Part 1/4 series blog on HRT
HRT/MHT can be used interchangeably, this article will use the term HRT.
Estrogen (also known as oestrogen)
The most effective way to treat perimenopause and menopause symptoms is to replace the hormones that are declining (in perimenopause) or the body is no longer producing (in menopause). Besides treating often distressing menopause symptoms, HRT has other health benefits. Women who take HRT have a lower risk of developing conditions like osteoporosis, diabetes, stroke, heart disease, high blood pressure, depression and dementia in future.
What is HRT?
HRT is the broad term used to describe:
1. Estrogen-only therapy: Estrogen-only HRT, is sufficient for women who have had a hysterectomy.
2. Estrogen plus progesterone therapy: For women with an intact uterus (not had a hysterectomy).
In addition to Estrogen, women with an intact uterus must have progesterone to protect against overgrowth of the lining of the womb due to estrogen.
In Australia, Testosterone is now licensed for low libido, a common symptom of menopause. Look out for my upcoming blog on testosterone.
Why use HRT?
The primary goal of HRT is to relieve menopause symptoms, including, but not limited to hot flushes. Some symptoms associated with menopause or perimenopause are joint aches and pains, back pain, muscle pain, mood swings, anxiety, depression, headaches, lightheadedness, tinnitus, sleeplessness, unusual tiredness, dry vagina, painful intercourse, low libido, weight gain, crawling feeling under the skin and frequency of urination. Women being treated for menopausal symptoms such as hot flushes require systemic estrogen (estrogen via patch, oral tablet or gel). Women being treated only for genitourinary syndrome of menopause (GUSM) such as dry vagina, frequency of urination or discomfort with intercourse, are treated with low-dose vaginal estrogen rather than systemic estrogen. Systemic estrogen means that estrogen is available and effective in all the body systems with estrogen welcome sites (receptors).
Benefits of HRT
Estrogen is available to all the tissues in our bodies, but the cells of these tissues have to have welcome sites for Estrogen to work in them. Estrogen enters the cells via the welcome sites, it then binds to DNA and kick-starts reading genetic code which makes various proteins. In turn, the proteins have different positive effects on the body systems.
Apart from relieving menopausal symptoms, which, in itself, is a massive benefit of using HRT. Estrogen has also been shown to lower the risk of metabolic syndrome by improving lipid profile, reducing the risk of heart attacks, stroke, high blood pressure and diabetes. HRT has also been shown to lower the risk of dementia and prevent and treat osteoporosis. There are suggestions that estrogen therapy reduces the risk of bowel cancer but more high-quality studies are needed in this area.
Taking HRT is like running a marathon
I normally describe the experience of taking HRT as running a marathon. It takes time to work, so don't get disheartened if you don't feel better overnight! It takes approximately 3 months of oestrogen use to notice a significant improvement in symptoms.
I consistently find that the younger a woman is, when she starts HRT the faster their response to HRT. Hot flushes and anxiety are usually the first symptoms to get better, it takes about 2-6 weeks to get a reduction in the severity of hot flushes. Whereas, muscle, joint and back pain takes about 6-9 months to significantly improve. The average age of menopause is 51, but women with a hysterectomy, even if their ovaries were not taken experience menopause early.
Although HRT is not licensed for perimenopause, it is an effective treatment of perimenopause symptoms and is used widely by menopause specialists all over the world. Perimenopause is the period of a woman's life leading to menopause. It usually starts in the mid-40s and may last for 4 months to 10yrs. Some unfortunate women may experience perimenopause in their mid to late 30s.
What are the risks of Taking HRT?
For the majority of women who start taking HRT under 60, the benefits outweigh the risks. Oral estrogen has a slight increase in the risk of blood clots. Synthetic progestogen has a slight increase in the risk of breast cancer. However, with micronised progesterone e.g. Prometrium this risk is reduced.
However, the risk of breast cancer with any type of HRT is low. For comparison, the risk of breast cancer is greater in a woman with a BMI >40, who drinks on average 2 standard alcohol drinks a day, smoker or lacks exercise. Oestrogen alone does not increase the risk of breast cancer and body-identical progesterone has not been shown to increase the risk of breast cancer for the first 5 years of use. For women that use progesterone beyond 5 years, the risk of breast cancer is not much more.
Note: Any symptomatic woman of any age can benefit from HRT provided it is in the hands of an experienced menopause doctor.
Who cannot take HRT?
Women who are being actively treated for breast cancer
Women who are being actively treated for endometrial cancer (cancer of the lining of the womb)
Women with a history of breast or endometrial cancer should discuss their treatment options with their oncologist or menopause doctor. Individualised and shared decision-making between the woman, her menopause-treating doctor and her oncologist is advised in this case.
The risks and benefits of HRT are discussed and the individual risk of recurrence of breast cancer recurrence is discussed. Ultimately, with the support of her treating team and with the right information and risk discussions, a woman can make up her mind for or against HRT.
More on this crucial topic in a later blog.
6 Take-home tips:
1. Majority of women can talk HRT safely. Discuss your options with a doctor knowledgeable in menopause management.
2. In the hands of an experienced menopause doctor, symptomatic women of any age, can get benefit from HRT. Women who are more than 10 years after their last period, may have no additional benefits in the prevention of cardiovascular disease but other problematic menopause symptoms including prevention or treatment of osteoporosis, muscle aches, vaginal symptoms, anxiety and depression and sleep troubles can be effectively managed with HRT.
3. Estrogen through the skin or patch does not increase the risk of blood clots, strokes or heart attacks and women with a history of liver disease or blood clots can use oestrogen in this form, however, tablet estrogen has an increased risk of blood clots.
4. Body-identical progesterone (micronised progesterone) has been shown to have no increase in the risk of breast cancer for the first 5 years of use. for those that use it for more than 5years, the risk is not much more. Know your other risks for breast cancer and modify your lifestyle to reduce risk.
5. Women do not have to take HRT at the lowest dose (even if their symptoms are not controlled) and for the shortest amount of time possible. There is no evidence basis for the practice of giving HRT for the shortest amount possible and stopping. Any Cardiovascular, bone and metabolic benefits derived from their use of HRT diminish when a woman stops HRT. If they so choose, women can take HRT forever; unless there's a medical or health reason why not.
6. Every woman should receive individualised care for their menopause symptoms. Women should be furnished with evidence-based information including all the pros and cons of the options of treatment available to them. Then, they can make an informed decision that will benefit their current and future health.
This is called empowerment to take control of your health! Your health is in your hands, isn't it?
The next blog in the series will go into more detail on estrogen. Have you heard of body identical, bio-identical, CEE (or estrogen derived from a pregnant mare's urine)? Confused by the terminologies? Look out for the next blog
If you want to discuss your symptoms further
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