What is hormone replacement therapy?
Just as the name implies hormone replacement therapy (HRT) is a replacement of female sex hormones in women. These hormones are called oestrogen and progesterone. They are released from the ovaries and influence changes in the body’s cycle which controls periods, moods and may contribute to a sense of wellbeing and healthiness. Usually every month in a normally healthy woman of childbearing age hormones are produced and released from the pituitary gland in the brain to encourage one of her two ovaries to produce an egg (ovum). At the same time oestrogen and progesterone are released from the ovaries, which cause changes that help to prepare the body for a pregnancy.
If pregnancy does not occur the hormone levels fall and the woman will have a period. After the menopause or ‘the change’ the ovaries no longer respond to the hormones from the pituitary gland and shut down; no longer producing an ovum. This means a woman can no longer become pregnant naturally and her periods stop. At this time symptoms may appear, including hot flushes, night sweats, insomnia, palpitations, mood changes, vaginal dryness and painful intercourse, and mild skin changes such as dryness and loss of elasticity. Treating patients with HRT replaces the hormones no longer being released from the ovary and some of these symptoms can be helped.
When can hormone replacement therapy be used?
Most women have their menopause between 50-55 years of age. Some women go into an early menopause before they are 45. In these women HRT can be used before the age of 50 without increasing their risk of breast cancer. Most women are postmenopausal by 54. The menopause may last any time from one up to five years, and some women still experience hot flushes some 10 years after their menopause began, but some lucky ones may not have hot flushes at all.
What types of therapy are there?
HRT can be given by tablets, patches, creams or gels under advice from a GP. HRT can take different forms:
Cyclical combined - which is oestrogen and progesterone together and re-introduces monthly periods
Continuous combined - which is oestrogen and progesterone, but prevents periods
Women with an intact uterus must take combined HRT, replacing both oestrogen and progesterone, to prevent the lining of the womb thickening and thus reducing the risk of endometrial cancer.
If a woman has had a hysterectomy then therapy can be oestrogen only. If she has already been on a cyclical combined course of therapy and reaches 54 years of age, or has had no periods for 12 months before starting HRT, she should start continuous combined HRT to avoid regular monthly bleeds.
For how long can hormone replacement therapy be given and what are the risks?
The current recommendations are for the lowest dose for the shortest possible time to control symptoms. Women who do not have symptoms of menopause should not use HRT. All types of HRT are linked with a small increase in the risk of breast cancer and some therapies increase the risk of cancer of the uterus. After five years of continuous HRT there is an increased risk of ovarian cancer, with research indicating one extra case of ovarian cancer for every 8,000 women taking HRT each year. The risk of breast cancer depends on age but increases with the length of the therapy.
As an example, a woman aged 50 has a 6.1% risk of getting breast cancer in the next 30 years. If she takes oestrogen-only HRT for five years, the risk is 6.28%. If she takes combined HRT (oestrogen and progesterone) for three years, the risk rises to 6.4%. If she takes it for five years, it increases to 6.7%, and for 10 years to 7.69%.
There are some benefits of HRT including strengthening the bones, which reduces the risk of osteoporosis and broken bones, but this is only during the time of taking HRT. HRT also reduces the risk of getting bowel cancer but does not prevent heart disease, strokes or dementia in women, and should not be used for these purposes.
Can symptoms be prevented from returning after HRT is stopped?
It has been suggested that slowly reducing the therapy dose over a period of months may help reduce the return of flushes, but there is no scientific evidence for this. Unfortunately, the symptoms will return if they are going to, whether therapy is stopped gradually or suddenly.
Active women may suffer fewer symptoms than inactive women, so swimming and running may help. Reducing alcohol and caffeine intake may help reduce hot flushes. Some prescription medications from the doctor such as clonidine and some of the antidepressants may also help.
Herbal medicines may help in some cases, especially as they may contain small amounts of plant oestrogens - phyto-oestrogens. Their value has not been confirmed, and often the amounts contained are so low that they are unlikely to be effective. Black cohosh, red clover, dong quai, evening primrose and ginseng are among those that have been used, apparently with some success, but they should be taken in consultation with a GP because they may have a negative effect on other medication or may not be suitable for some women. In particular there have been concerns about black cohosh because of its potential for liver damage. There is limited evidence of the general effectiveness of complementary therapies which can also include acupuncture and other physical treatments. However, many women have found complementary medicine to be effective in relieving the symptoms and effects of menopause in individual cases.
Written: April 2011. Review due: April 2013.