Menopause and HRT

What do you know about HRT? Do you know enough to make an informed choice about whether it’s right for you?

We were joined by Dr Heather Currie MBE, Founder and MD of Menopause Matters, to give us some answers.

Henpicked: First and foremost: what is HRT? 

Dr Heather Currie: It’s the short version of hormone replacement therapy or menopausal hormone therapy, which aims to replace oestrogen. When we are in perimenopause, the time leading up to menopause, we can notice a changing pattern in our periods and gradual changing oestrogen levels. Ultimately, our ovaries run out of eggs and don’t produce oestrogen any more, so the aim of HRT is to replace this.

Henpicked: What are the different types of HRT?

Dr Heather Currie: It can be taken as a daily tablet, or a twice-weekly or weekly patch, a gel or a spray where it’s absorbed through the skin and known as transdermal. All of these are called systemic oestrogen, which means it’s picked up by the bloodstream and circulates through the body.

There is also vaginal oestrogen which can be used to treat the common vaginal and bladder symptoms of menopause. The difference here is that’s not going through your whole system, it’s concentrated in the vagina and the bladder. 

The other important hormone is progestogen. If we give oestrogen systemically, it could eventually cause a thickening of the womb lining and increase the risk of cancer there. To prevent that, if the womb is still present we use progestogen. This can be given combined in the tablet or patch, or taken separately as a tablet or capsule.

Henpicked: Is testosterone part of the mix? 

Dr Heather Currie: Not initially. Our ovaries do produce it, but we don’t suddenly produce less around the time of menopause. We also produce it through our adrenal glands, so there isn’t that sudden drop unlike oestrogen.

There are times it can help, though. Our ovaries produce around 50% of our testosterone, so if someone has had a surgical menopause and their ovaries removed it can be applicable.

National and international guidance is that we can consider replacing testosterone for the ‘complaint of persistent troublesome low libido in women when all other factors have been considered’. Female sexual function is incredibly complex. There’s a lot to consider and address before we look at testosterone. This includes optimising oestrogen (or considering vaginal oestrogen or moisturiser if dryness is causing a problem), and looking at lifestyle, stress, sleep, all things that can affect libido.

There’s a good video on NHS Inform about sex and menopause. Ultimately, sex is supposed to be enjoyable. Testosterone will likely give you one more satisfying sexual episode a month. . It can be an option to consider if your libido has dived, but sometimes it’s about rebuilding routines and rediscovering intimacy.

Something to add is that testosterone is converted to oestrogen, so if you’ve been told not to take oestrogen then this won’t be suitable for you. 

Henpicked: If you’ve tried a type of HRT and it doesn’t work is it worth trying a different type? 

Dr Heather Currie: First we need to be clear about how we want HRT to work. Sometimes there are unrealistic expectations. HRT does provide a lot of benefits for most women who choose to use it. But it doesn’t fix everything. Sometimes how we’re feeling might not be hormone related, it might be due to life stresses, diet and lifestyle, for example.

But if we’re taking it for symptoms which are clearly related to being low on oestrogen then the first type you try might not be the answer. There isn’t one type which suits everyone. We often start with a daily tablet, but some women don’t absorb it enough into their circulation to have the desired effects.

If we use transdermal oestrogen, through the skin, then the absorption varies. Some will respond well to a patch, for others, the gel or spray is better. We can’t predict. It’s about starting at a reasonable point and being prepared to adjust the dose and the method if needed. 

I’d always recommend giving it at least three months before deciding if you need a change. Some people do respond well straight away, but for others it takes a little time.

Henpicked: There’s a lot of conflicting information out there. Can you give us a clearer idea of the risks versus benefits of HRT?

Dr Heather Currie: The benefits are that it is the most effective treatment for the symptoms of menopause. Other options can be helpful for women who medically might not be able to take HRT, or if it’s not their preference.

For most women who have troublesome symptoms, starting HRT under the age of 60 or within ten years of menopause, the benefits will outweigh any risk. . There are also long-term benefits. Oestrogen is good for bone health, reducing risk of osteoporosis and related fractures. If you have a strong family history of osteoporosis as well as menopausal symptoms, that would be another reason to consider HRT. 

Another indication is for women who have an early or premature menopause. Under the age of 40 is known as premature ovarian insufficiency (POI), while under 45 is early menopause. This can affect heart and bone health. For younger women the recommendation is to offer hormone therapy even if they’re not having troublesome symptoms, but for heart and bone protection. For these women, up until the age of 50 we just look at it as replacing the hormones which would be there anyway.

In terms of risk, current understanding is if HRT is taken for more than five years after the age of 50, there is an association with a small increased risk of breast cancer. This is believed to be due to the hormones promoting breast cancer cells that are already there but haven’t yet become clinically evident, rather than causing cells to turn into cancer. For those who take oestrogen only, there’s very little risk.

But we need to put that risk into perspective. It isn’t higher than being overweight or drinking alcohol regularly. For most women the benefits in terms of symptom control, improved quality of life, bone health and heart health do outweigh the risks.

Henpicked: Is there a relation between HRT and Alzheimer’s? 

Dr Heather Currie: This is complex as there are different types of research out there. Overall the current information related to HRT and prevention of Alzheimer’s is that there may be a beneficial effect. But we wouldn’t offer HRT as a preventative, only for those with menopausal symptoms. There have also been some studies suggesting long-term use of HRT may slightly increase the risk of dementia.

At the same time there’s some research showing that we should be looking at brain health in the same way as heart health, including regular exercise, not smoking and taking a healthy diet. 

There’s no definitive answer as research is ongoing.

Henpicked: Can everybody take HRT? 

Dr Heather Currie: There are very few women who can never take HRT but there are some who we’d be cautious about using it. Some women just don’t want to take it and that’s fine. If you’re not having symptoms and you feel fine, focusing on your diet and lifestyle can help your bone and heart health.

If someone has had a previous deep vein thrombosis, we’d be wary of offering a tablet form of HRT, but they could try a transdermal method. And HRT isn’t recommended for those who’ve had a hormone-sensitive cancer, such as breast or womb cancers.

There’s no limit to the duration you can take HRT, and you can’t predict how long your symptoms will last for. At some point you might want to have a trial coming off it for three months. Your symptoms won’t automatically come back. For most women there are more benefits than risk up to the age of 60, but after that many will be able to come off it. Our life is changing during this time as well so impact of any symptoms might not be the same. If troublesome symptoms continue, continuing HRT over the age of 60 can still be beneficial.

Henpicked’s Deborah Garlick was joined by Dr Heather Currie.

Dr Heather Currie is a Gynaecologist at Dumfries & Galloway NHS, Trustee and past Chair of the British Menopause Society.

She is co-editor of Post Reproductive Health, the journal of the British Menopause Society, Founder and MD of Menopause Matters, and past Scottish National Clinical Lead for Modernising Gynaecology Outpatients and clinical Advisor to Scottish Government for the Women’s Health Plan for Scotland.

Watch the video here:

There’s more information on her website:

And check out the rest in our Lunch & Learn video series!

Available from Bloomsbury, Waterstones, Amazon and good bookshops.