Menopause

Hormone replacement therapy (HRT)

From the 1970s hormone replacement therapy (HRT) was heavily promoted for the relief of menopausal symptoms and the prevention of osteoporosis and heart disease. In the early 2000s, when some medical research began to suggest that it caused harm, attitudes to HRT changed. However this medical research has recently been reviewed and “Most experts agree that if HRT is used on a short-term basis (no more than five years), the benefits outweigh the risks” (NHS Choices 2014). National Institute for Health Care Excellence has also published Menopause: diagnosis and management (NG23 November 2015) in which it states that women should be offered HRT for vasomotor symptoms (hot flushes and night sweats) after discussing with them the short-term (up to 5 years) and longer-term benefits and risks.

Here women we interviewed talked about their experiences of HRT, how they saw its risks and benefits, and their concerns about long-term use. Women also explained why they had chosen not to take HRT.
 
Why women don’t take HRT
Although HRT can alleviate menopausal symptoms, most women we spoke to choose not to take it. They felt the risks associated with its use were too high after the publishing and media coverage of two studies, the Women’s Health Initiative (WHI) study in the US in 2002 and the Million Women Study (MWS) in the UK in 2003. These studies raised concerns over the safety of HRT, particularly over a possible increased risk of breast cancer with HRT and also a possible increased risk of heart disease. Findings from the MWS published in The Lancet in 2007 also showed a small increased risk of ovarian cancer.  Findings from another study published in The Lancet in February 2015* have also shown an increased risk of ovarian cancer. “It is important to put the risk in context; in real terms, for every 1,000 women using HRT for five years, there will be just one additional ovarian cancer diagnosis. And if prognosis is typical, there will be one additional ovarian cancer death for every 1,700 users.” (NHS Choices, February 13 2015, reporting on the study)
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After the WHI and MWS studies, the number of women taking HRT fell by 66% (Women's Health Concern 2013). The value of these studies has since been reviewed and findings downplayed and although HRT does increase the risk of developing certain problems the increased risk is very small in most cases. HRT is still: “a very effective method of controlling menopausal symptoms, and it can make a significant difference to a woman’s quality of life and wellbeing.” NHS Choices 2014.
 
Controversy arising from the WHI and MWS study findings has added to the confusion women feel about the safety of HRT (see  Women's Health Concern website in 'resources and information' for an analysis of the findings of the two studies). Recent studies continue to examine the effects of taking HRT. In 2012 The British Menopause Society reported studies from Denmark and the US (KEEPS study) which showed beneficial effects of taking HRT and the NICE guidelines also suggest women should be offered “HRT for vasomotor symptoms after discussing with them the short-term (up to 5 years) and longer-term benefits and risks.”. 
 
As with any medication, HRT has benefits and risks and these should be discussed with your doctor as it may not be suitable for everyone. HRT is not recommended for women who:
  • have a history of breast cancer, ovarian cancer or womb (uterus) cancer
  • have a history of blood clots
  • have a history of heart disease or stroke
  • have untreated high blood pressure – your blood pressure will need to be controlled before you can start HRT
  • have liver disease
  • are pregnant
 
Some women we spoke to said their symptoms were not serious enough to justify using HRT; others just did not like ‘putting chemicals’ into their body. For others, pre-existing health conditions or a family history of cancer made HRT unsuitable. Some women were determined to go through the menopause as a ‘natural process’, trying complementary therapies if necessary rather than go down the medical route (see ‘Complementary therapies’).
Why women chose HRT
HRT can help relieve menopausal symptoms such as hot flushes and vaginal dryness by replacing declining levels of oestrogen and progesterone (see ‘Hot flushes and night sweats’ and ‘Libido, vaginal dryness and urinary problems’). Although in the past some women took HRT to prevent diseases such as osteoporosis, today it is usually the debilitating effects of hot flushes and sweats, lack of sleep, and inability to function effectively at work which send women to their GP (see ‘Consulting the doctor’, ‘Sleep’ and ‘Work’).
 
Some feel they have no choice. Women described HRT as being ‘like a miracle’, ‘completely rejuvenating’, ‘unfailingly excellent’, and ‘the most wonderful drug in the whole wide world’. As hot flushes and night sweats eased, they noticed improvements in their sleep, concentration and stamina. For women who have experienced an early menopause, HRT is recommended at least until the average age of the natural menopause and is often prescribed up until the early 50s to help prevent osteoporosis as well as to relieve symptoms (see ‘Early (premature) menopause’).
Yet while women who take HRT speak positively about its effect on their quality of life, some said that ‘at the back of your mind there’s a bit of a worry’. Deciding to take HRT and to stay on it long-term involves a careful weighing up of risks versus benefits. Aware of the negative publicity, women stress the importance of studying the available research, discussing the pros and cons of HRT use with their doctor, having regular blood pressure checks, and ensuring they attend for routine mammograms and cervical smears.
Finding the right HRT
There are many different types of HRT. What suits one woman may not suit another. Although women who have had a hysterectomy can be prescribed an oestrogen-only HRT, women who are still having periods or who stopped within the last year are usually given a combined (oestrogen plus progestogen) cyclical form of HRT and will continue to have a monthly period. Postmenopausal women may be prescribed a ‘period-free’ continuous combined HRT. Women troubled by vaginal dryness sometimes chose to use an oestrogen tablet, cream, ring or pessary to help raise local levels of oestrogen without affecting the whole body.
Women may experience side effects and it may take them some time to find a suitable type of HRT. On some types of HRT, women experienced diarrhoea and nausea, facial hair, and weight gain (see ‘Changes in the body and keeping healthy’). One woman, who remained on HRT at the advice of her doctor despite heavy bleeding, turned out to have large polyps and fibroids (see ‘Changes in periods’). Some women who had been prescribed HRT patches complained about allergic reactions and skin rashes or disliked the ‘filthy plaster marks’ left when the patch was removed.
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Despite its benefits, HRT is not a miracle cure for all menopausal symptoms. While pleased that HRT had stopped her hot flushes, one woman complained that she’d put on weight and lost interest in sex. Another pointed out that HRT didn’t relieve her night sweats for ‘quite some time’.
 
How long to stay on HRT
Women we spoke to had been on HRT for periods up to 15 years. Current guidelines, however, recommend restricting HRT to the ‘lowest effective dose for the shortest possible time’. This can be ambiguous and GPs interpreted these guidelines in different ways. ‘The shortest time possible’ seems generally to be taken to mean between 2-5 years (see ‘What is the menopause?’). A new oral low dose HRT has been introduced. While some women were willing to come off HRT, others were reluctant to stop taking HRT despite their doctor’s advice. One of Dr Sally Hope’s patients is still taking HRT at age 82 and ‘just will not stop’. She records in the patient’s notes that ‘it’s her evidence based patient choice’.
Women reported that coming off HRT ‘cold turkey’ could lead to a return of symptoms such as hot flushes and memory problems because of the change in hormone levels. One woman described the sudden return of hot flushes and ‘memory gone to bits’ as ‘absolutely horrendous’. Another, who came off HRT in her 70s after long use, once again got hot flushes.
Other women, however, found that coming off HRT slowly over a period of weeks or months helped to minimise withdrawal symptoms; some remained symptom-free.
 
Used short-term to relieve menopausal symptoms, HRT can restore well-being and quality of life for many women. But the available evidence indicates that long-term use incurs significant risks. Women should be guided by their own research and by discussions with their doctor before making a decision.
 
*Collaborative Group on Epidemiological Studies of Ovarian Cancer: Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. The Lancet published online: 12 February 2015.
 
Last reviewed November 2015.
 
Last updated November 2015.

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