Hormone Replacement Therapy (HRT): understanding its benefits and risks
HRT, once a source of worry and confusion, is now considered an effective and safe treatment for many women troubled by symptoms of menopause.
For some women, the physical, psychological, and mental symptoms of menopause can be debilitating and life-changing.
But there are things women can do to help them regain control of their physical and emotional health during this period of their life; and hormone replacement therapy, which was once a source of great concern, is recognized as a safe and effective way to treat menopause symptoms.
What are HRT and its effects on menopausal symptoms?
Hormone replacement therapy (HRT), also known as hormone therapy (HT), is a medication containing the hormones Oestrogen and progesterone, and in some cases testosterone, that can help reduce symptoms of menopause.
It is internationally acknowledged that HRT is the most effective treatment to combat these symptoms, which include hot flushes, night sweats, insomnia, joint aches, muscle pains, and vaginal dryness. There is also evidence it may improve psychological wellbeing during this time.
HRT is best started:
- during the years leading up to menopause or peri-menopause
- before the age of 60
- within ten years of menopause (that is from the final period a woman has).
It is also recommended that women experiencing premature menopause take HRT, at least until the age of natural menopause, which is between the ages of 45 and 55 (51 being the average).
Oestrogen-only formulations can be taken by women who’ve had a hysterectomy; combined HRT, which contains both oestrogen and progesterone, is recommended for women who haven’t had a hysterectomy because progesterone protects the uterus against cancer.
Can HRT benefit your health in other ways?
Although HRT is prescribed to alleviate the symptoms of menopause, it can have additional positive effects on a woman’s health, particularly if she takes it before the age of 60 or within 10 years of menopause.
- Osteoporosis: it can prevent osteoporosis-related fractures. This protection doesn’t continue after five years of stopping HRT.
- Heart disease: oestrogen-only HRT can reduce the risk of coronary heart disease. But it may actually increase the risk in women who start HRT tablets after the age of 60, and particularly over 70.
- Dementia: while some studies indicate oestrogen may prevent or delay the onset of Alzheimer’s disease, the evidence is still slim and inconclusive.
Does it have side effects or negative health risks?
Publicity about negative health risks associated with HRT peaked in the years following a major 2002 study, known as the Women’s Health Initiative (WHI), which showed HRT was linked with a raised risk of breast cancer, blood clots, and strokes.
However, later analysis found the interpretations of the original findings from this study were flawed. One of the key problems was that the women in the study were significantly older than those who would normally seek treatment with HRT (with different underlying risks of disease), and yet the findings on disease risk were inappropriately extrapolated to healthy newly menopausal women. Anxiety about the WHI study results led to a 50 percent drop in the use of HRT.
Evidence that has emerged in the decade since the 2002 study shows “that for most women starting treatment near the menopause, the benefits outweigh the risks, not just for the relief of hot flushes, night sweats, and vaginal dryness, but also for reducing the risks of heart disease and fractures,” the principal investigator at the WHI Clinical Centre at the University of California, Dr. Robert Langer, said in a statement marking the 10th anniversary of the study.
Current evidence shows there can be minor side effects with some HRT formulations. These include intermittent bleeding, breast discomfort, bloating, and nausea.
HRT can also increase the chance of developing more serious health complications, but this risk is usually small and can be lowered further with a careful and tailored approach to HRT medications.
- Blood clots: although there is a small risk of developing a blood clot while taking HRT (especially tablet form), it is rare if you are under the age of 60. It is more common in the first year of use and with other risk factors such as smoking and obesity.
- Breast cancer: research shows an increased risk of developing breast cancer, but it is small and dependent on the type of HRT and length of time it’s used. For women taking oestrogen-only HRT their risk doesn’t increase for at least seven years of use; for women taking combined HRT it doesn’t increase for four to five years of use.
- Uterine cancer: while oestrogen-only HRT can increase your chance of developing this cancer, combined HRT doesn’t. This is why women who haven’t had a hysterectomy are advised to take HRT that includes progesterone.
- Bowel cancer: some evidence suggests it may protect against bowel cancer.
HRT is not recommended in women who have a history of breast cancer, blood clots, heart disease or stroke, or who have endometrial cancer or unexplained vaginal bleeding.
Which HRT formulation may suit you best?
Before taking HRT it’s vital women have a full medical check-up and discuss their own personal and family medical history with their doctor, so the risks and benefits of HRT can be individualized and the HRT tailored appropriately.
The different formulations are tablets, skin patches, intra-uterine devices (IUD), gels, and creams.
- Tablets: taken daily, tablets are the most popular and commonly available formulation.
- Skin patches: applied every three to four days, these work by slowly releasing hormones into your body. They can have fewer side effects (particularly in relation to nausea and clots) but can be irritating for some women. Absorption is understood to be more reliable and even than tablets.
- IUD: for women who can’t tolerate progesterone tablets, the hormone can be delivered via an IUD.
- Gel: an oestrogen gel, rubbed onto the skin daily, is a good option for women who can’t tolerate tablets and who don’t want a patch.
- Creams: oestrogen creams that are inserted into the vagina can be useful for symptoms such as bladder leakage and dryness.