Hormone Replacement Therapy

HRT (Hormone Replacement Therapy)

What is menopause?

Menopause, also known as the 'change of life', simply means the end of menstruation. The term is also used to refer to the months and years in a woman's life before and after her final period — a time that may or may not bring with it some physical or emotional changes.

Menopause is usually a gradual process. The ovaries begin to produce lower amounts of hormones. The reduced amounts of hormones cause menstrual periods to become irregular and eventually to stop completely.

Women going through the menopause may suffer symptoms such as hot flushes, night sweats, irregular periods, decreased energy and concentration levels, generalized pains and aches and low mood.

In later years, women may suffer from vaginal dryness or urinary symptoms. Women are at increased risk of osteoporosis (bone thinning) and heart disease in their later years as a consequence of the decrease in oestrogen levels after the menopause.

What is HRT?

For some women, symptoms of the menopause can prove very difficult to live with. If you are troubled by symptoms of the menopause, you may wish to consider hormone replacement therapy (HRT) as an option.

HRT replaces the hormones that a woman's body stops producing after the menopause. This results in the easing or alleviation of most of the symptoms of the menopause such as hot flushes and night sweats. It also helps to prevent osteoporosis and heart disease in women who are at risk of these conditions in their later years.

HRT is usually taken in tablet form, but it can also be taken in other ways such as through a skin patch.

How does HRT work?

In the years leading up to the menopause, the ovaries become less efficient, producing fluctuating hormone levels which result in irregular, heavy periods.

Eventually they stop working and periods cease altogether. While this is happening, the pattern of the monthly hormonal cycle, which was usually fairly regular up to this point, becomes erratic. Levels of oestrogen start going up and down, resulting in a number of symptoms such as hot flushes and poor sleep patterns. (In fact most symptoms of the menopause can be attributed to falling oestrogen levels.)

In HRT, oestrogen is given in steady doses that are the sufficient to relieve symptoms.

The advantages of oestrogen replacement are:

  • The relief of menopausal symptoms such as hot flushes, etc.
  • Protection against osteoporosis (bone thinning) and fractures.
  • Protection against heart disease.

The disadvantages are:

  • Women over the age of 50 who take HRT for five years or more have a slightly increased risk of developing breast cancer. If you have been taking HRT for five years or more, regular breast screening and self-examination is essential, especially if someone in your family has had breast cancer.
  • Women who take HRT have a slightly increased risk of developing blood clots in their veins. This risk, while small, is most pronounced in the first six months of treatment. Women who have had a blood clot in the past (deep venous thrombosis or pulmonary embolus) should not take HRT.
  • Some women may develop side effects from HRT. However, most of these side effects are transient and will settle down within the first three months of treatment.

While oestrogen replacement relieves many of the symptoms of the menopause, it also stimulates growth of the endometrium (lining of the uterus). This could result in the growth of potentially cancerous cells if it was not counteracted. This can be achieved by taking a second hormone, a progestogen, for 10—14 days of each month. This second hormone protects the lining of the womb and, in fact, women who take this combined form of HRT actually have a lower risk of developing endometrial cancer than women who have never taken HRT. Obviously, women who have had a hysterectomy have no risk of developing endometrial cancer and thus will not require this second hormone.

I have always been unable to take the (oral contraceptive) pill. Does this mean I cannot use HRT?

No. This is a myth that often surrounds HRT.

The pill contains high doses of synthetic oestrogen. HRT on the other hand uses lower doses of natural oestrogen. Therefore many women who were unable to take the pill for a number of medical reasons can use HRT. Women who were unable to take the pill should discuss the reason with their doctor when considering taking HRT.

How do HRT tablets work?

HRT is available on prescription only therefore your doctor can advise you on the different methods of using it.

The most common way HRT is taken is in tablet form. These tablets are taken every day, without a break, at roughly the same time.

If you have had a hysterectomy, you will only need oestrogen replacement.

If you have not had a hysterectomy, you will need to take progesterone tablets for between 10 and 14 days every month on top of the oestrogen tablets. (Synthetic progesterone is also known as progestogen.) You will usually get a bleed soon after taking the progestogen tablets. This is usually lighter and more regular than your own periods.

If you are at an age when your own periods would have naturally stopped, a different type of HRT where each tablet contains oestrogen and a tiny amount of progestogen, will provide protection for the lining of the womb without causing monthly periods.

Tablets are advantageous because they are easy to take and if you wish to stop treatment, their effects are quickly reversed.

However some women may forget to take them everyday, especially if their normal routine is disrupted, for example if they are on holiday. Forgetting to take tablets can result in irregular bleeding.

HRT tablets can sometimes cause nausea. However taking the tablet with food or at bedtime may help.

How does the HRT patch work?

The skin patch results in the required hormones being delivered directly to the bloodstream. Since they don't have to travel through the stomach and liver first, the dose is lower than the dose in tablets, resulting in less side-effects.

The patches are replaced once or twice weekly. They should be placed on clean, dry skin. Do not use cream or talcum powder on the area where you intend to put the patch. The best area is usually the upper buttocks.

The patch may be left on while swimming or having a bath. It should be covered when sunbathing and should be removed if using a sun bed.

You should also alternate sites. Do not place the patch on the same area every time.

Some women develop skin irritation at the site of the patches but this is less of a problem with the more modern patches. Until recently it was not possible to deliver progestogens through a patch and women with a womb who were using oestrogen patches had to take progestogens in tablet form for fourteen days each month. Patches are now available combining both hormones.

How do HRT implants work?

HRT implants are inserted into the fat under the skin in a simple procedure. A local anaesthetic is used to numb the skin. Then a small cut is made, usually in the lower abdomen, the implant is inserted and the wound is stitched or taped closed. The stitch or tape is removed a few days later.

One implant of oestrogen lasts about six months.

The main advantage of an implant is that the woman doesn't have to remember when to take her HRT as she would with a daily tablet or a weekly patch. This is very useful especially if her routine changes a lot, for example if she travels frequently.

A disadvantage is that, if this method does not suit you, it is almost impossible to remove the implant once inserted.

At present it is not possible to have progestogen in the implant so women with a womb will need to take progestogen tablets for fourteen days every month. For this reason implants are mainly used by women who have had a hysterectomy.

How does HRT gel work?

For women who have had a hysterectomy and do not need progesterone replacement, an oestrogen gel is available. It can be applied to the arms and shoulders or the inner thighs and takes about five minutes to dry.

This gel is especially useful for women who find HRT patches irritate their skin, as the gel rarely causes skin irritation.

Some women worry that they are not applying the right amount of gel or are not putting it on the right area. Consult your doctor if you are unsure of applying the gel.

Are there any other ways in which I can take HRT?

There are other ways of taking HRT:

  • It is possible to insert cream, tablets or pessaries directly into the vagina. A pessary is a plug or cylinder of soft material that is fitted into the vagina, releasing the required hormones. This should not be mixed up with a pessary that is used to keep a prolapsed womb in position. Creams and pessaries are applied directly, but can be messy. However, if vaginal dryness is a problem for the woman they can provide useful lubrication. The oestrogen tablet is inserted high into the vagina using a special applicator.
  • There is a synthetic preparation available, which combines the properties of oestrogen and progesterone in a tablet that must be taken daily. As bleeding is an occasional side-effect, it is only recommended to women who have not had a natural period for at least 12 months. This preparation is known to treat the symptoms of the menopause, reduce the risk of osteoporosis fractures and increase libido (sex drive). However it is expensive. For postmenopausal women at risk from osteoporosis, who cannot take conventional HRT, SERMs (Selective Oestrogen Receptor Modulators) may be recommended. These are a type of compound that mimic some of the actions of oestrogen but oppose others. SERMs do not treat hot flushes or sweats but are effective in preventing osteoporosis. It is likely that they will also be shown to lower the risk of heart disease — research is ongoing - and they may also be shown to decrease the risk of breast cancer.

Can a diabetic woman take HRT?

Yes. HRT has little effect on blood sugar levels, therefore it is safe for a woman with diabetes to take it.

In fact, women with diabetes should be encouraged to take HRT because the diabetes increases their risk of getting heart disease and HRT will help to prevent this.

How long do I need to take HRT?

It depends what you are using it for. If you are using it simply to control menopausal symptoms, two or three years may suffice, although some women need it for longer.

If you are taking it for long-term protection against heart disease or osteoporosis, you may need to take it for five to 10 years.

Taking it for even longer is possible as long as you are aware of the possible risks of long-term usage.

Your doctor will help you to decide whether the potential benefits outweigh the potential risk of long-term usage in your individual circumstances.

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