The menopause: an expert view on the risks and benefits of HRT

11 October 2021 | Science and research

Dr Louise NewsonDr Louise Newson is a GP and menopause specialist.

The menopause is an event that will happen to roughly half the world’s population at some point in their lives. Yet mystery and misinformation surround the menopause, especially when it comes to hormone replacement therapy (HRT).

As a GP and menopause specialist, my working life is devoted to providing the best possible care for my patients. But as a health professional and as a woman, I have been dismayed at the sheer lack of credible information about the menopause that exists online, in the media and even in some consulting rooms.

For women approaching the menopause, there are far too many scare stories about HRT. So, along with outlining what the menopause is and the symptoms it can trigger, I want to dispel myths and show why HRT is the gold standard treatment to alleviate symptoms and safeguard long-term health.

What is the menopause?

The menopause is when the ovaries stop producing eggs and the levels of the hormones oestrogen, progesterone and testosterone fall. The definition of being in the menopause is when a woman has not had a period for 12 months, while the perimenopause is the time directly before the menopause, when hormone levels start to fall but she still has periods (though these can fluctuate in flow and frequency).

We have oestrogen receptors on cells throughout our bodies, so when oestrogen levels fall, the knock-on symptoms can be embarrassing, uncomfortable and, in some cases, devastating.

Yet menopausal symptoms aren’t just about hot flushes: other symptoms triggered by changing hormone levels range from joint pains to vaginal dryness, low libido to thinning hair, itchy skin to fatigue and memory lapses.

Low mood and other psychological symptoms can be particularly hard to cope with: nearly every week I will see a woman in my clinic as an emergency appointment because she is suicidal.

Prompt, effective treatment for all of these symptoms is incredibly important, and this is where HRT comes in.

What is HRT and what is it made from?

Menopause is a long-term hormone deficiency and, as the name suggests, HRT replaces those missing hormones.

HRT will always contain oestrogen, and often contains a form of progesterone, either known as micronised progesterone or a synthetic progestogen. Progesterone is prescribed for women who still have a uterus, to protect the lining of the uterus. Taking oestrogen and progesterone together is known as combined HRT. For some women, HRT will also include testosterone, which is another important female hormone.

Older forms of HRT contain oestrogen made from a pregnant mare’s urine, but these days the most common type is 17 beta-estradiol. This is derived from yam plants. It’s known as a body-identical oestrogen because, unlike older forms of HRT, it has the same molecular structure as oestrogen produced in our bodies. Micronised progesterone is also made from yam plants, and so is body-identical.

A female doctor talks to a female patient

How do I take HRT?

No two women will have the same menopause experience and the same goes for HRT. It should always be prescribed by a healthcare professional, after a discussion about symptoms, age, medical history, lifestyle and personal choice. There are dozens of types and doses, and this allows for greater flexibility.

Oestrogen can be delivered via a skin patch, gel or spray. These methods are known as transdermal oestrogen because they are absorbed through the skin, bypassing the liver and leading to fewer side-effects. Oestrogen is also available as an oral tablet, though this is less common these days as there is a small risk of clot associated with it.

The progesterone part of combined HRT can be delivered as an oral tablet, or as a progestogen via the Mirena® coil. This is a T-shaped device inserted into the uterus that releases a type of progestogen, which can also be used as a long-acting contraceptive.

Testosterone is used as a cream or gel.

Benefits: why should I take HRT?

Your symptoms will subside – symptoms should improve within a few months (and if they don’t, speak to your health professional about adjusting the dose or method of delivery).

Women will often describe the effect of hitting on the right treatment as like a fog lifting from their eyes. They tell me they have renewed energy and are able to exercise after many months or even years of avoiding the gym or exercise classes.

As their mood improves so do relationships with loved ones and work colleagues. And improved self-esteem can lead to healthier lifestyle choices: where once they found solace in comfort food or alcohol at the end of a hard day, they now have a zest for life they thought had gone for good.

But HRT is not just beneficial in tackling the immediate symptoms; it also safeguards a woman’s future health, including:

Some studies show HRT can also reduce the risk of developing Alzheimer’s disease, osteoarthritis, depression, type 2 diabetes, and bowel and other cancers.

Women who have had a hysterectomy and take oestrogen-only HRT have been shown to have a lower risk of breast cancer.

Women who take any type of HRT have a lower risk of dying from breast cancer.

Model of a woman's reproductive organs with a sign saying HRT

And what about the risks?

HRT has been in use for half a century, but damaging headlines in the early 2000s meant prescriptions plummeted and many women stopped taking HRT altogether.

A 2002 study suggested there was an increased risk of breast cancer and cardiovascular disease in women who took combined HRT. But there are important points to make here: first the women took an older type of oral oestrogen and progestogen. Second, the risk they found was very low and not statistically significant. The National Institute of Health and Care Excellence (NICE) states the risk as:

  • HRT with oestrogen alone is associated with no, or reduced, risk of coronary heart disease.

  • HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease.

  • HRT with oestrogen alone is associated with little or no change in the risk of breast cancer.

  • HRT with oestrogen and progestogen can be associated with an increase in the risk of breast cancer.

It’s completely understandable why headlines on HRT and breast cancer caused so much alarm, but there are multiple reasons – unrelated to taking HRT – why women develop breast cancer. These include:

All these factors are associated with a higher risk of developing breast cancer than the risk of taking any type of HRT. Risk of breast cancer with any type of HRT is either non-existent or is very low.

Women unsure about HRT may be increasing their personal risk of breast cancer through unhealthy lifestyles: women will tell me how before HRT they lacked energy to exercise, used alcohol to help them get to sleep or had put on weight from comfort eating and lack of movement.

The NICE guidelines on menopause are clear: for the vast majority of women, the benefits of taking HRT far outweigh the risks.

I want to try HRT. What are my options?

Don’t wait for symptoms to become unbearable before seeking help. Make an appointment to see your GP, and ask if someone has a special interest in menopause at your surgery so you see the most appropriate person. Before you go, arm yourself with the facts by reading up on the menopause and make a list of your symptoms and their severity to bring along to the appointment – write them down or log them in an app such as Balance. This will help build up a full picture of how the menopause is affecting your quality of life.

Menopause treatment is an individualised thing, so you should expect a conversation around your symptoms, medical history and preferences.

Be clear that you want to be prescribed HRT and if you don’t feel you are being listened to, push for a second opinion. Your health and wellbeing is your priority, and it should be for your health professional too.

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Dr Louise Newson | 11 October 2021