Menopause and HRT: what you need to know
In my role as a menopause specialist, I’m often asked lots of questions about HRT. There are so many myths and so much misinformation out there, it’s unsurprising women are confused.
Here are some of the main questions I’m asked:
What are the benefits of HRT?
Relief of symptoms
Most women who take HRT want the most obvious benefit which is to feel better, to get back to normal life. They’re looking to relieve symptoms such as flushes, sweats, vaginal dryness, irritability and mood swings. It can eliminate symptoms for some women, and for all women who use HRT those symptoms will usually be improved. That’s the short-term benefit.
Long term, you can be reassured while you’re on it you’re getting the added benefits of bone protection, skin, hair, collagen improvement – things you may not actually go onto HRT for but all an added benefit. The NICE guidelines say that HRT is the most effective way of managing symptoms.
Lots of women don’t realise that HRT can be good for your bones. As you go through menopause your bone health declines, leading to an increased risk of fracture, and for some women that deterioration can be quicker than for others. HRT puts a halt on your bone loss, for as long as you’re on it.
If you start HRT from around the time of your menopause, which is when most people do start it, you’ll also get cardiovascular benefits from your HRT, as it reduces cholesterol, helps with the tone of the cardiovascular system and has other positive effects on your heart health.
There has been extensive research looking at whether oestrogen is responsible for some of the effects of dementia in women, as they greatly outnumber men in incidence of dementia. So there is a theory that oestrogen must have some relation. What we don’t know is whether taking HRT after menopause is enough to reduce risk.
There is some suggestion that HRT could help for vascular dementia, where blood flow is restricted. It’s not a reason to use HRT but it could be added benefit if used in early menopausal years.
What are the risks of HRT?
Unfortunately a lot of benefits are overshadowed by negative headlines about the risks of HRT. It’s important when making informed choices that women understand both the benefits and the actual facts around the risks. I tend to separate side effects and risks, as they are two different things.
There are so many types of HRT that we don’t always get it right first time and sometimes doses need tweaking. Women can experience breast tenderness, leg cramps, headaches or bleeding. But all these can generally be managed by changing your HRT.
The one risk everyone is concerned about here is breast cancer. And we know there is an associated risk if you stay on it long term. What is the quantity of the risk?
Breast cancer is quite a common cancer for women and around 22/23 in 1000 women of menopausal age will sadly get breast cancer whether they’re on HRT or not. On top of that, if 1000 women were to take HRT for more than five years there may be another 4/5 women presenting with breast cancer sooner than they would have done. It rarely initiates cancer but it may speed up cancer that you don’t know anything about. How does that measure up? If you’re slightly overweight your risk is about the same. A glass of wine is very nice but a glass a day will bring your risk to about the same as using HRT.
Lifestyle plays a significant part in your menopause management. You wouldn’t take HRT so you can continue to overeat, drink too much and not take any exercise. If you can’t take HRT you shouldn’t feel too short changed, because you can help maintain good health with lifestyle changes too, which are just as important.
Is HRT one-size-fits-all?
Emphatically not. HRT is a whole world of different medications and when I’m thinking about prescribing I have to weigh up all kinds of things, the type of HRT, the dose, the regimen, how long you might use it for. Patches, gels, spray, tablets, vaginal treatment, coils, implants – HRT is a whole spectrum of medication and within that spectrum it’s a whole range of doses. So I do encourage women to not give up at the first attempt with HRT as it can take a bit of tweaking.
There are some HRTs which we know are better for women with certain medical conditions. For example, if you have high blood pressure you’re better off using a patch, gel or spray. If you have migraines, you’re better off with a continuous HRT so you don’t get cyclical triggers, if you have gastric (stomach) issues avoiding a tablet will help.
Is there still a shortage of HRT?
Recent shortages have been frustrating. Women have been told their HRT is out of stock but not been offered alternatives.
The good news about supplies is that many HRTs are now back in stock. However, there are regional variations, some will find it harder than others because of wholesaler issues, but it is getting better. We do have a brand-new HRT on the market now, a spray, which works in a similar way to patches, so this may be a suggestion for those who can’t get patches. I always say it shouldn’t be down to you to go shopping for your HRT. Healthcare professionals should be guiding you to the right HRT.
Is HRT really made of horse urine?
I’m asked this a lot, and some women are actively avoiding HRT for this reason. The reality is that there is one made from horse urine – but it’s one of about 20 HRTs. More recently, we are using body identical ranges with oestradiol, the body’s own natural oestrogen. It’s understandable people don’t want horse urine when there are alternatives, although it is still an effective HRT.
How do I talk to my GP?
My advice is to think very carefully before your appointment. What is it you’re hoping to get from it? Are you asking for treatment, do you want to discuss the risks? The information you give will guide the discussion. Some clinics offer double appointments, or you could ask the receptionist who is the best person to talk to about menopause. It might not be your usual GP.
Can women under 50 that are on HRT have breast screening on NHS?
The evidence for mammograms prior to the age of 50 is not as strong as those after 50. There are some parts of the country introducing them at 45 as a trial, so we may be going that way in the future but not just yet. You can’t request one if you’re outside those areas – you’ll get one in your 50th year, though, and remember if you are under 50, you would expect your breasts to be exposed to oestrogen normally.
Does menopause cause hair to thin?
Hormone disruption can lead to thinning hair, especially if you go into surgical menopause. But our hair is also affected by our diet, health, whether we smoke and, of course, our genes. Look at your iron levels, make sure your thyroid is working properly, maintain a healthy, varied diet and look at hair products aimed at someone like you. HRT can help sometimes, but doesn’t always.
When you’re looking at ways to treat your symptoms, remember menopause can affect us all differently. Think not necessarily about those that are the most prevalent, but which are the most bothersome. For instance, sometimes fixing your sleep patterns can help with other issues.
Educate yourself as much as possible about menopause and HRT so you can make an informed choice. Go to reputable sources, rather than reading headlines, and remember your requirements will change as you go through the different stages of menopause. HRT is not everyone’s choice, but for most women it is low risk, and for many women offers great benefit.