What is hormone replacement therapy and why is it used?
As women go through menopause, production of the female sex hormones (oestrogen and progesterone) is dramatically reduced, resulting in low levels of the hormones in the body. This means that many women experience unpleasant symptoms as a result of the decreased levels of these hormones, particularly oestrogen.
Hormone replacement therapy (HRT) that is prescribed by your doctor replaces the body’s female sex hormones, oestrogen and progesterone.
The levels of another hormone, testosterone, gradually decline over the course of a woman’s life, and more quickly in women who have had both ovaries removed. Some women also choose to have supplemental testosterone in addition to their HRT therapy, but the role of testosterone in menopause treatment remains an area of debate among doctors.
There is an increasing range of alternative treatments for menopause symptoms on the market, but despite this, the HRT that is available on prescription from your doctor remains the standard treatment for relieving the symptoms of the menopause that many women find troublesome.
In Australia, nearly half of menopausal women use HRT in the early years of the menopause.
There are several reasons why it can be advantageous to put some oestrogen back into your body. As well as helping to treat the immediate symptoms of the menopause (such as hot flushes, night sweats, insomnia, mood swings, a dry vagina and bladder problems), oestrogen replacement appears to guard against osteoporosis by preventing bone loss. It also helps the skin to maintain its thickness and elasticity. It may also reduce the risk of colon cancer.
Findings of a large US study in 2002 have highlighted the fact that there are some risks associated with long-term use of combined (oestrogen + progestogen) HRT including a slightly higher risk of breast cancer, stroke, heart disease and thromboembolism (blood clot formation) compared to not taking combination HRT. Your doctor will be able to advise you on the risks and benefits of HRT and whether it is right for you.
You should be aware that HRT is not a ‘quick fix’ solution to the challenge of menopause, but only one aspect of its overall management. You should make sure you take regular exercise, eat a varied diet low in fat and high in fruits and vegetables, and make time for relaxation.
HRT is not the same as birth control pills and it will not stop you from falling pregnant. If you are still getting your periods you should discuss with your doctor whether or not you still need to use contraception.
What does HRT involve?
HRT can be given in various ways and there are many different formulations and combinations of hormones available. Depending on your medical history your doctor may suggest one of the following.
* Cyclic combined treatment. This is usually given if you are still getting periods or have not yet had a clear year without periods. It involves daily oestrogen and 10-14 days per month of progestogen, a synthetic formulation of progesterone. Because this mimics your normal menstrual cycle, you will probably get some bleeding with this treatment — like a period. The progestogen is given to prevent cancer of the womb (uterus). This is because if oestrogen is given continuously without a progestogen to balance it there is an increased risk of cancer of the womb.
* Continuous combined treatment. This is usually prescribed for women who have had more than a clear year without periods. It involves oestrogen and progestogen daily, every day, but the dose of progestogen is lower than for cyclic HRT. You should not experience bleeding with this treatment after therapy is established, which may take 3-6 months.
* Continuous oestrogen alone. Treatment with oestrogen alone is normally reserved for women who have had a hysterectomy (removal of their uterus), because oestrogen without the balancing effect of a progestogen has been associated with an increase in cancer of the lining of the uterus. It is sometimes called ‘unopposed oestrogen replacement therapy’.
* Testosterone. Sometimes this is used in addition to HRT to help women with a reduced sex drive, although some controversy exists among doctors about the merits of this treatment.
* Tibolone. Tibolone (Livial) is an alternative to traditional HRT for women who have gone through the menopause. It acts like oestrogen on some body tissues, but like progesterone and testosterone on others. It is said to cause less breast tenderness than some HRT medications do and may help women with a loss of sex drive. It does not cause period-like bleeding when used in women after the menopause. Doctors do not recommend it if you are still having your periods.
How long will I need to take HRT?
For the relief of menopause symptoms, doctors usually suggest taking the lowest dose for the shortest amount of time necessary to control your symptoms. However, it depends on your individual needs. It is now recommended that HRT be used for short-term (2 to 5 years) treatment of menopausal symptoms, as this length of treatment is not associated with an increased risk of breast cancer. Longer term use is possible if you and your doctor believe that the benefits outweigh the risks. Talk to your doctor about the benefits and risks of long-term HRT, and whether or not long-term HRT is suitable for you.
How can HRT help me?
HRT has been shown to control hot flushes and night sweats effectively. It improves the elasticity of skin and helps skin to keep its thickness. HRT also helps to prevent the thinning of vaginal walls, which can lead to pain and inflammation. It may also improve mood and feelings of depression. Some women also find that their short-term memory and clarity of thought improves while they are on HRT.
How is HRT taken?
There are several different ways of taking HRT. Your doctor will choose the best one for you based on your medical history and potential for side effects. However, you may need to try different combinations before you find one that suits you.
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Tablets
These are still the most popular and widely available method of HRT. There are several permutations of HRT tablets, and there are also several dosage ‘strengths’ to suit different women.
You may take an oestrogen tablet every day and a progestogen tablet every day continuously (e.g. Provelle-28) or an oestrogen tablet for 14 days followed by a combined oestrogen and progestogen tablet for the next 14 days (e.g. Climen 28, Femoston, Premia 5) or both hormones may be combined into a single tablet (e.g. Kliovance, Kliogest, Premia Low, Premia 2.5 Continuous, Premia 5 Continuous), depending on the product.
In addition, there are packs of tablets with a set number of oestrogen tablets which are followed by combined tablets which are then followed by a week-long gap without tablets (e.g. Climen). There are also packs of tablets with a set number of oestrogen tablets which are followed by combined tablets then by oestrogen tablets again for a 28-day cycle (e.g. Trisequens). Most tablets come in easy-to-follow calendar packs.
* Transdermal skin patches
These are applied every 3-4 days (e.g. Dermestril, Estraderm, Menorest) or every 7 days (e.g. Climara, Femtran). They are applied to your skin and release the hormones into your body slowly over time. Most patches contain oestrogen only but combination oestrogen/progestogen products are available, either in one patch (e.g. Estalis Continuous) or in separate patches which may be supplied in the same pack but are applied at different times of the month (e.g. Estalis Sequi, Estracombi). The patches come in varying strengths, and need to be replaced once or twice a week depending on the product. They may have fewer side effects than tablets because the dose of oestrogen is often lower, but some women may find them irritating to the skin. Oestrogen patches are often a good choice for women who find they get side effects such as nausea from oestrogen tablets.
* Progestogen tablets
Progestogen is available on its own in tablet form (e.g. Primolut N) for use with oestrogen therapy, usually in the last 14 days of the cycle in women who have not had a hysterectomy.
* Oestrogen tablets
Oestrogen is available on its own in tablet form (e.g. Estrofem, Ogen, Ovestin, Premarin, Progynova or Zumenon).
* Oestrogen gel (Sandrena)
This is available in sachets and is helpful for women who cannot tolerate tablets and who do not want to wear a patch. It is rubbed onto the skin once daily.
* Oestrogen nasal spray (Aerodiol)
A nasal spray containing oestrogen that is usually taken once a day.
* Oestrogen implants
Best suited to women who have had a hysterectomy, these are small pellets that are inserted under your skin by your doctor under local anaesthetic. They are usually placed in the fatty tissue in your stomach or buttocks. They are replaced when symptoms return, which is usually every 4-8 months, so you do not need to remember to take tablets or apply patches. You can forget about the therapy until it is time for the pellet to be replaced. Disadvantages include the cost and the fact that if you have problems with the implant it is messy and inconvenient to remove it.
* Intra-vaginal treatments
These include oestrogen creams (e.g. Ovestin), or pessaries (e.g. Ovestin, Vagifem) and are usually prescribed if you are getting localised (confined to one area) menopausal symptoms such as a dry vagina or bladder problems and do not want to take systemic treatment. However, you should be aware that your symptoms may return if you stop the treatment. Generally, oestrogen creams and pessaries are used for limited courses, e.g. 2 weeks to 3 months. If oestrogen is given for 6 months or more, you may need to take progestogen tablets as well to protect your womb from the risk of cancer.
* Herbal HRT remedies
Despite the advertising claims, there is no reliable scientific evidence for many herbal products to show that they give relief from menopausal symptoms. However, black cohosh is one herbal remedy for menopausal symptoms that has shown some effectiveness in scientific trials in providing relief from menopausal symptoms. Be aware that the composition of herbal products in Australia is largely unregulated, and that some herbal products may have adverse effects or interact with prescription medicines.
* Bio-identical hormones (‘troches’)
So-called bio-identical hormones in the form of lozenges or ‘troches’, which are dissolved in the mouth, are prepared by a compounding pharmacist according to a doctor’s prescription. Troches are composed of a mix of hormones, such as a mix of different types of oestrogens and sometimes testosterone. The Australian Menopause Society and the Australian Medical Association warn that, despite marketing claims, using these troches is no safer than using traditional HRT, troches may contain hormones that are not approved for use in Australia, and there are no scientific data to support the safety or effectiveness of troches in relieving menopause symptoms.
Before starting HRT
You should have a full gynaecological examination and blood pressure check. Your doctor might also send you for a Pap smear or mammogram, or a bone density scan if you are considered at particular risk of developing osteoporosis.
What side effects are there?
Some women experience side effects as a result of taking HRT. These include breast enlargement and tenderness, abdominal bloating and fluid retention, nausea, headaches and an aching pelvic area. Side effects may pass with time, or your doctor may need to change the dose or change to another method of treatment. If you are getting unusual bleeding, you should see your doctor straight away. A common worry women have about HRT is that it will make them gain extra weight. Most studies of women taking HRT show either a smaller weight gain than women not taking it or no difference to women not taking it.
Does HRT have any risks?
A large US study in 2002 showed that use of combined HRT (oestrogen + progestogen) for more than 5 years can lead to a slightly increased risk of breast cancer, stroke, heart disease and thromboembolism (blood clot formation). An Australian expert committee of the Therapeutic Goods Administration (TGA) examined these findings and issued a statement advising that short-term use of HRT around the time of the menopause remains an appropriate treatment option, as does continuing combined HRT in women already diagnosed with osteoporosis. However, they suggest that long-term use of combined HRT for disease prevention in general is not justified in the face of these risks. Subsequently, another study — the UK ‘Million Women Study’ — also showed an increased risk of breast cancer in HRT users, although this detrimental effect was shown to wear off a few years after stopping HRT.
You should be aware of these new findings and discuss them with your doctor. If the symptoms of menopause are not really bothering you, and your doctor believes you have a low risk of osteoporosis, HRT may not be necessary for you at all.
Who should not take HRT?
You may not be able to take HRT if you have, or have had, liver disease, high blood pressure, a thrombosis, endometriosis, or a history of breast or uterine cancer.
Your doctor will be able to inform you fully about the risks and benefits of HRT and address any concerns you have. The more you understand, the easier it should be to make informed decisions.
Other current news articles about Hormone Replacement Therapy:
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