This post was written by London-based GP, broadcaster, author, journalist and mother of three kids – Dr Philippa Kaye.
HRT, or hormone replacement therapy, does what is says – it replaces hormones that naturally fall to lower levels during the peri-menoapuse and after the menopause itself.
HRT can contain a number of hormones, depending on your symptoms sand medical history, including oestrogen, progesterone and sometimes testosterone. If you have your womb you will need to have oestrogen and progesterone, but if you have had a hysterectomy then only oestrogen is needed, testosterone can be added in both scenarios. You can start HRT during the peri-menopause if you have symptoms, even if you are still having periods, or it can be started after the menopause.
The specific regime you are given will always contain oestrogen but the progesterone component is only needed if you still have a womb as this decreases the risk of womb cancer.
Depending on whether or not you are still having periods, and therefore your ovaries are still working will depend on which regime you are offered. Sequential HRT is offered if you are still having periods, whether or not they are regular or irregular. In a sequential HRT regime you take oestrogen daily and then take progesterone for 10-14 days each month, in the majority of women this will then lead to a monthly bleed. If however your periods have stopped for over a year and you are considered menopausal you will be offered a continuous combined form of HRT, which involves taking oestrogen and progesterone continuously which means that you don’t have a bleed.
Nothing is ever simple though and there is a half way house, using an intrauterine system, a Mirena coil (IUS) can be the progesterone component in both situations, and you take the oestrogen on top. 90% of women using the Mirena IUS will not have bleeds after 1 year of insertion whether menopausal or not. If you start on a sequential regime you will be changed to a continuous combined form either after a year or so on sequential HRT or after the age of 55. If you bleed on the continuous combined form then you are likely to still have some ovarian function so you will be switched back to sequential for a bit.
There are various ways to take HRT, be it tablet, patch or gel. The safest way to deliver the oestrogen component is transdermally, though the skin.
However, the question I am asked most commonly is not what to take, or how to take it but whether or not HRT is safe. So let me answer the question, for most people, the answer is yes HRT is safe to take.
HRT is often in the media with articles written about its safety or risks and the truth is that the evidence has changed over the last few decades. Doctors respond to the evidence at the time, so when it was thought that HRT increased the risk of various conditions they stopped prescribing it. However we now have a large body of evidence about the safety of HRT and for most cases it is safe.
Benefits of HRT:
- Symptom control, put simply HRT works! It is effective against all the pesky menopausal symptoms which women presents with from sweats and flushes, insomnia, irritability and mood swings, vaginal and urinary symptoms as well as tiredness and psychological symptoms such as low mood and anxiety.
- Protection against osteoporosis. Osteoporosis is a condition where the bones are thinner than usual, meaning they are more fragile and prone to fractures.
- The oestrogen part of HRT seems to also be protective against dementia, particularly Alzheimer’s dementia.
- With regards to cardiovascular disease such as heart attacks, if HRT is started within 10 years of the menopause there is no increased risk and it could be protective.
- Other benefits include protection against osteoarthritis, the ‘wear and tear’ arthritis association with increasing age, as well as improving muscle mass and strength. It may also protect against colorectal cancer and eye conditions such as cataracts.
- From a more aesthetic than medical point of view it also improves the
quality and condition of your skin and hair.
Risks of HRT:
Breast cancer – this is the one that most people have heard of. Here are the facts:
- Oestrogen only HRT actually leads to a reduction in breast cancer.
- Therefore the progesterone in HRT may be related to breast cancer risk.
- Women who have had a premature menopause don’t have an increased risk of breast cancer.
- Taking oestrogen and micronised progesterone, which are the same those made in the body are not associated with an increased risk of breast cancer for the first 5 years, and even after that the risk is not considered significant.
- For other forms of progesterone and oestrogen HRT it is important to consider the risk in relation to other risk factors. 23 women per 1000 between the ages of 50 and 59 will develop breast cancer without HRT, with an extra 4 cases per 1000 women on HRT. So your risk increases from 2.3% to 2.7%, so the increased risk is small.
- But, obesity is associated with an extra 24 cases per 1000 women, so doubles your risk, smoking in an extra 3 cases, drinking more than 2 units a day an extra 5 cases yet exercising at least 2.5hrs a week results in 7 fewer cases per 1000 women. So your risk of breast cancer is not related to HRT alone, and what is, is very small.
- Importantly HRT does not affect your risk of dying from breast cancer, those related to HRT are likely to be most responsive to treatment.
Endometrial/womb cancer – if you have a womb and are only given oestrogen HRT your risk of womb cancer will increase, this is why we use progesterone to prevent this!
Venous thromboembolism – blood clots, which can occur in the lungs or legs. Oral HRT increases the risk of blood clots, but there is no increased risk if the oestrogen is delivered transdermally, through the skin by patch or gel.
And if that whistle-stop tour of risks and benefits was too much, here is a summary in a nutshell!
- For women who experience a premature menopause there are no risks associated with HRT up until about age 50, as it is simple replacing the hormones which are generally there until age 51.
- For those between 50-60, the benefits of HRT generally outweigh the risks.
- Between 60-70 the benefits of starting HRT tend to be about equal to the risks.
- After the age of 70, the benefits of starting HRT tend to outweigh the risks.
However, this is about starting HRT, and once you are on it there is no defined stop point, if you are aware of the risks and benefits and still feel that you need HRT there is no need to stop.
For more information please see my book “The M Word: Everything you need to know about the menopause:, published this month (February 2020) and available on Amazon now.
