Facts about the menopause

Immediate menopausal symptoms can include hot flushes, night sweats, vaginal dryness. These are definite symptoms of oestrogen deficiency. Other symptoms may include irritability, depression, poor concentration and forgetfulness, lethargy, loss of confidence and aching joints. Although these symptoms often occur around the time of the menopause, if they do not respond to HRT then they are probably not caused by oestrogen deficiency and further investigations may be required. The menopause can have more long-term effects. The loss of oestrogen can lead to a hardening of the arteries thus increasing the risk of heart attack or stroke. It can also cause osteoporosis (brittle bones) in some women.

Hormone replacement therapy?

Hormone replacement therapy (HRT) aims to replace the female hormones that are lacking in the body after the menopause.  It aims to reduce the symptoms of the menopause (see above) both in the short and long-term. There are three basic types:

  • Oestrogen – for women who have had a hysterectomy
  • Oestrogen plus progesterone – for women with a womb
  • Tibolone – for women who have had at least 12 months without natural periods.

There are many methods of administration – tablets, skin patches, run-in gels, vaginal pessaries, cream, or as a pellet implanted under the skin every few months.

Starting HRT

You can start HRT as soon as you experience symptoms of oestrogen deficiency. Treatment is sometimes not commenced until after a woman’s final normal period but it may be started before this if symptoms are particularly troublesome.

When HRT is not recommended

It is generally not a good idea to give HRT to a woman who has had cancer of the breast or endometrium (lining of the womb) as these tumours are oestrogen dependent. However, if such a woman has very severe menopausal symptoms which make her life intolerable then, providing she accepts the risk, HRT may occasionally be prescribed. A previous history of a blood clot, high blood pressure, smoking and obesity are not absolute contra-indications to HRT but they may influence the chosen route of administration. Possible side effects Tender breasts, nausea, leg cramps, fluid retention and mild abdominal bloating. There is NO significant weight gain.

Alternatives to HRT

Some drugs treat individual rather than collective aspects of the menopause eg Clonidine controls the hot flushes and night sweats and raloxifene protects bones against osteoporosis. Natural products such as vitamin B6 and evening primrose oil have helped some women with a number of menopausal symptoms. Some alternative therapies may help with some of the symptoms (reflexology, aromatherapy and acupuncture) but these treatments have not been medically proven and should be discussed with your doctor.

HRT : Some common questions and our answers

What regular monitoring and check-ups should I get on HRT?
We recommend 6 monthly checks of weight and blood pressure and a pelvic and breast examination every year. It is also recommended that all women over the age of 50 should have a mammogram and a cervical smear every 2-3 years whether or not they are on HRT. In addition if there is a history of cancer in a near relative (e.g. mother, sister, grandmother) it is probably better to have a mammogram annually and to consider starting mammography earlier. We also strongly urge all women to practice self-examination of their breasts.

Will HRT make me fertile again?
No. The menopause indicates cessation of ovarian function and therefore an inability to conceive. However, women who commence HRT before their natural periods finish are advised to use contraception until their early 50s.

After nine months on HRT I am still getting symptoms. What can I do?
There are 3 possible reasons for this. 1.    You may not be receiving enough HRT to control your symptoms; this is usually solved by increasing the dosage. 2.    You may be on the wrong type of HRT. Some women who take HRT tablets do not absorb them from their gut and therefore no active hormone reaches the blood stream where it is required to be effective. Such women usually improve when treated with either a hormone patch or an implant. 3.    Your symptoms may not be due to oestrogen deficiency at all (see “Facts about the menopause”).

My GP gave me six months supply of HRT, then stopped. Why? and what will be the consequences?
Unfortunately despite growing research into HRT and continued publicity there still seems to be a lot of confusion about the safety and benefits of long term HRT. The duration of menopausal symptoms (untreated) varies tremendously from woman to woman; they usually continue for at least 2 years and often last for considerably longer. Therefore stopping treatment after only 6 months will usually result in their recurrence. It is particularly important for women who are at risk of developing osteoporosis to take HRT for at least 5 years to get proper protection for their bones. As long as women undergo a regular medical check-up, practice breast self-examination and remain healthy there is no reason why HRT should suddenly be stopped after 6 months.

Will HRT help my sex drive during and after my menopause?
There are many reasons why women lose interest in sex at this time. However, HRT relieves vaginal dryness, a cause of painful intercourse, and consequently may reawaken your interest in sex. If after treatment with oestrogen your libido (sex drive) is still low then a small dose of the male hormone, testosterone is often helpful. However this is only available as an implant.

Is there any increased risk of cancer on HRT?
Although it is the oestrogen which produces all the positive benefits of HRT for a woman who still has her uterus (womb) it is important that she should take a small does of progesterone for a part of each month to protect against endometrial (womb) cancer. Providing a short course of progesterone is taken each month there is no increased risk on endometrial cancer. The effects of long term HRT on breast cancer risk are very controversial. With the low doses of hormones used on HRT there appears to be no increase in risk of breast cancer with up to 5 years of treatment. There may however be a slight increase in risk of breast cancer if HRT is taken for 10 years or more. However, not all studies have reported this; some have observed no increase in risk even with long term treatment. There is no evidence at present that HRT changes the risk of cancer of the ovary or cancer of the cervix.

Before starting HRT do I need any tests to check my hormone levels?
Not usually. Obvious menopausal symptoms such as hot flushes indicate low oestrogen levels and therefore no tests are necessary. Sometimes where there is some doubt as to whether symptoms are menopausal in origin a blood test may be carried out but even here a short trial of HRT may be undertaken. Blood tests are also sometimes taken in cases of suspected early menopause to confirm the diagnosis.

What is osteoporosis and how can HRT help to prevent it?
Osteoporosis literally means porous or brittle bones. It affects one woman in four (compared to one man in twenty) and develops over a period of years after the menopause. It is now known that bones are dependent on oestrogen and it is therefore very important, especially for women who are at increased risk of developing the disease (see below), to take HRT for a minimum of 5 years. It has also been shown from research that bone is lost at a greater rate during the first 2 to 3 years after menopause than in the following years. Therefore HRT should be started sooner rather than later.

Am I susceptible to Osteoporosis? 
All post menopausal women are at risk of osteoporosis and there is no simple way of telling which women are at increased risk. However, your risk is greater if you fall into any of the following categories: •    Thin, fair skinned, small boned •    Early menopause (before 45) •    If your mother or grandmother lost height because of bone fractures •    If you smoke •    If you have regularly consumed more than two alcoholic drinks per day Black people have a much denser skeleton than white people and therefore their risk of developing significant osteoporosis is reduced. One final comment: HRT can only arrest the process of osteoporosis, it cannot put backbone which has already been lost.

Do oestrogens change the risk of heart attack and stroke?
Numerous studies conducted in the USA have reported that HRT reduces the risk of “furring up” the major arteries in the heart and lower the chance of heart attack. Similar results are now becoming available for arteries in the brain with a reduced risk of stroke. These arterial diseases are the most common cause of death in women aged over 50 years and are much more common than breast and endometrial cancer. Most of the studies from the USA were conducted in women taking oestrogen by itself. It is not known whether combined HRT (oestrogen plus progesterone) has the same beneficial effects.

Can older women benefit from HRT?
Maximum benefits are derived from HRT by starting as soon after your menopause as possible, particularly for bone protection. However, even starting treatment many years after your menopause will maintain your existing bone thickness for as long as the treatment is continued. Many women who start HRT later on in life find they get other benefits. They feel more lively and sleep better and are less likely to be troubled by vaginal dryness. However, it is important to remember that HRT will usually lead to a return of a monthly bleed. The vulval and vaginal area of older women often becomes very dry and sore and short intermittent course of oestrogen cream can often relieve these symptoms and may reduce the feeling of constantly wanting to empty the bladder.

Can I have too much HRT and will it do me any harm?
Your body will alert you to oestrogen overdose by certain symptoms such as tender breasts and nausea. Although these symptoms are common they usually settle down after a few months.

Do I need HRT after a hysterectomy if I still have my ovaries?
So long as you were having periods before your hysterectomy (i.e. your ovaries were working normally) you will not need HRT. However, it is recognised that women who have undergone hysterectomy often develop menopausal symptoms at an earlier age than those who have not, and these women obviously need to start HRT earlier.

My hair is falling out and my skin is dry. Will HRT help me?
The relationship between oestrogen and hair is poorly understood at present. Hair loss is more likely to be age dependent, whereas dry hair may be due to oestrogen deficiency. Similarly, dry skin sometimes improves with HRT.

What can I do about incontinence?
This is a common female problem, especially in later life, and is often triggered by a sneeze, cough, laughter or playing sport. There is some evidence that some types of incontinence may be helped to some degree by HRT. Pelvic floor exercises may also help. These are done by tightening the muscles as if you were trying very hard to hold back your urine. Tighten, hold and relax at least 25 times on each occasion. Also, try to stop your flow of urine mid-stream. If there is no improvement despite HRT and exercises, you should see your doctor again.