This article focuses entirely on HRT for women whose problem is caused by the menopause.
When estrogen and progesterone levels drop, as they do when the menopause approaches, some women may benefit from artificially boosting their hormone levels to reduce certain menopausal symptoms.
The hormone estrogen stimulates the release of eggs. As soon as a woman's supply of eggs has ended, estrogen levels start to go down.
What are the signs and symptoms of a drop in estrogen levels?Estrogen helps maintain good bone density, skin temperature and regulating moisture of the vagina. A drop in estrogen levels can cause:
- Vaginal dryness
- Urinary problems
- Thinning hair
- Sleep problems
- Night sweats
- Lower fertility
- Irregular periods
- Hot flashes (UK: hot flushes)
- Concentration and memory difficulties
- Breasts get smaller
- Accumulation of fat in the abdomen
Symptoms may sometimes occur before the menopause starts (peri-menopause). In this case the woman's supply of eggs has not finished, they have just dropped significantly, which can trigger a fall in hormone levels. So, the patient may still have regular periods as well as menopausal symptoms.
HRT estrogen comes from pregnant horse urine or plants.
Progesterone's main function is to prepare the woman's womb for possible pregnancies. This hormone also helps protect the endometrium (the lining of the uterus).
Lower progesterone levels do not really cause the woman any immediate discomfort. Experts say her risk of developing endometrial cancer may be higher.
HRT, once the "Elixir of Youth", then a source of fear, and now....In 2002, HRT was referred to as the "Elixir of Youth". This golden period gradually deteriorated as studies started linking HRT with potentially life-threatening consequences, including a greater risk of breast cancer, ovarian cancer and other illnesses and conditions. Consequently, HRT guidelines changed and doctors were told only to prescribe it in certain circumstances.
Since the findings from the Women's Health Initiative (WHI) Trial of 2002, menopausal women and many doctors have been confused about which treatment is best. Sadly, over the last ten years, HRT has received so much negative attention from the media that its benefits have been mostly forgotten.
The WHI estrogen and progestogen study identified a slight increased risk of breast cancer after five years HRT usage. The increase was approximately 1 extra case of breast cancer per 1,000 women per year. The WHI estrogen-alone trial reported a statistically significant (but still small) reduction in breast cancer risk.
Experts have recently said that the WHI study and MWS (Million Women Study) had key flaws which make it harder to establish a casual link between HRT and breast cancer.
Almost 50,000 unnecessary deaths because estrogen therapy was withheld - researchers from Yale School of Medicine reported in the American Journal of Public Health (July 2013 issue) that tens of thousands of women have died unnecessarily over the last ten years because doctors avoided prescribing estrogen-only hormone replacement therapy.
What are the benefits of HRT?HRT is approved for the relief of menopausal symptoms and the prevention or treatment of osteoporosis. Below are some other benefits linked to HRT:
- HRT improves muscles function - Dr. Lars Larsson, from Uppsala University Hospital Sweden, reported in The Journal of Physiology that HRT improved muscle function in women, even down to the muscle fiber.
Dr. Larsson said "We found that even though individual muscle fibers did not change in size, the muscles of HRT users showed greater strength by generating a higher maximum force compared to non-HRT users. It is thought that using HRT, at least in part, reduces modifications of muscle contractile proteins that are linked to aging."
- HRT reduces heart failure and heart attack risk - females who receive HRT soon after the menopause have a dramatically lower risk of heart attack and heart failure, a team of Danish researchers reported in the BMJ.
- HRT lowers mortality in younger postmenopausal women - an article published in The American Journal of Medicine informed that HRT "almost undoubtedly" decreased mortality in women whose menopause arrived early.
- HRT protects against brain aneurysms - a team from Rush University Medical Center found that HRT and oral contraceptives reduce the risk of the formation and rupture of brain aneurysms in women.
New HRT Guidelines releasedWith a sigh of relief, British doctors received new guidelines regarding HRT from the British Menopause Society and Women's Health Concern in May 2013. The guidelines - "The 2013 British Menopause Society & Women's Health Concern recommendations on hormone replacement therapy" - were also published in Menopause International and are likely to be replicated around the world.
The new guidelines are the result of extensive consultations and meetings among endocrinologists, gynecologists and other health care professionals - collectively known as the "Panel of Experts". They carefully researched and re-assessed the WHI and MWS studies, as well as several other human trials and studies.
The Panel believes the new guidelines offer doctors "a detailed review of the available evidence to help them make the best possible clinical decisions, as well as providing women with more balanced, impartial and accurate HRT treatments for menopausal females."
Lead author of new recommendations, Nick Panay, Chair of The British Menopause Society, said: "Our aim is to provide helpful and pragmatic guidelines for health professionals involved in prescribing HRT and for women considering or currently using HRT. With these updated recommendations, it is hoped that HRT will once again be used appropriately and provide benefits for many women in their menopause."
The new guidelines include the following key points:
- An individual decision - each patient must receive proper and comprehensive information from her doctor so that she can make a fully-informed choice. Whether or not to use HRT is an individual decision.
- HRT dosage - should be calculated on an individual basis, as should overall regimen and duration.
- Annual evaluation - every woman on hormone replacement therapy must have her treatment evaluated once a year for pros and cons.
- No arbitrary limits on duration - the duration of HRT usage should not be restricted by arbitrary limits. "If symptoms persist, the benefits of hormone therapy usually outweigh the risks."
- HRT more favorable for younger patients - when deciding on HRT usage, the patient as well as the doctor must remember that there is a more favorable benefit/risk profile for patients who start therapy before they are 60 years old.
- Premature ovarian insufficiency - patients should be on HRT at least until the average age of the menopause.
- Older patients - patients over 60 who are prescribed HRT should initially be on lower doses and ideally with a transdermal route of administration.
- R&D must focus on risks and benefits - as people continue having longer lifespans, research and development needs to concentrate on maximizing benefits and minimizing risks and side effects. "This will optimize quality of life and facilitate the primary prevention of long-term conditions which create a personal, social and economic burden."
Most HRTs include estrogen and progesteroneMost women who take HRT for menopausal reasons are given an estrogen/progesterone combination, except for those who have had a hysterectomy, they do not need progesterone.
HRT slightly increases a woman's risk of some cancers and stroke. It is not a long-term therapy and should last no longer than five years for the benefits to outweigh known risks.
The patient can start HRT as soon as menopausal symptoms begin. Most women have the menopause at around 52 years of age, according to the National Health Service (NHS), UK. However, ages can range from early forties to well into the sixties. We cannot predict when a woman starts to have her menopause.
Menopause test is not usually requiredIn most cases women do not need to be tested for menopause, unless they are very young or have abnormal bleeding patterns during menstruation. In such cases, the patient needs to be tested for other conditions with similar symptoms, such as a thyroid problem or cervical cancer.
HRT may not be suitable for women who:
- are pregnant
- have uncontrolled hypertension (high blood pressure). The hypertension needs to be treated first
- have severe migraines
- have a history of thrombosis or blood clots
- have a history of stroke
- have a history of heart disease
- have a history of endometrial, ovarian or breast cancer
Three main types of HRT
- HRT with only estrogen - women who have had a hysterectomy where their uterus (womb) and ovaries have been removed do not need progesterone, because there is no risk of endometrial cancer.
- Cyclical HRT (sequential HRT) - for patients who are still menstruating but have menopausal-like symptoms. The cycles may be monthly, an estrogen plus progestogen dose at the end of the menstrual cycle for 14 days, or a daily dose of estrogen and progestogen for 14 days every 13 weeks.
- Continuous HRT - used for post-menopausal patients. They take a continuous combination of estrogen and progestogen.
How does the patient take HRT?The doctor will try to control menopausal symptoms with the lowest possible dosage - it may occasionally take some time to get it right.
HRT may be taken in the following forms:
- Cream/Gel - it is placed either on the skin or in the vagina if the woman has vaginal dryness
- Skin patch
Recent developments on HRT from MNT news
HRT linked with ovarian cancer risk - A new study has found that use of hormone replacement therapy for the menopause is associated with an increased risk of developing the two most common forms of ovarian cancer, even if it is used for just a few years.
Does HRT affect memory and cognitive abilities?Some women may be concerned that HRT might affect their memory and thinking skills (cognitive abilities). Researchers from Wake Forest School of Medicine, Winston-Salem, N.C., USA, reported in JAMA Internal Medicine (June 2013 issue) that women aged 50 to 55 on HRT have no risk of memory problems or cognitive declines.
Their study demonstrated that HRT for post-menopausal females with CEEs (conjugated equine estrogens) is not associated with overall sustained benefit or risk to cognitive function. The researchers added that we do not know whether this might be the case with younger patients.
Lead researcher, Mark A. Espeland, Ph.D., said "Global cognitive function scores from women who had been assigned to CEE-based therapies were similar to those from women assigned to placebo. Similarly, no overall differences were found for any individual cognitive domain. Our findings provide reassurance that CEE-based therapies when administered to women earlier in the postmenopausal period do not seem to convey long-term adverse consequences for cognitive function."
Some things the woman can do herselfThe following measures may help ease symptoms:
- Consume less caffeine
- Consume less alcohol
- Consume less spicy food
- Don't smoke
- Do exercise regularly
- Wear loose clothing
- Sleep in a well ventilated, cool rom
Anecdotal accounts say that consuming ginseng, block cohosh, red clover, soya beans and Kava help with menopausal symptoms. Experts say scientific studies are needed to confirm this.