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Many women go through the menopause around the age of 50 or 51 without any problems at all. But some women may struggle with symptoms, leading them to consult their GP or another healthcare professional to discuss whether HRT is right for them.

This article was included in issue 85 (summer 2020) of The Menopause Exchange newsletter.

The National Institute for Health and Care Excellence (NICE) in the UK provides national guidance and advice to improve health and social care. Their November 2015 menopause guidance lists the following menopausal symptoms:

  • hot flushes and night sweats
  • menstrual cycle changes, with irregular periods or no periods
  • sleep problems, low moods and feelings of anxiety
  • vaginal dryness and bladder problems
  • sexual problems with loss of libido

Deciding on HRT
If you go through a natural menopause (any time between the ages of 45 and 55), you may be offered a trial of HRT based on your symptoms and you may not need to have any blood tests. If you also have any medical conditions, such as thyroid problems, high blood pressure or diabetes, these conditions must be controlled before you can try HRT.

The exception to this will be if you go through an early menopause (before the age of 45). If so, you’ll need to have a hormone blood test to check your Follicle Stimulating Hormone (FSH) levels twice, four to six weeks apart. If your FSH levels are high in both of these blood tests, you’ll be considered to have gone through the menopause and will be offered HRT after a full medical history and after assessing whether or not HRT is right for you (called an individualised risk benefit evaluation).

If you have gone through an early menopause, HRT will be suitable until you reach 50 or 51, the age of a natural menopause. You’ll benefit from having oestrogen hormones to this age, as these would have come from your ovaries naturally if your menopause hadn’t started early. Using HRT after 51 will be based on risk benefit evaluations every year with your GP or healthcare professional.

If you have a hysterectomy, you’ll go through a surgical menopause. If your uterus (womb) is removed during surgery but you keep your ovaries, you may not have typical menopausal symptoms, such as hot flushes and night sweats, straightaway. But if your ovaries are removed at the same time as your uterus, you’ll be advised to start on oestrogen replacement therapy (ERT). If you have a hysterectomy, you only need ERT, not HRT containing oestrogen and progestogen.

Monitoring effects
Before you start on HRT, you should be told about any possible initial ‘expected’ side effects, such as breast tenderness or pain, breast size increase and a feeling of some changes in your body. These side effects should settle after around four to six months.

You should keep a diary of your bleeding patterns. Then at your next review appointment with your healthcare professional you can discuss whether you’ve settled or are slowly settling on HRT, or whether you need some changes to the type of the hormones it contains (oestrogen or progestogen).

Once you’re settled on HRT, you should have an annual risk-benefit evaluation with your GP or medical specialist to decide how long you should stay on HRT. With annual assessments, the decision to stay on HRT or to stop HRT will be based on any new research during the previous year. At this appointment, you should mention if you’re worried about anything, especially if you’ve read about some of the new research in the media.

HRT choices
HRT is available in many different forms and can be used as tablets or capsules, patches, gels and spray. If you only have vaginal dryness (atrophy), you may find that using vaginal oestrogen replacement therapy (vaginal ERT) is enough to help ease your symptoms. Vaginal ERT is available as vaginal creams, vaginal tablets, vaginal ring, vaginal gel and pessary. Some women taking ‘monthly bleed’ or ‘no bleed’ HRT may also need extra vaginal ERT. If you have a loss of libido that’s still present after your settling phase on HRT, your healthcare professional may discuss whether adding in testosterone replacement is suitable for you. If you have a loss of libido due to partnership issues, you may find that psychosexual counselling can help.

Settling time
Women settle differently on HRT, and some settle faster than others. If your symptoms are due to the lower hormone levels that occur during the menopause, you should find that your symptoms are eased very quickly.

If you’re on a ‘monthly bleed’ type of HRT, you should settle on a monthly bleed pattern by three or four months. If you’re on ‘no bleed’ HRT, which is only given to postmenopausal women (who have been naturally bleed free for a year or more before starting on HRT), you’ll be advised to keep a bleed diary for up to six months. Some women settle on this straightaway, and some keep on getting breakthrough bleeds for up to six months. If your bleeding episodes are getting less often and lighter, you’re considered to be slowly settling on your ‘no bleed’ HRT. But if your bleeds are getting heavier and are continuous, you’ll need to be investigated for any other cause, such as polyps, fibroids or uterine cancer.

If your bleeding patterns are changing, your healthcare professional may consider making some changes to your HRT. It may be that a change in the type of oestrogen or progestogen may suit you better. If you have any medical conditions or are a ‘complex case’, you may need to take certain types of HRT and change the hormone types, based on current research. Currently there are HRT product shortages in the UK, and a change in HRT may be necessary.

About the author
Dr Nuttan Tanna is a pharmacist consultant in women’s health. She runs weekly menopause and osteoporosis medication management clinics at Northwick Park Hospital, in Harrow, Middlesex, and is also actively involved in education and research.

Created Summer 2020 

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