Menopause simplified – is HRT a good option for me?

Written by Dr Camilla Janssen - Nov 2021

The menopause is a natural part of ageing that usually occurs between 45 and 55 years of age, as a woman's oestrogen levels decline. In the UK, the average age for a woman to reach the menopause is 51. The perimenopausal stage normally lasts for a few years leading up to this.


You are thought to be “post-menopausal” when you have had a year since your last period. (But you are only able to know this if you are not on any hormones or contraception that may affect your periods).

If you have read the information below and you feel HRT would be beneficial


1. Book an appointment to discuss this with your GP and have the following information available.

2. An up-to-date blood pressure from a home machine, the pharmacy or your GP surgery waiting room.

3. An up-to-date weight.

4. Fill out this questionnaire and send back to your practices' inbox before your consultation.

Symptoms may include some or all of the below and can be intermittent initially

  • Hot flushes / Night sweats
  • Anxiety
  • Mood changes / Irritability / Tearfulness
  • Forgetfulness / Poor sleep
  • Brain fog
  • Skin dryness/ crawling sensation
  • Joint aches
  • Poor or no libido / Vaginal dryness
  • Urine infections / Urinary incontinence
  • Hair loss

We typically diagnose menopause from symptoms alone and don't need to do blood tests.


When should you start on HRT?  

It is beneficial to start HRT when menopausal symptoms impact on your home, work, social or sex life and you deem that the benefits of HRT will outweigh the risks. This may start a few years before your periods actually stop. We normally advise starting HRT within 10 years of your menopause.


What are the Risks and Benefits?         

This advice has fluctuated over the years and has caused considerable confusion. More recently published findings show that although not entirely risk free, it remains that HRT is 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. The issue with regards to Breast Cancer is more complex, and many women worry about this in relation to HRT. Essentially 1 in 7 women born after 1960 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 if you have a Mirena coil) you have a reduction in risk of being diagnosed or dying from breast cancer. If you take combination HRT you have a slight increased risk of being diagnosed with breast cancer but no increased risk of dying from breast cancer. In trials, obesity or drinking 2 glasses of wine a night posed a bigger risk factor than being on HRT in respect to the risk of getting breast cancer. Click here to see WOMEN’S HEALTH CONCERN FACT SHEET on the Risks and Benefits of HRT.


Symptom control and therefore improved quality of life is a big benefit of HRT. Symptom control and reduction of hot flushes should be apparent within weeks of starting HRT.

Other personal characteristics can play a bigger part than HRT in increasing the risk for many conditions such as Breast Cancer, Stroke and Venous Thromboembolic events such as a Deep Vein Thrombosis or Pulmonary Embolus. These include Obesity, Smoking and Alcohol. It is important to manage these risks independently. Click on this infographic to see the comparison of lifestyle risk factors versus Hormone Replacement Therapy (HRT) treatment and the risk of Breast Cancer 

 

Many lifestyle factors can improve the symptoms of the menopause. A lower carbohydrate diet is a good way to stabilise blood sugars and help with menopausal symptoms as well as addressing obesity and hence other risk factors. Sleep, physical exercise, mental wellbeing, with a healthy out look on life, have a huge impact on how we feel. We suggest looking at our lower carbohydrate pages link here as well as all the health and well being resources embedded in this website. It is worth optimising how you are running your body before adding medications. 

 

Who can’t have HRT

  • Recent Heart attack or poorly controlled angina
  • Recent clot in the lung or leg
  • History of breast cancer or other hormone dependant cancer.
  • Pregnancy
  • Undiagnosed vaginal bleeding
  • Newly diagnosed or uncontrolled high blood pressure
  • Severe or active liver disease with abnormal liver function test results


Non hormonal prescribed HRT alternatives options to address the menopausal symptoms click this link.

 

Common Side effects of HRT - These are common in the first 3 months of starting HRT and tend to improve with time.

  • Breast tenderness
  • Change in skin/acne
  • Bloating, mood swings


Bleeding on HRT - Common in 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 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 at this point.


Body Identical vs Bioidentical - Body identical HRT are medicines that have been subjected to safety testing and quality control and are regulated by the Medicines Regulatory Agency. This is the HRT we prescribe in the NHS. It comes as a transdermal preparation (i.e. one that you take via the skin) either as a gel that you rub on daily or as a patch that you change twice a week. Uterogestan is the body identical progesterone. Bioidentical HRT products are unregulated and is a term used for products which are marketed as being "natural" or "individualised" or "customised" for women. These products are unregulated by the Medicines Regulatory Agency and are unlicensed. They have not been subject to the same safety testing or quality control as the regulated HRT products in body identical HRT. The use of bioidentical compounded hormones is not recommended by the British Menopause Society.


Natural Alternatives to HRT - beware, natural doesn't mean safe - arsenic is natural. This Menopause Matters website has wealth of information on menopause, including information on natural alternatives to HRT.  Most GPs are not trained in this area and are not able to prescribe these, so you may have to do your own research on these products.


How long should you continue with HRT? - This varies dependant on lots of different factors. Often menopausal symptoms are worse during the perimenopausal years and improve with time. The symptoms tend to subside as your body gets used to lower oestrogen levels and as you get older you may need a lower dose of HRT or none at all. Occasionally some people do suffer from lifelong menopausal symptoms and want to stay on HRT long-term.

I suggest using HRT for 2-5 years and at then consider reducing the oestrogen dose or trialling without HRT at this point and see how your body responds. You can either stop abruptly (expect some initial symptoms) or gradually reduce over time. There is no long-term differences in the outcome between stopping abruptly versus gradually decreasing your dose. If you do stop abruptly, it is normal to have some initial symptoms due to the relative lack of oestrogen, but this should settle over time – over a few weeks to a couple of months, so please do expect this.


Please ensure that you participate in regular breast and cervical screening programmes.


Once started on HRT, we would suggest a follow up with your GP in 3 months’ time with an up-to-date blood pressure reading. Once things are stabilised, an annual review, including and up to date blood pressure, is perfectly appropriate.


If you get new bleeding once established on HRT for more than 6 months, please discuss this with your doctor, as this usually needs investigating.


USEFUL WEBSITES and RESOURCES

The British Menopause Society (BMS) is also a good source of reliable information. BMS tools for clinicians has a useful range of resources that summarise the NICE Guideline, provide guidance on HRT prescribing and other treatment options, and to clarify some of the most common myths and misconceptions of menopause.


Newson Health is a private Menopause and Wellbeing Centre. There is a wealth of information on its website including a comprehensive resources page which features fact sheets, booklets and podcasts on many different areas of menopause.


Menopause Matters website has wealth of information on menopause, including information on natural alternatives to HRT.



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