About HRT (hormone replacement therapy)

HRT (hormone replacement therapy) is a treatment commonly used for women during and after the menopause; the aim of treatment is to replace the hormones, oestrogen and progesterone. As you age, hormone levels fall and eventually this causes the ovaries to cease releasing eggs and the menopause to occur.

Many women experience unpleasant symptoms as they approach the menopause and HRT can help to ease these symptoms; not everyone needs HRT, but it can be a very effective solution for many women.

What exactly is HRT and why is it needed?

Hormone replacement therapy is designed to counteract falling levels of female hormones, which occur in the run-up to menopause. Using HRT can help to reduce symptoms, which result from decreased levels of oestrogen. Although reduced progesterone levels do not have a significant impact on you like decreased oestrogen levels, it is important that oestrogen and progesterone are provided by HRT (progesterone is replaced by a man-made form of the hormone called progestogen), as oestrogen only HRT can increases the risk of uterine cancer. If you have had a hysterectomy (this is a procedure to remove the uterus), you do not need progesterone and you can take oestrogen-only HRT.

Falling levels of oestrogen in the body contribute to a host of symptoms, as oestrogen has a number of important roles within the body; these include regulating the temperature of the skin, controlling periods, preparing the body for pregnancy, maintaining moisture in the vagina and increasing bone density. As a result, decreased levels may result in:

  • hot flushes and sweating
  • vaginal dryness
  • weak bones
  • reduced sex drive
  • incontinence (this relates to being unable to keep control of your bladder when it is under stress, for example when you sneeze)

In most cases, these symptoms are temporary, but incontinence and weakness in he bones tend to get worse as you get older.

HRT is not required by all women who have menopausal symptoms, but it can be effective in cases where symptoms are severe or there is a heightened risk of osteoporosis.

Types of HRT treatment

There are various different types of HRT available and they come in different forms including patches and tablets. The different types of HRT include:

  • Oestrogen only treatment: this is usually recommended only for women who have had a hysterectomy, as it can increases the risk of womb cancer in women who still have their womb. If you haven't had a hysterectomy, you will be advised to have combined HRT treatment, which uses both oestrogen and progestogen.
  • Cyclical HRT treatments: these HRT treatments combine oestrogen and progestogen and there are 2 main options: monthly and 3-monthly treatment.

With monthly treatment, you receive oestrogen on a daily basis and progestogen for 14 of the 28 days; this is followed by a light period-like bleed, which occurs when the lining of the womb is shed. HRT doesn't make your more fertile or cause the ovaries to release eggs, but the progestogen does cause the endometrium, the living of the womb, to build-up and the bleed is the lining breaking down.

With 3-monthly treatment, you take oestrogen on a daily basis in addition to 14 days worth of progestogen treatment every 3 months. With this treatment, you will have a light bleed every 13 weeks.

Monthly cyclical HRT is most commonly recommended when you are still having regular periods, while 3-monthly treatment may be better in cases where periods have become irregular.

Continuous treatment: this form of HRT involves taking both oestrogen and progestogen on a daily basis. It is generally recommended for post-menopausal women and when women have been using cyclical treatment for over a year. In most cases, this form of treatment does not cause bleeding; if you experience bleeding, consult your GP for advice.

What are the advantages of HRT?

HRT is predominantly used to treat symptoms associated with menopause and it can make a really positive difference to day to day life, especially or those who have severe or prolonged symptoms. Once you start taking HRT, you can expect:

  • reduced hot flushes and night sweats (usually within just a few weeks)
  • reduced vaginal dryness
  • reduced vaginal discomfort
  • reduced susceptibility to UTIs (urinary tract infections)
  • improved mood and reduced risk of mood swings
  • improved libido and reduced pain during sex
  • reduced muscular pain
  • reduced risk of osteoporosis and fractures

Studies into the relationship between HRT and cardiovascular disease and Alzheimer's disease are ongoing.

Are there any risks associated with HRT?

There is a common perception that HRT is dangerous and carries serious risks to human health thanks to some studies, which were highly publicised in the media; however, the reality is that much of the information has been exaggerated and in many cases, the benefits outweigh the risks. Before you start taking HRT, your doctor will outline all the potential risks, as well as the benefits and this will enable you to make a well-rounded decision.

Breast cancer

One of the most contentious issues related to HRT is the risk of developing breast cancer; the media reported that HRT significantly increases your risk of breast cancer, but it is important to read the figures in relation to the average risk, rather than to focus solely on the risk in those using HRT. According to Cancer Research UK, using HRT does increase the chance of developing breast cancer and the longer you use it, the greater the risk. Studies show that the actual increase in risk is similar to 1 case per 1,000 women per year; there is also no increased risk in women who take HRT under the age of 50. One problem, which may arise from interpreting the figures, is that women who take HRT are perhaps more likely to attend mammogram screenings and in this case, more cases of breast cancer may be detected. The risk also returns to normal after 5 years of not using HRT.

If you are using HRT, it is very important to attend routine mammograms and to check your breasts regularly.

Blood clots

Combined HRT increases your risk of developing a blood clot in your vein (known as deep vein thrombosis), which may travel to your lungs (known as a pulmonary embolism) also known as venous thromboembolism. Studies show that combined HRT carries a greater risk than oestrogen-only treatment and tablets increase the risk more than patches. If you have other risk factors for blood clots, your risk will be higher; other risk factors include previous clots, obesity and smoking.

It's important to see your doctor as soon as possible if you experience sudden swelling or pain in your legs, difficulty breathing or a sharp pain in your chest.

Ovarian cancer

Cancer Research UK claims that there is a very slight increase of ovarian cancer when using HRT; the longer you take HRT, the greater the risk; however, the risk returns to normal after 2-3 years of not using HRT.

Uterine cancer

Studies show that when progestogen and oestrogen are combined, there is no increased risk of uterine cancer associated with HRT.

Strokes

The risk of strokes and blood clots may be increased in women who have additional risk factors, for example those who smoke or are obese. There is no additional risk associated with starting HRT treatment under the age of 60 years old.

Before you begin HRT, your GP will consider your general health status and your medical and family history; if you are at greater risk of developing certain health complications by using HRT, an alternative therapy may be recommended.

What are the side-effects of HRT?

It is uncommon to experience side-effects when you start HRT; however, it is possible; some examples of side-effects of using HRT include:

  • nausea
    • aches and cramps in the legs
    • mild discomfort in the breasts
    • mild skin irritation (when using patches, rather than tablets)
    • headaches and migraines
    • dry, itchy eyes

    Sometimes, simply switching to another type or brand of HRT can help to ease side-effects.

    Is HRT suitable for everyone?

    HRT is suitable for many women and will usually be recommended in cases where the benefits of treatment outweigh the risks. If you have any of the following issues or health conditions, HRT may not be recommended for you:

    • if you have had breast, ovarian or womb cancer in the past or you have family history of any of these forms of cancer
    • if you have had clots in the past or you have family history of DVT (deep vein thrombosis) or strokes
    • if you have family or personal history of heart attacks or heart disease
    • if you have high blood pressure and you are not already receiving treatment (you may be able to start HRT once your blood pressure is under control)
    • if you have liver disease
    • if you are pregnant
    • if you have a breast lump, which has not been treated or tested
    • if you have experienced abnormal or irregular bleeding from the vagina

    In some cases, it may be necessary to carry out some basic health checks and tests before your doctor can give you the all-clear to start HRT.

    HRT does not offer any contraceptive benefits and if you are still having periods and you do not wish to get pregnant, you will still need to use contraception.

    Are there alternatives to HRT?

    If HRT is not suitable for you due to your medical or family history or you decide against it, there are some alternatives, which are worth considering. Here are some examples, which may be beneficial:

    Medication

    Medicines used to treat depression and high blood pressure may be effective in talking hot flushes and night sweats; however, there is often a risk of side-effects and it's important to be aware of these before you begin treatment. Antidepressants, which may be recommended, include citalopram and venlafaxine hydrochloride; possible side-effects include nausea, anxiety, insomnia, reduced interest in sex and feeling drowsy and light-headed.

    Clonidine, a drug, which is used to treat hypertension (high blood pressure), can also help to reduce sweating and hot flushes; however, the side-effects can be nasty and include constipation, an elevated risk of depression and dry mouth, which can increase the risk of dental diseases. Usually, doctors trial this drug for 2 weeks to see if it is effective; if you experience side-effects during this time, another form of medication may be recommended.

    Tibolone is a synthetic hormone, which may be suitable for women who have gone through the menopause; treatment involves taking a single tablet, which contains both hormones. This treatment is suited to women who have not had a hysterectomy, but it may not be viable for those who cannot take HRT due to medical reasons, such as history of breast or ovarian cancer.

    Vaginal creams may be recommended as a safer alternative to HRT when the symptoms are predominantly linked to the vagina and include dryness and pain during sex.

    Lifestyle choices

    Sometimes, making positive changes to your lifestyle can really help to ease symptoms. These include:

    • Exercising regularly: regular exercise helps to reduce stress and anxiety and it can also help with hot flushes and decrease your risk of insomnia. Exercise is also proven to release endorphins, which makes you feel better.
    • Avoiding stress: stress can trigger anxiety and mood swings, so try your best to avoid stressful situations and practice stress management techniques, including deep breathing, massage, meditation and yoga.
    • Quitting smoking: smoking is bad for your general health and it can make hot flushes worse; giving up with the help of your GP, local support groups and nicotine replacement therapy, can help to ease episodes of hot flushes and reduce your risk of serious illnesses, such as cancer.
    • Keeping your bedroom cool: night sweats can be unpleasant and severe sweating can disturb your sleep, so try to keep your bedroom cool, avoid tight clothing and sleep with your window open.
    • Avoiding triggers: if you've noticed that certain foods or drinks trigger hot flushes, try to avoid these; common triggers include caffeine, hot and spicy dishes and some types of alcohol.

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