Introduction:
Perimenopause is the transition from normal ovulatory menstrual cycle to cessation of ovulation & menstruation: The average age is around 47 years (39 – 51) and usually lasts 4 years (2-8). During this time, periods may become irregular and periods may be missed. Some women need help at this stage.
Menopause: Average age worldwide is around 51 years (45-55) and Is defined as the absence of periods for at least one year. Menopause is the time when the ovaries stop releasing eggs and periods stop. During this time 8 out of 10 women suffer but only 2-3/10 seek help,
Low levels of oestrogen often trigger symptoms with 75% of women in the West suffering hot flushes.
What is Hormone Replacement Therapy (HRT)?
HRT also known as Hormone Therapy (HT) or Menopausal Hormone Therapy (MHT) is the use of hormones, usually oestrogen and progesterone or oestrogen only and sometimes with the addition of testosterone.
HRT is available as tablets, skin patches, gels or nasal spray. Your doctor will guide you to help you choose the best option for you.
HRT provides low doses of oestrogen and progesterone (sometimes with testosterone to improve sex drive, libido, bone health and concentration) to try and replace the levels the body lacks in the post-menopausal period.
HRT is useful for relief of symptoms
- Hot flushes
- Night sweats
- Vaginal dryness
- Can help with mood and libido
A woman should consider HRT if menopausal symptoms adversely affect quality of life and lifestyle changes haven’t helped or can’t be followed. HRT can also benefit those women who are not suffering significant menopausal symptoms but wish to get the benefits of hormone therapy such as cardiovascular protection when stated within ten years of menopause or before the age of 60. However, hormone therapy will not change life circumstances and stress maybe due to other factors, in which situation HRT may not be as helpful as one hoped.
Women need both oestrogen and progesterone if the uterus (womb) is still present (no hysterectomy) as the progesterone (in the form of patch, tablet, injection or coil) is used to protect the lining of the womb from abnormal thickening and womb cancer, if the oestrogen were to be used alone, leading to bleeding.
While oestrogen is the most effective treatment available for relief of menopausal symptoms, most importantly hot flushes, night sweats and vaginal dryness, Hormone Replacement Therapy (HRT) is not for everyone. Side effects of HRT include breast soreness, water retention and vaginal bleeding. Mood changes and bloating are seen more often with the combined preparations. All these symptoms tend to settle within a few weeks.
Lifestyle advice: It is important to encourage women to adopt a healthy lifestyle which includes a whole food plant based way of eating oi the main, undertake regular exercise, aim to be normal weight, ensure adequate sleep, identify and address stress triggers and avoid risky substances such as alcohol and smoking. This will help women to reduce risks of lifestyle diseases such as breast, bowel, womb cancers, osteoporosis, heart disease, diabetes and dementia, the biggest killers for women. A healthy lifestyle will also help women come off HRT when they wish to as their life circumstances change. (see Lifestyle medicine and menopause nutrition leaflets)
Women should be advised to make lifestyle changes alongside starting HRT.
Before starting HRT:
If above the age of 45 years and there is no doubt of the diagnosis and pregnancy is ruled out, then no further tests are needed.
It is advisable to start with the lowest dose of HRT and increase as needed, especially if starting above the age of 60, where studies are still not as robust as in women below this age. However, hormone therapy can still be considered for this age group after a detailed discussion, ideally with a health professional with experience in treating in menopause.
Younger women and those having a surgical menopause often benefit from higher doses which can then be adjusted.
A thorough medical history and appropriate examination and tests will be advised by the GP or specialist (medical doctor or nurse).
The GP or specialist should explain the various preparations, risks and benefits before recommending HRT.
The woman should be aware of family history if possible and mention to the doctor of relevant information, including allergies and medications.
The woman should be encouraged to follow a healthy diet and lifestyle and to avail of the screening programmes as recommended by the NHS such as smear tests and mammograms.
An annual review with GP or specialist is advised after an initial review in 3 months.
While women can take HRT for as long as they find it beneficial, it is prudent to review the situation yearly to help the woman decide if she wishes to continue HRT. If coming off HRT, I have found my patients find it is better to wean off gradually over a period of 6 months in most situations. However, some women may prefer to stop HRT without weaning. Studies haven’t shown benefit one way or the other. If menopausal symptoms return after stopping HRT, women may wish to consider restarting it and, provided they are fully informed of the risks, it should not be withheld.
If a woman is counselled properly of the risks by her GP or specialist and wishes to take HRT for longer, then she should be prescribed HRT.
Advise women to seek urgent medical advice if vaginal bleeding is heavy or unusual or occurs any time after three months of starting HRT.
Different types of HRT
Oestrogen: All types of oestrogen preparations are effective in managing menopausal symptoms of hot flushes and night sweats and should be administered continuously. The GP or specialist will guide a woman so she can choose the HRT best suited for her.
To start with the lowest effective dose of HRT is recommended and the dose can be increased after review, if symptoms are not fully controlled. An exception is young women after a hysterectomy and removal of ovaries, who often need a high dose which can be tapered after a couple of years.
Oestrogen Patches: Transdermal 17-beta oestradiol is body identical and is like the oestrogen made in our body in the reproductive phase and is preferred to tablets, because it is associated with a negligible risk of thrombosis, stroke, and raised triglycerides when compared with oral oestrogens. The transdermal route bypasses the liver and is particularly important in women with abnormal lipid levels or risk factors for thromboembolism.
Oestrogen Tablets: may be prescribed for women with no other risk factors if they prefer tablets to other routes. Most are from plant-based sources except for Premarin (animal source and rarely used)
Oestrogen Gels or Pump ( Body identical) are very popular and are very convenient and transdermal preparations carry the lowest risk of complications or side effects.
Progesterone:
Levonorgestrel Intra Uterine System (IUS): This progesterone hormone containing coil allows the lining of the womb to be protected, provides contraception, especially for women who have been started on HRT because of symptoms but have not completely stopped menstrual cycles. It can be left in for 4 years and is very convenient, as women can then just use oestrogen gel.
Progesterone Tablet (Body identical): Oral natural micronised progesterone is tablet of choice with the lowest risk profile on the heart and breast (200 mg/day for 12 -14 days/month or 100 mg daily). The daily dose is best for women who have stopped their periods and are well into their menopause and younger women who are perimenopausal or recently become menopausal, may have unscheduled bleeding do better with cyclic progesterone for 12 days of each month.
Progesterone Patch: This is used as a combination patch with oestrogen and is usually changed twice weekly. Patches can work well for women who do not wish the IUS or the oral tablets. Women who are into the menopause do better with the patch as younger women may experience bleeding on the patch.
Testosterone is safe and can be added after a few months of allowing the initial preparations to settle in and can bring significant benefit for women in terms of concentration and libido. There are no preparations licensed yet in the UK, but Testogel/Testim are preparations which can be used as per medical prescription. A menopause specific 1% testosterone cream Androfeme is available in Australia)
Contraindications to HRT
Generally, a woman with a history of cancer (especially breast or womb) is not recommended to have HRT. If it is to be used, this would be a highly specialised decision made by a team of experts.
Similarly, a personal history of thrombosis is considered a contraindication for HRT. With a family history, certain tests may be needed before starting HRT.
A history of heart disease (ischemic heart disease, peripheral arterial disease) is considered a relative contraindication for the use of HRT.
Any hormone treatment in these situations must be individualised with specialist guidance and advice.
Local Vaginal Symptoms:
Topical vaginal oestrogen in the form of a cream, pessary, or vaginal ring containing oestrogen works best for local vaginal or urinary symptoms of cystitis. The oestrogen helps to strengthen the vaginal and bladder lining by improving the blood supply (vascularity), reduced shedding of cells and making the tissues less atrophic and more supple. Local oestrogen treatment can be helpful in reducing recurrent urinary tract infections in some women. This can be used for as long as a woman needs to help with local symptoms and can also be safely used in combination with HRT. Natural oils and water based vaginal moisturisers as well as vaginal dilators can help.
Laser treatment for the vagina to improve the collagen in the vaginal tissue may help with painful sex and may be considered in those women who cannot use oestrogen or if it has not proved as helpful as hoped. (see vulval and vaginal care and painful sex leaflets).
What are the risks with taking HRT?
In general, HRT is very safe and is used by women worldwide with no real concerns about breast cancer, thrombosis, or stroke, especially with the transdermal preparations (gel, patch) and micronised progesterone or Mirena IUS. Previous concerns from flawed studies are no longer considered relevant. More studies are needed in women who start HRT after the age of 60 but preliminary reports suggest they are safe. However, protection against dementia or heart disease is not evident in this group.
Breast Cancer Risks:
- 1 in 7 UK women will be diagnosed with breast cancer in their lifetime, making it the most common cancer in women in the UK.
- 23% of breast cancer in the UK is preventable.
- Only 2 % of breast cancers are caused by taking HRT
To lower one’s risk of breast and other lifestyle cancers, it is advisable to
- Be a normal weight
- Eat a mostly whole food plant based (WFPB) diet
- Undertake regular exercise
- Avoid alcohol and smoking
There is an increased risk of breast cancer which amounts to one extra case for every 50 women taking combined HRT but not for the first 5 years of taking medication and the risk is negligible if only on oestrogen treatment (those who have had their womb removed). There also appears to be no real risk on micronised progesterone which is like the progesterone our own body makes. Any risk also returns to the background risk after stopping HRT. The risk with combined oestrogen and progesterone HRT risk is higher than with oestrogen HRT alone.
Being breast aware is important. Seek medical advice if you feel a breast lump. Be aware if there is a strong family history of breast cancer.
Stroke: The number of women on HRT tablets who suffer from stroke is very small, especially under the age of 60 years and HRT is considered safe if there are no other risk factors. HRT patches or gels do not carry the same risk, as they bypass the liver metabolism. The effects of HRT have been studied worldwide and research shows that, for most women, HRT works
Thrombosis: The risk is highest when HRT is taken in the form of a tablet and is highest in the first year of use.
Dementia: There is no definite evidence one way or the other with HRT but more recently there is encouraging evidence that oestrogen only HRT may be protective against Alzheimer’s. It also appears to be more brain protective when menopausal hormone therapy is started in the perimenopause. There appears to be no increase in dementia on combined HRT when used in women under the age of 60 or within ten years of starting menopause. Over 60, the evidence has not yet been gathered or studied in detail due to smaller numbers.
Are there alternative methods for managing hot flushes?
It is generally always better to focus on eating the whole plant foods such as soya or flaxseed powder in its natural form rather than in its processed form in a tablet. Moreover, these supplements are expensive and generally do not provide the immediate relief that women hope for.
Using the reductionist approach with supplements is not really the best way forward but instead it is best to encourage women to introduce whole plant foods including whole or minimally processed soya foods.
- Soya Isoflavones have shown to be of help in studies with regards to hot flushes, body weight, blood glucose levels but it is advisable to eat soya in its natural form regularly rather than taking isolates in a processed tablet form, as one then misses out on the benefit of the whole food. Soya products should be included due to their cardiovascular benefits and potential efficacy for treating certain menopausal symptoms.
- (see soya leaflet)
Some of these alternative treatments may benefit women, especially those who cannot or don’t want to take hormone therapy.
- Alternative medicine – acupressure, acupuncture and homeopathy.
- Complementary therapy – aromatherapy & HRT.
- Hypnosis has been shown to help women with hot flushes and night sweat in a study.
Herbal alternatives to HRT
Many of these medications and preparations have not been fully studied, hence their effects on the body and on other drugs that one may be taking for breast cancer, asthma, heart disease, epilepsy etc is not fully understood and most cannot be scientifically recommended as their safety profile is largely unknown.
Women should be aware of side effects and effects on organs like the liver should be considered when taking these over the counter mostly unlicensed medications.
Women should advise their healthcare professional of any herbal medicines they may be on as it may affect medical and surgical management.
- Red clover (Trifolium pretense) contains isoflavones and has been shown in a trial to help with hot flushes.
- Sage
- Black cohosh (may cause liver issues)
- John’s wort
- Evening Primrose Oil
- Starflower Oil
- Agnus Castus
Medical treatments instead of hormone therapy:
Antidepressants such as Gabapentin and Clonidine can help with hot flushes in those that cannot take formal HRT, but these drugs have a poor side effect profile and should not be first line of management. Speak to your doctor for further information.
Why are Bioidentical hormones not recommended by experts?
These are not recommended and refer to the use of custom-compounded, multihormone regimens with dose adjustments based upon serial hormone monitoring. While bioidentical hormones are derived from soya and plant extracts and are modified to be structurally identical to endogenous hormones, this is also the same approach used for most approved and commercially available menopausal hormone preparations. The difference is that bioidentical hormones are not regulated, and the dose is not standardised.
Bioidentical hormones are not recommended by any of the Royal Colleges worldwide or expert groups as there is no evidence for their safety or efficacy when compared with standardised HRT.
Instead choose the standardised BODY IDENTICAL hormones (gel/spray/ /patch) and micronized progesterone which are safe and recommended by experts all over the world.
Common questions a woman may wish to ask her GP or specialist when considering Hormone Replacement Therapy (HRT)
Should I take HRT?
When should I start it?
Which preparation of hormone therapy is best for me?
Why are gels or patches better than tablets?
What are the side effects?
What are the benefits?
What about the reports suggesting adverse effects?
How long should I take it for?
What happens if I have had a hysterectomy?
What are the other alternatives available?
Should I have patches or tablets?
Should I have regular check-ups?
Am I at increased risk of breast cancer?
Can I have HRT if I have had cancer?
Can I have HRT if I have had thrombosis?
Should I see a specialist?
Further information:
See Menopause nutrition advice, Lifestyle medicine, Perimenopause and Menopause, Calcium, Vitamin D, Supplements, What should I eat, Soya, nutrition leaflets
Dr Nitu Bajekal FRCOG Dip IBLM
Consultant Gynaecologist and Women’s Health Expert
Lifestyle Medicine Physician
Updated June 2022
