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In 2015, the National Institute for Health and Care Excellence (NICE) in the UK published guidelines to help doctors provide individualised care to menopausal women. Treatment options for troublesome menopausal symptoms include hormone replacement therapy (HRT) or non-hormonal alternatives.

This article was included in issue 70  (autumn 2016) of The Menopause Exchange newsletter.

The use of HRT for menopausal symptoms plummeted following large research studies at the beginning of this century. But reanalysis of some of these results and further clinical experience has led to increased HRT prescribing again.

Every woman should consider the benefits and risks of HRT carefully and decide whether to take it. For women who experience a premature (early) menopause, the benefits of taking HRT (especially for bones and heart health) far outweigh any potential risks.

Do you need HRT?

The average age of the menopause is 51 in the UK, but some women may experience a premature menopause in their 30s or 40s. For most women, menopause isn’t an illness, but a phase of natural transition in later life. Sometimes this change can be associated with symptoms such as hot flushes (suddenly feeling hot and going red in the face), bouts of sweating during the day and night and a dry and uncomfortable vagina, which may make sex painful. Other symptoms include tiredness, irritability, trouble sleeping, joint or muscle aches, low mood, less interest in sex and skin/nail changes.

Not every woman who experiences menopausal symptoms needs treatment. Some women find their symptoms don’t bother them much, while others find them very distressing and affecting their quality of life. Most symptoms will pass within two to five years, although vaginal dryness is likely to get worse if untreated.

Which HRT and what dose?

HRT consists of oestrogen, either alone or in combination with progesterone or therapy with other drugs such as tibolone. Women who have had a hysterectomy (removal of their uterus) can take oestrogen-only HRT (without progesterone) as there’s no chance of getting endometrial cancer. Common brand names of oestrogen-only HRT are Premarin, Estraderm MX and Evorel.

Women with an intact uterus need to take a combination of oestrogen and progesterone as part of HRT. Taking oestrogen alone can increase the chance of getting cancer of the uterine lining (endometrial cancer), whereas adding progesterone to oestrogen reduces this risk. Some common brands of combined HRT are Evorel Sequi, Evorel Conti, Nuvelle Continuous, Premique, Cyclo-Progynova, Kliovance, Kliofem and Prempak-C.

Cyclical HRT is often prescribed for women who are having menopausal symptoms but still have periods or for those who have stopped having periods for less than one year. Continuous HRT, oestrogen and progesterone, taken together daily (one a day) for 28 days (no withdrawal bleeds), is more suitable for women who haven’t had periods for more than one year.

Which form?

HRT is available on prescription in several different forms: as a skin patch, tablet, gel, implant, vaginal ring, progestogen (which has progesterone-like activity) releasing uterine coil and vaginal cream or pessary. Some forms work best for certain symptoms.

Transdermal oestrogen (patches and gels) is associated with fewer risks than oral HRT, so this may be preferable for many women. It’s also of benefit for women with diabetes, hypertension and other cardiovascular risk factors especially with advancing age. Low-dose vaginal oestrogen preparations can be used long-term in symptomatic women. There’s usually no requirement to combine this with systemic progestogen treatment for endometrial protection.

Discussing the side effects

Women react differently to HRT, so no one preparation is better than any other. Some common HRT side-effects include:

  • Oestrogen-related – breast tenderness, leg cramps, skin irritation, indigestion, nausea and headaches.
  • Progesterone-related – premenstrual syndrome (PMS)-like symptoms, fluid retention, bloating, backache, depression, mood swings and pelvic pain.

You can reduce nausea by taking an HRT tablet at night with food instead of in the morning, or by changing from tablets to another form. There’s no evidence of weight gain with HRT.

Monthly sequential preparations should produce regular, predictable and acceptable period-like bleeds. Erratic breakthrough bleeding is common in the first three to six months of continuous combined and long-cycle HRT regimens (with no regular period-like bleeds).

Several risks are associated with HRT. For most women, any increased risks are very small, but women should talk to their healthcare professional to weigh up their own risks and benefits. The main risks of HRT are blood clots in veins and lungs, stroke, cardiovascular events, gallbladder disease, breast cancer, ovarian cancer and endometrial cancer.

Do I need tests first?

You don’t usually need any tests before starting HRT. Your healthcare professionals will discuss your age, symptoms and medical conditions before looking at the risks and benefits of HRT that are specific to you. However, you may need tests if there’s a sudden change in your menstrual pattern (e.g. heavy periods), you have a personal or family history of blood clots, a high risk of breast cancer or risk factors associated with cardiovascular disease.

Monitoring HRT

Women are generally asked to attend for a follow-up consultation about three months after starting HRT. Most symptoms are likely to have responded to oestrogen in this time period.

About the author

Dr Vikram Talaulikar is an Associate Specialist in reproductive medicine at University College London Hospital. His specialist interest is the menopause

Created autumn 2016

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