Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a medicine used to relieve menopausal symptoms by replacing hormones that reduce over time as you approach menopause. They essentially top up the hormones that the body stops producing during the menopause.

Menopause and perimenopause symptoms can have a big impact on the quality of your daily life, including relationships, social life, family life and work. Some people may experience a number of symptoms, and some may experience none. The symptoms can start several months or years before your period stops. This is known as perimenopause. Menopause occurs naturally in a woman’s life where menstruation stops permanently due to loss of ovarian follicular activity. Women have a limited number of eggs (oocytes) and over times these decline with each menstrual cycle. The menopause if characterized by the eventual depletion of the egg store. Menopause occurs with the final menstrual period and is officially diagnosed after 12 months of no periods. In the UK the women tend to hit menopause at 51 although this can vary between different ethnicities.

Menopause symptoms can start several months or years before your periods stop. The first signs of perimenopause in some women are the change in the normal patterns of your period. The symptoms can last from months to years (average 5-7 years but some women continue to experience symptoms for 10-15 years) and can change over time. The most common symptoms include:

• Changes to your mood: low mood, anxiety, mood swings and low self esteem.
• Problems with memory or concentration (brain fog)
• Hot flushes
• Difficulty sleeping (night sweats) which can make you feel irritable and tired during the day
• Palpitations
• Headaches and migraines
• Muscle aches and joint pains
• Changed body shape and weight gain
• Skin changes including dry and itchy skin
• Reduced sex drive
• Vaginal dryness and pain, itching or discomfort during sex
• Recurrent UTIs.

The choice of HRT depends on your age, symptoms, medical health, and preference. There are 2 main hormones used in HRT medication:

1. Oestrogen – estradiol, estrone and estrone.
2. Progesterone – dydrogesterone, medroxyprogesterone, norethisterone and levonorgestrel or a micronized progesterone (Chemical identical to human hormone)

They can be taking as combined HRT which contain both the hormones or just oestrogen only HRT. Oestrogen only HRT is recommended for patients who have no womb/uterus.

Hormone replacement therapy comes in various different forms each carrying their own benefits and weaknesses.

In addition to the type of HRT treatment you need to consider the treatment routine of HRT. This depends on whether you are in the early stages or have had menopause symptoms for a while. The two types include:

• Cyclical/Sequential HRT: Recommended for women taking combined HRT who are still having their periods. You can take it monthly where you take oestrogen every day and take progesterone for the last 10-14 days of your menstrual cycle. This is recommended for women with regular periods. Or 3 monthly HRT where you take oestrogen everyday and progesterone alongside it for 10-14 days every 3 months. These are for women who have irregular periods and you may notice having a period every 3 months.
• Continuous combined HRT: Recommended for women who are postmenopausal (no periods for at least 1 year). This involves taking both oestrogen and progesterone daily without a break.
• Oestrogen only HRT is also usually taken daily without a break. Oestrogen HRT is recommended for patients who have no womb/uterus (hysterectomy).

Women experiencing menopausal symptoms can start HRT medication straight away usually without having any tests first. Normally you would start on a lower dose which may be increased over time. This is to manage some of the side effects and allow the body to respond to changes to hormone levels. You would normally trial treatment for 3 months to see if it helps. If it doesn’t its worth contacting The Family Chemist clinician who may suggest changing the dose or changing the type of HRT you’re taking.

Patients suffering predominantly from hot flushes/night sweats/mood changes.

With a uterus: Combined (with oestrogen and progesterone) tablets and patches (Evorel Conti, Evorel Sequi)

Without a uterus: Oestrogen only tablets (Elleste Solo, Zumenon, Premarin), patches (Evorel, Estradot, Elleste Solo MX), vaginal gels (Ovestin, Gynest), vaginal tablets (Vagifem), pessary and vaginal rings.

Women under 50 years of age: HRT or a combined oral contraceptive as an alternative option.

Women with vaginal irritation, discomfort, burning, itching and/or dryness, reduced libido, increased passing urine and urgency, and recurrent urine infections.

Low dose vaginal oestrogen (Vagifem or Ovestin/Gynest) and continue treatment if needed to relieve symptoms.

Vaginal oestrogen is the safest and it acts on the vagina and not your whole body like the patches or oral tablets. It doesn’t need progesterone because it doesn’t affect the womb. Vaginal oestrogen also improves vaginal dryness the most.

HRT can be continued if benefits of symptoms control and improved quality of life outweigh any risks. Patients with hot flushes or night sweats tend to the medication for 2-5 years but some women may need it longer. Patients with premature menopause should take HRT up to 51 years and then reassess the benefits against risk.

HRT should be gradually reduced over 3-6 months but can be stopped suddenly depending on the patients circumstances. Symptoms may recur shortly after stopping especially if HRT is stopped suddenly. If symptoms do recur and become troublesome then contact your GP for a trial of non hormonal treatments.

In most cases the benefits of HRT far outweigh the risks. The risks depend on the type of HRT you use, how long you take it and your medical history.

The benefits of HRT include:

Reduced menopausal symptoms (hot flushes, night sweats, improve sleep: higher energy levels and improved mood, relieves vaginal dryness, improves urinary symptoms, improve libido and reduce pain during sex, improve skin condition, improve joint pain and help with dry eyes) therefore improving quality of life.

Reduced risk of fractures: HRT reduces loss of calcium and helps maintain bone mineral density (strength). HRT promotes new bone growth and prevents chance of osteoporotic fractures.

Improved muscle mass and strength

Reduced risk of cardiovascular disease and osteoporosis: Relaxes smooth muscles and therefore lowers blood pressure. HRT prevents build up of fatty deposits on the blood vessels, encourages cholesterol to increase HDL and lower LDL and therefore reducing risk of heart attacks and strokes.

The risks of HRT include:

Venous thromboembolism (VTE): Blood clots. These risks are increased when taking oral medication (although still small). Evidence suggests patches have no greater risk than patients not using medication.

Heart disease and stroke: HRT with oestrogen alone is associated with no or reduced risk of heart disease. Combined HRT (oestrogen and progesterone) carry little or no increase in the risk of heart disease. Risk of stoke in women under 60 is very low. Oral oestrogen (not patches) are associated with a small increase in the risk of stoke). HRT does not increase cardiovascular disease risk whens tarted in women younger than 60 years.

Breast Cancer: Oestrogen only HRT is associated with little or no increased risk. Combined HRT is associated with increased risk of breast cancer and is dependent on the duration of treatment (reduces after stopping HRT). The risk is slightly lower with cyclical compared to continuous HRT.

Here’s some information extracted from MHRA:

In the UK about 1 in 16 women who never use HRT are diagnosed with breast cancer between the ages of 50

and 69 years. This is equal to 63 cases of breast cancer per 1000 women.

Over the same period (ages 50–69 years), with 5 years of HRT use, the study estimated:

• about 5 extra cases of breast cancer per 1000 women using estrogen-only HRT
• about 14 extra cases of breast cancer per 1000 women using estrogen combined with progestogen for part of each month (sequential HRT)
• about 20 extra cases of breast cancer per 1000 women using estrogen combined with daily progestogen HRT (continuous HRT)

These risks are for 5 years of HRT use. The numbers of extra cases of breast cancer above would approximately double if HRT was used for 10 years instead of 5.

Endometrial Cancer: women who have not had hysterectomy and are postmenopausal are at increased risk of endometrial cancer if they take oestrogen only HRT

Ovarian Cancer: Increased risk is every small (0.4 increased risk per 1000 women compared to someone not taking HRT)

Like all medication HRT medications do carry risk of some side effects. Any side effect usually improve over time so I would recommend to persevere for at least 3 months, unless the side effects are severe or uncommon. The most common side effects of oestrogen include:

• Bloating (HINT: take with food)
• breast tenderness or swelling (HINT: eat a low fat high carb diet)
• swelling in other parts of the body
• feeling sick (HINT: take with food)
• leg cramps (HINT: regular exercise and stretch)
• headaches
• indigestion (HINT: take with food)
• vaginal bleeding
• headaches or migraines
• mood swings
• depression
• acne
• tummy (abdominal) pain
• back pain

If side effects persist after 3 months or become severe then consult your GP or The Family Chemist clinician.

HRT treatment isn’t right for everyone. HRT may not be for you if you have the following medical conditions:

• Current, past, or suspected breast cancer.
• Known or suspected oestrogen-dependent cancer.
• Undiagnosed vaginal bleeding.
• Untreated endometrial hyperplasia.
• Previous idiopathic or current venous thromboembolism (deep vein thrombosis or pulmonary embolism), unless the woman is already on anticoagulant treatment.
• Active or recent arterial thromboembolic disease (for example angina or myocardial infarction).
• Active liver disease with abnormal liver function tests.
• Thrombophilic disorder.
• Porphyria cutanea tarda.
• Diabetes mellitus (increased risk of heart disease).
• Factors predisposing to venous thromboembolism.
• History of endometrial hyperplasia.
• Migraine and migraine-like headaches.
• Increased risk of breast cancer. See the CKS topic on Breast cancer – managing FH for more information.

The list above is not complete and you must fill in the questionnaire accurately and completely to allow The Family Chemist clinician to safely prescribe you the correct HRT.

Rock My Menopause website (www.rockmymenopause.com) has a variety of factsheets and podcasts on various aspects of menopause.

Menopause Matters (www.menopausematters.co.uk) provides information on the menopause, menopausal symptoms, and treatment options.

Women’s Health Concern (the patient arm of the British Menopause Society, website available at www.womens-health-concern.org) has a range of factsheets and an email advice service.

The Royal College of Obstetricians and Gynaecologists (www.rcog.org.uk) has various patient leaflets in the section on Menopause and women’s health in later life.

The Daisy Network (www.daisynetwork.org) is a nationwide support group for women diagnosed with premature ovarian insufficiency or premature menopause.

The NHS leaflet Menopause.