As part of our Lunch & Learn series we were joined by Dr Clare Spencer of My Menopause Centre.
What does HRT do? What are the benefits and risks of HRT? Expert information here.
Henpicked: Let’s start with the basics. What is HRT and what does it do?
Dr Clare Spencer: HRT stands for hormone replacement therapy. It’s important to look at what happens in the menopause transition to understand how it works.
Our oestrogen levels go from a predictable fluctuation up and down every month before the menopause to much more erratic fluctuations during perimenopause. At the point of the menopause periods stop and your oestrogen levels are low and stay low.
HRT aims to give back enough oestrogen to manage symptoms and reduce long-term consequences of menopause, heart disease and osteoporosis.
The mainstay of HRT is oestrogen. But if you have still got your womb – so you haven’t had a hysterectomy – then you also need another hormone, progestogen. Oestrogen can thicken the womb lining which increases the risk of abnormal cells and cancer of the womb lining, so you need the progestogen to offset this.
In terms of dosage, you might need to try a few different ones before you get the right one for you. But it will always be a static dose – you can’t really chase symptoms by constantly changing your dose of HRT.
You do also need to consider lifestyle as part of your menopause management, too. HRT is great for most women
but it may not take away every single symptom, so looking to your lifestyle and other factors such as managing stress and sleep is important also.
Henpicked: How do we take HRT?
Dr Clare Spencer: Most oestrogen prescribed now is oestrodial, which is body identical – the same as our own oestrogen. You can take this as a gel, spray, patch, or you can swallow it in tablet form.
If you have a womb you also need a progestogen to keep the womb lining thin. Progestogen can be delivered via a tablet, combined patch or capsule, or you can have a Mirena coil fitted.
There’s not a one-size-fits-all best approach, so there might be some trial and error. Some people don’t like waiting the five minutes for gel to absorb, others react to the adhesive in patches. Really, you need to start with a combination of oestrogen and progestogen (assuming you have not had a hysterectomy), give it three months and then have a review. There’s often an element of trial and error involved so don’t be disheartened if the first thing you try doesn’t work. Also to add, it’s very common to have some irregular bleeding in the first three months of starting or changing HRT.
Henpicked: Can you outline some of the risks involved with HRT?
Dr Clare Spencer: Breast cancer is always at the forefront of women’s minds when we talk about HRT. And there are risks, but they are small. The Women’s Health Initiative study showed that over five years there are 23 cases of breast cancer diagnosed per thousand for women in their 50s, but when you added the old-style HRT (conjugated equine oestrogens with medroxyprogesterone acetate) there were four additional cases per thousand.
In that study, being very very overweight or obese added an extra 24 additional cases, so it’s a question of putting this into perspective, without diminishing the impact of a breast cancer diagnosis.
Blood clots are another consideration. If you swallow oestrogen it more than doubles your risk of blood clots. For most healthy women who don’t smoke and haven’t had a blood clot before, this means taking it from a tiny risk to a slightly higher tiny risk. For those who do have any risk factors, taking oestrogen transdermally – through the skin – doesn’t increase the risk at all.
If you’ve had a hormone-dependent cancer in the past, HRT is likely to increase recurrence. If you have awful menopause symptoms then you could have a conversation with your cancer specialist to see what your options are. If you’ve had a non hormone-dependent cancer then you might be able to have HRT, but again speak with your specialist about the risks and benefits.
Henpicked: And what are the benefits?
Dr Clare Spencer: For most women HRT is the most effective way of managing menopause symptoms. Plus it can significantly reduce the risk of osteoporosis, helps to reduce the risk of fracture, and also reduces the risk of heart disease, which is a big cause of mortality in women.
You can also get topical vaginal oestrogens, which can help to manage vaginal and bladder symptoms.
It’s important to say that if you go through menopause under the age of 45 you should be offered HRT due to increased risks of increased time with a lower oestrogen, and if you’re under 40 it’s very important to take HRT until at least the average age of menopause, 51.
Henpicked: It can be hard to get a GP appointment. Any tips on who to speak to about HRT?
Dr Clare Spencer: Ask the receptionist at your practice who the best person is to talk to about menopause. It might be your GP or it might be a pharmacist or practice nurse. Increasingly there is someone in each practice with extra training or knowledge.
HRT has relatively few interactions with other medications, so make sure to also tell your GP about any other medications you’re taking.
If you feel you’re not getting anywhere, you can ask for a referral into a specialist menopause service. Don’t be afraid to question what you’re told or to go in armed with your own information. Menopause management is highly personal and you need to be able to access the right support for you.
Henpicked Menopause in the Workplace’s Deborah Garlick was joined by Dr Clare Spencer of My Menopause Centre.
Dr Clare is a registered menopause specialist and an NHS GP. She qualified from Cambridge University and holds membership of the Royal College of Obstetricians and Gynaecologists and the Royal College of General Practitioners. She initially trained in obstetrics and gynaecology where she gained a Doctor of Medicine for research in fetomaternal medicine.
As well as her role of Clinical Director at My Menopause Centre, she currently runs an NHS menopause service and is a GP partner in a practice in Leeds. She is also a British Menopause Society menopause trainer and is involved in educating GPs about the menopause transition through talks, lectures and seminars. She wrote the menopause training module for doctors.net and has written for the Primary Care Women’s Health forum publication, Her Life Her Health, on a variety of menopause-related topics.
