Hormone Replacement Therapy - HRT

Hormone Replacement Therapy.

All women will make the transition through menopause at some stage in their life. The perimenopause is the portion of time that leads up to the complete cessation of periods. During this time women can experience profound physical and psychological symptoms. Some might say that ‘they just don’t feel like themselves anymore’. In addition, the menstrual cycle is often erratic.  Although it is a time of significant change, there are ways to make the transformation a smoother one. 

Menopause occurs due to falling levels of the reproductive hormones, oestrogen and progesterone. These are usually released in a cyclical way from oocytes or eggs in the ovaries. A woman will have 300,000 eggs at the time of puberty but not all of these will be viable and only 300-400 would be released over the reproductive lifetime. The number of viable eggs reduces over time, with a resulting drop in hormone levels. The falling hormone levels themselves have dramatic effects on many systems in the body and they also contribute to a cascade reaction of a hormone from higher centres in the brain that is thought to cause one of the most troubling symptoms, hot flushes. 

What are the main symptoms?

Hot flushes

These are thought to be caused by the decreasing oestrogen levels. They affect up to 80 % of peri and post-menopausal women. They are characterised by an intense feeling of heat in the face and upper body that spreads throughout the body. They usually last up to 5 minutes but can occur every half an hour, often accompanied by palpitations, anxiety and night sweats. Up to 25 % of women report them to be very debilitating. A quarter of women may have symptoms for more than 5 years. 

Vaginal dryness

The lack of oestrogen can cause the vaginal walls to become thinner and less stretchy or ‘atrophic’. This contributes to vaginal discomfort and irritation and can make intercourse painful and much less appealing, impacting on libido.  It can also cause a constant urge to pass urine which can be mistaken for symptoms of a urine infection. The onset of these symptoms can be delayed as much as 10 years after the last period. 

Brain Fog

Many women report problems with concentration and attention during this time. Tasks which were carried out easily in the past may now seem daunting. There may be an impact on mood, with irritability, anxiety and mood swings. Although these can lead to depression, often the symptoms are more episodic and related to cyclical hormonal fluctuations. 

Decreased Libido

Reduced sex drive can occur due to falling levels of oestrogen and testosterone. Vaginal dryness leading to painful intercourse can also contribute to reduced sexual desire. Women may also be impacted by reduced self confidence in their body image that may be triggered by the menopause. 

Insomnia

The physical symptoms of menopause themselves such as hot flushes can lead to disrupted sleep patterns, with fluctuations in mood also playing a part. Poor sleep can result in fatigue, poor concentration and irritability which may cause subsequent sleepless nights, leading to a vicious cycle of waking unrefreshed.

Joint pains

Painful joints, headaches and fatigue are also reported and may be due to falling hormones or associated mood disturbance.

How long do symptoms last?

Typically, symptoms last 5-7 years but they can go on for as long as 10-15 years. Perimenopause itself can last for several years.

What can be done to relieve symptoms?

Lifestyle measures

Hot flushes can be triggered by spicy food, smoking and alcohol so avoidance of these may improve the situation. In addition, exercise, weight loss, wearing looser clothing, decreasing the room temperature directly or using fans may help

Stress can also trigger hot flushes so relaxation techniques and mindfulness exercises could also play a role. Stress management is vital to improving some of the other symptoms such as poor sleep and problems with mood and concentration.

Lubricants such as KY Jelly or Replens vaginal moisturiser could relieve symptoms of vaginal dryness and irritation; and are available over the counter.

Complementary therapies

There is some evidence that isoflavones and black cohosh relieve some menopausal symptoms. However, their manufacture and regulation are not subject to the strict controls that are applied to licensed medication in the UK. Therefore, their quality, purity and safety profile may be unknown and can vary from one preparation to the next.&

Hormone Replacement Therapy and its Benefits

HRT can relieve many of the symptoms of menopause and should be offered an option to all those with severe symptoms impacting on their quality of life. In addition, there is some evidence that it promotes healthy bones and reduces the risk of osteoporosis or thinning of the bones, a condition that can lead to fractures.

How Should it Be Taken?

This depends on whether the woman is postmenopausal or perimenopausal, is still menstruating or not and whether they wish to continue doing so, and whether they have had a hysterectomy, as well as individual preference.

In women with a womb, oestrogen should be given together with progesterone. This is because oestrogen alone can cause thickening of the womb lining which can be precancerous. Taking oestrogen with progesterone counteracts this risk. The hormones can be taken together individually or as a combined preparation.

Combined preparations

These can be taken orally (in a tablet) form eg Indivina,Tridestra,Kliovance.  Or they can be administered transdermally (as a patch) eg Evorel conti, Evorel Sequi, Femseven conti, Femseven sequi.

Individual preparations

These can also come in tablet eg Elleste Solo, Zumenon, or gel/patch form eg Evorel, Estradot. They would always need to be combined with a progesterone eg Utrogestan, Norgeston for the reasons already mentioned.

Vaginal preparations

These are in the form of oestrogen tablets or cream eg Vagifem, Ovestin.  They are inserted directly into the vagina and can relieve the symptoms of vaginal dryness and irritation. They are safe to be used long term and do not have the same risks associated with them as HRT in the form of patches, tablets or gels.

As illustrated above, there are many different preparations of HRT available, and they can only be obtained with a prescription after consultation with a doctor. This is to ensure that the prescription is tailored to the needs of the individual and ensures that any risks can be identified as well as monitoring carried out.

So, what are the risks?

Blood clots

There is an increased risk of blood clots or ‘venous thromboembolism’ with use or oral HRT. The risk with transdermal preparations is not thought to be greater than the average risk of a woman not taking HRT.

Stroke

There is a small increased risk of stroke with the use of oral HRT, with transdermal HRT the risk is not increased. HRT does not increase the risk of coronary heart disease if started before the age of 60 years.

Breast cancer

A recent study published in 2019 has shown that all forms of ‘systemic HRT ‘, which refers to anything oral or transdermal, are associated with an increased risk of breast cancer. There is little or no increase in risk if used for less than a year but over one year the risk increases. The risk is related to the duration of use and can remain increased even 10 years after HRT is stopped. The risk is slightly lower for cyclical HRT (progesterone is given for part of the cycle) rather than continuous combined (progesterone is given throughout the cycle).

In the UK about 1 in 16 women who have never used HRT will develop breast cancer. This equates to about 63 women in a 1000. If the same age bracket of women were to use HRT for 5 years this would lead to between 5 and 20 extra cases of breast cancer per 1000 women, depending on the type of HRT.

The risk is not increased with vaginal oestrogens such as Vagifem and Ovestin.

Ovarian Cancer

A recent study concluded that there is also an increased risk of ovarian cancer with all forms of systemic HRT. In a group of women who use HRT for 5 years from about the age of 50, there would be one extra case of ovarian cancer per 1000 users and one extra death per 1700 users.

Are there other alternatives to HRT?

There are other prescription medications that can be helpful in some cases. Clonidine can improve hot flushes in 40 % of women but may be associated with side effects such as dry mouth, headaches, dizziness and insomnia. Antidepressants such as Fluoxetine, Citalopram and Paroxetine can also be used to treat hot flushes. They could also have benefits in those with mood disturbance.  It is best to make an appointment with your family doctor if you are interested in trying any of these medications.

Tibolone is a synthetic steroid with stimulates oestrogen, progesterone and testosterone receptors. It is used as a form of HRT but only in post-menopausal women. It has advantages in that it should not cause bleeding in post-menopausal women, and its use is not associated with an increased risk of blood clots. However, it has a similar breast cancer and ovarian cancer risk to other forms of HRT, and its use does also have an increased risk of stroke, hence a consultation and full risk assessment with a doctor is always needed prior to starting this medication.

Light at the end of the tunnel……

Menopausal symptoms can be persistent, relentless and somewhat overwhelming. However, the right advice and guidance can make the transition a smoother one. With the right help, hopefully women can feel transformed, with a new energy and zest for the next chapter in their lives. If you are unsure about which treatment would be best for you then please call and speak to one our pharmacists on 01295 262925

Please find some links below to useful Menopause resources
www.rockmymenopause.com
www.menopausematters.co.uk
www.womens-health-concern.org
www.nhs.uk/conditions/menopause/

Note about Transgender patients: We are completely sympathetic to your situation but this is a very specialised field which we feel we cannot safely prescribe for you. This must be done through your GP, who we feel sure will be equally sympathetic.

IVF Treatment - unfortunately we cannot prescribe for IVF treatment - I am sorry but this is only a service for Hormone Replacement Therapy.