The Menopause Exchange Blog

COMING OFF HRT

Every woman is different. Not all women need HRT and of those women who would benefit from HRT, not all of them choose to use it. For those who do use HRT, there will always be a question of when and how to stop.

This article was included in issue 71 (winter 2016/2017) of The Menopause Exchange newsletter.

Sometimes this question is forced by a drastic change in circumstances, such as a diagnosis of breast cancer. Often though, it is a recommendation by a healthcare professional who remains influenced by the media suggestion that HRT should only be taken for five years. This was never an expert recommendation, however. Ideally, stopping HRT should be a decision made with the help of a healthcare professional who knows the evidence basis and is familiar with national advice. Ultimately, it should be a voluntary decision taken by women themselves.

Symptom check
One of the great myths of the menopause is that HRT simply puts off the inevitable. This isn’t true. The evidence from recent research studies is that menopause-related symptoms can last for many years and that if you stop taking HRT, the symptoms that you would have had anyway will simply reveal themselves.

Clearly if you take HRT for two years and your symptoms are scheduled to last for seven years, then after the two years the hot flushes, sweating and miseries will return. The length of time that menopause symptoms last varies greatly. While the average length may be three to five years, women can continue to have hot flushes through their 60s and even their 70s. This is more likely if the menopause results from the surgical removal of both ovaries.

Lowering the doses
Some women will decide to wait until they retire before trying to stop HRT, as the need to cope and multitask will be reduced by then. As menopause experts, we find that as women get older they simply don’t need the doses they did previously to keep on top of their symptoms. There has been some research on this topic but it isn’t definitive. What I suggest to women is that after several years of being well, a dose reduction using the same constituents would be advisable. For example, reducing the tablet dose from continuous 2mg oestradiol with 1mg norethisterone to continuous 1mg oestradiol with 0.5mg norethisterone is often just as effective in a woman’s late 50s. We know that only very small doses are needed to protect bone so this benefit isn’t lost or reduced. The principle is always to use the lowest dose that works (with the emphasis on getting the desired effect).

It’s often difficult to stop HRT if a woman is still close to her last natural period as that is when her symptoms are often at their worst. Stopping a cyclical regimen is therefore uncommon. If this does occur, then the progestogen component is still needed for 12 to 14 days of a 28-day cycle. Usually women will have switched from a predictable bleed regimen to continuous progestogen as this provides best protection for their uterus and usually no bleeding. After two to five years, they may be able to reduce the dose and after a further two to five years will often decide they would like to see if they can then manage without it.

Once a lower dose combination is already being used, it’s less challenging to stop. The options are to stop abruptly or wean off. If using tablets, then the strength of the tablet can be reduced if a lower dose version is available, a tablet splitter can be used or the tablets could be taken on alternate days. If after three months, the symptoms aren’t bothersome then the HRT can be finally stopped.

Changing the route
As well as lowering the dose, there’s the consideration of whether the route of delivery is appropriate. As clotting risks (deep vein thrombosis (DVT) and stroke) rise with age, there’s a point at which a further, even though small, increase in risk due to HRT isn’t desirable.

To avoid clotting effects from taking tablets, which are absorbed into your gut and through your liver, a doctor may advise a change from tablets to patches or gel. If a woman using patches or gel still has her uterus, it’s important to ensure that the progestogen dose is enough to protect it. Combined patches can be cut in half to halve the dose, although technically this is off label (not an official recommendation).

Gel is available in both pump delivery and very low dose sachets, which allow effective dose reduction. No progestins (natural progesterone or synthetic variants) are available as a gel, but oral, vaginal or intrauterine options are available. Women should discuss with their healthcare professional which would be most suitable for them. If a hormone delivery coil is used to protect your uterus, the expert advice is that this will provide adequate protection for five years and then need replacing. If coming off implants, women should allow at least two years’ use of progestogen after the last implant.

Symptom return
If your symptoms return, I would suggest that you revert to the lowest dose of HRT that helped. I would go back over the whole risk analysis process to ensure that an appropriate HRT combination in terms of dose, route and exact type of the hormones had been chosen. If several years have elapsed, it may take two to three months to restore stability. I would wait one to two years before attempting any dose reduction again.

Long term use
There’s no official limit to how long HRT can be used for. Official guidance sensibly recommends an annual review. This is an opportunity to revise the balance for each individual woman. While the decision whether or not to continue to use HRT should be made by the woman herself, the doctor needs to maximise the benefit and minimise real or potential harm.

Some women tell me that they will take their HRT to their graves. Provided that this is a fully informed decision, then I would argue that they should be allowed to make this choice. If they are fit and fully active and need little or no other medication, I am happy for women in their 80s to continue with low doses of an HRT gel or a patch. Quality of life is paramount.

About the author

Dr Sarah Gray is a GP in Cornwall with 30 years of specialist experience in menopause. Her NHS clinic has closed for financial reasons, but she still sees patients privately.

Created winter 2016/2017

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