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The Menopause Exchange Blog

HRT: MAKING A DECISION

National Institute for Health and Care Excellence (NICE) guidance on the menopause, which was published in 2015, recommended that women who are experiencing menopausal symptoms shouldn’t ‘suffer in silence’, and that a range of treatment options, including HRT, are available and can help. It’s difficult to decide whether or not to take HRT, especially because there are so many myths and misconceptions about its safety, following the publication of the UK’s Million Women’s Study and the US Women’s Health Initiative in the early 2000s. This article aims to inform you about the benefits and potential risks of taking HRT before you make the final decision with your doctor or nurse. The use of HRT is a personal choice and, for many women, it markedly improves flushes and sweats. However, not all women can take HRT or choose it as an option, so it’s important to discuss the pros and cons with a healthcare professional.

This article was included in issue 77 (summer 2018) of The Menopause Exchange newsletter.

Benefits of HRT
There’s clear evidence that HRT offers a number of health benefits. HRT is the best treatment for troublesome hot flushes and night sweats, reducing these symptoms by up to 87%. HRT may reduce mood swings and tiredness, along with improving your libido (sex drive). It can have local effects on your urogenital system, improving vaginal dryness and decreasing urinary frequency and urinary tract infections.

HRT has long-term benefits as well, helping to protect against osteoporosis (thinning of the bones) and improve muscle strength and muscle/joint aches. It has been shown to reduce the risk of bowel cancer and improve cognition. Recent studies suggest HRT may also help to prevent heart disease in women who have experienced an early menopause. Studies describe a ‘window of opportunity’: starting HRT within 10 years of the menopause reduces the incidence of heart disease by 50%.

Potential risks
Despite HRT reducing the risk of heart disease in younger women, when HRT is started (or restarted) in women over 60, their risk of heart disease increases. Heart disease is more common in women after the menopause when oestrogen levels fall, resulting in a furring up of their arteries. This is made worse by smoking, being overweight or obese and having high cholesterol. If these risk factors are present, a non-oral HRT preparation, such as a patch or gel, may be a safer choice.

The risk of stroke is very low in women under 60. There may be a small increased risk of stroke in women taking oral HRT, so healthcare professionals should prescribe the lowest effective dose that achieves symptom relief. Additional risk factors for stroke include smoking, high alcohol intake, high blood pressure, obesity, diabetes and high cholesterol. Non-oral HRT (patches or gels) don’t increase the risk of stroke, so these may be recommended for women who have a higher risk of stroke, as mentioned above.

One in eight British women develop breast cancer during their lifetime. Many women wonder whether taking HRT could further increase this risk. Women under 50 using HRT, and women taking only oestrogen replacement therapy following a hysterectomy, appear to have no increased risk of breast cancer. It’s thought that the progestogen in combined HRT increases the risk of breast cancer if it’s taken for at least five years in women over 50. The risk then increases with the length of use and falls back to the same level of risk as non-users when HRT has been stopped for five years or more. Overall, the risk is small and comparable to the risk of breast cancer in women who are obese, have had no children, drink two to three units of alcohol a day or experience a late menopause.

The risk of developing a blood clot in the leg veins (called deep vein thrombosis) and/or the lungs (pulmonary embolism) is low in young, active women with a normal body mass index (BMI). If a woman has an increased risk of developing a blood clot (due to a previous blood clot, first degree relative who has had a blood clot, being obese, immobility or an inherited blood clotting disorder), she should seek specialist advice. In some cases, she may be offered a low dose non-oral form of HRT.

There may be a small increased risk in developing ovarian cancer when taking HRT. If 1000 women start HRT at the age of 50 and take it for five years, there may be one extra case of ovarian cancer. From current evidence, if cyclical HRT is used (oestrogen with progestogen taken for 12 to 14 days a month) for over five years, there may be a small increased risk of endometrial cancer. However, women taking continuous combined HRT (oestrogen and progestogen continuously) have a much lower risk of endometrial cancer than the general population. For this reason, doctors will routinely prescribe or switch women to a continuous combined HRT once they’re postmenopausal.

A doctor may be unable to prescribe HRT in women with contraindications, which include current breast cancer, a strong family history of breast cancer and recent heart disease. In these situations, the doctor will discuss alternative treatment options and lifestyle changes. In more complex cases, women can be referred to a specialist menopause clinic.

Conclusion
HRT is the most effective treatment for menopausal symptoms and can have a positive impact on a woman’s quality of life. However, every woman is unique. It’s important that women have access to current information about HRT and are given the opportunity to balance the benefits and risks before making an informed decision. Most women can be reassured that HRT is safe when used for the shortest time needed to control their symptoms at the lowest effective dose.

About the authors
Dr Katherine Gilmore is a specialty registrar in Community Sexual and Reproductive Health at the New Croft Centre integrated sexual health service in Newcastle upon Tyne. Dr Diana Mansour is a consultant in community gynaecology and reproductive healthcare and Head of Clinical Service for Sexual Health in Newcastle upon Tyne. Her areas of expertise include menopause management and the prescribing of HRT to women with complex medical needs.

Created Summer 2018

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