieve period-free HRT. Usually, women start on cyclical HRT and change to CCT later.
Long cycle HRT uses a formulation that causes withdrawal bleeds every three months instead of every month, and is most suited to women who suffer side effects when taking a progestogen.
Local estrogen, such as vaginal tablets, creams, or rings, is used for treating local urogenital problems, such as the dry vagina, irritations, bladder problems, or infections.
Testosterone, in the form of a gel or subcutaneous implant, is indicated for women with decreased libido. It should be used in conjunction with conventional estrogen-containing HRT and women with a uterus require progestogens to protect the endometrium.
Benefits of HRT
The main benefit of HRT is that it helps relieve most of the menopausal symptoms, such as:
- hot flushes;
- night sweats;
- mood swings;
- vaginal dryness;
- reduced sex drive.
Many of these symptoms pass after a few years, but they can be unpleasant, and taking HRT can offer relief for many women.
It can also help prevent the weakening of the bones (osteoporosis), which is more common after menopause.
Risks of HRT
The benefits of HRT are generally believed to outweigh the risks. Speak to our doctor if you have any concerns about taking HRT.
You can usually begin HRT as soon as you start experiencing menopausal symptoms and will not usually need to have any tests first.
A doctor can explain the different types of HRT available and help you choose one that’s suitable for you.
How to get started?
You’ll usually start with a low dose, which may be increased at a later stage. It may take a few weeks to feel the effects of treatment.
A doctor will usually recommend trying treatment for 3 months to see if it helps. If it does not, they may suggest changing your dose or changing the type of HRT you’re taking.
Who can take HRT?
Most women can have HRT if they’re having symptoms associated with menopause.
HRT may not be suitable if you:
- have a history of breast cancer, ovarian cancer, or womb cancer;
- have a history of blood clots;
- have untreated high blood pressure – your blood pressure will need to be controlled before you can start HRT;
- have liver disease;
- are pregnant – it’s still possible to get pregnant while taking HRT, so you should use contraception until 2 years after your last period if you’re under 50, or for 1 year after the age of 50.
In these circumstances, alternatives to HRT may be recommended instead.
There’s no limit on how long you can take HRT but talk to a doctor about how long they recommend you take the treatment. Most women stop taking it once their menopausal symptoms pass, which is usually after a few years.
When you decide to stop, you can choose to do so suddenly or gradually.
Gradually decreasing your HRT dose is usually recommended because it’s less likely to cause your symptoms to come back in the short term.
Contact a doctor if you have symptoms that persist for several months after you stop HRT, or if you have particularly severe symptoms. You may need to start HRT again.
The Bottom Line
Women wishing to start HRT should carefully discuss the benefits and risks of treatment with a doctor to see what is right for them, taking into account their age, medical history, risk factors, and personal preferences. The majority of women use HRT for the short-term treatment of symptoms of menopause.
Women on HRT should be re-assessed by their doctor at least annually. For some women, long-term use of HRT may be necessary for continued symptom relief and quality of life.