Following on from our menopause blog earlier this year, we wanted to dive a bit deeper into Hormone Replacement Therapy (HRT). HRT is one of the most effective ways to treat menopause. However, people can still feel uncertain about whether it is the right thing for them or not.
We asked Dr. Elise Dallas, our Women’s Health Lead GP a few questions about HRT and why it is a good thing for people going through menopause.
1. How does HRT work?
Hormone replacement therapy does what it says on the tin. During menopause, your oestrogen levels drop. As hormones affect every cell in our body, this can cause a lot of different symptoms as you can see from our menopause symptom checklist here. HRT works by replacing the oestrogen which has been naturally depleted as a result of menopause.
In people who still have a womb, combined HRT is used. This contains oestrogen and progesterone. Whilst progesterone itself doesn’t improve many of the menopausal symptoms directly, it does help protect the lining of your womb.
Some HRT regimes also include testosterone but this generally needs to be started by a specialist first.1
2. Is HRT safe?
Let’s address the elephant in the room - HRT has had some bad press. Studies in the early 2000s were published highlighting the potential risks of hormone replacement therapy and as a result, some women and doctors have been reluctant to use HRT.
However, more recent published findings about the newer types of HRT, including body-identical HRT, show that although not entirely risk-free, it remains the most effective solution for the relief of menopausal symptoms. It can also help in the prevention of osteoporosis and provide protection against heart disease and possibly even dementia (although further research is needed on that one).2 If it is started under the age of 60, the benefits will outweigh the risks for many people.
3. Is HRT right for me?
Starting HRT can feel like a big decision but it is an important one to consider for all women. As with all medications, a decision about whether or not it is right for you will be made by you and your doctor, taking into account your medical history and preferences.
In general, if you are in your mid-40s and have menopausal symptoms, with or without periods, I would suggest considering HRT - it is not dangerous as long as you don’t have any contraindications. These are pre-existing conditions or risk factors which would mean it is not suitable to take HRT.
If you decide to go ahead with HRT treatment, you can generally begin a trial of HRT as soon as you start experiencing menopausal symptoms and usually will not need to have any tests first. We explain why here. If your symptoms improve, we will soon know whether they are due to perimenopause or not.
4. Where do I get HRT from?
Most HRT is prescription only - this means that you can get it after a consultation with your local GP or menopause specialist. However, an exciting new development in the UK in 2022 means that vaginal oestrogen is now available over the counter. This is a big step forward for HRT.
Vaginal oestrogen is helpful for symptoms of vaginal atrophy, like dryness, itchiness and burning among others. These are very common, particularly at the later stage of menopause and can be extremely distressing.
At the moment, this medication is available over the counter to postmenopausal women over 50 years who have not had a period for at least a year only. However you can still access this with a prescription if you do not fit this criteria yet.
Vaginal oestrogen is very safe and is not the same as other HRT preparations like transdermal oestrogen gel. Such small amounts get into the bloodstream that it is even considered safe to use for women with breast cancer.
5. What are the risks and benefits of taking HRT?
Hormones affect our bodies all the time (and not just around your menstrual cycle) so the implications of having a low oestrogen for a third of your life can be significant.
Oestrogen receptors are in every cell of our body. This is why you can experience so many different symptoms when levels are fluctuating during perimenopause. Taking HRT can help manage vasomotor symptoms like hot flushes and night sweats as well as the low mood and anxiety that you may experience. Replacing oestrogen also has long-term health benefits such as reducing your future risk of cardiovascular disease, osteoporosis and type 2 diabetes.
The most benefit is gained when you start HRT within 10 years of your menopause.4
6. How long can I stay on HRT?
It is now agreed that there is no definitive duration of use or age cut-off for HRT use and should not be discontinued solely based on patient age. Extended use of HRT beyond 65 years should be individualised and risks assessed on a patient-by-patient basis. Persistent symptoms such as hot flushes or need for bone protection are indicators for ongoing treatment.
7. Does HRT increase my risk of getting breast cancer, blood clots and strokes?
This is a really important question and we understand why this may be on your mind. The risks are usually very small and depend on the type of HRT you choose, how long you take it for and your own health risks.
Breast cancer risk:
- If you do not have a womb and take oestrogen-only HRT, there is little or no change in the risk of breast cancer.
- Combined HRT (oestrogen and progestogen) may be associated with a small increased risk of developing breast cancer. The increased risk relates to how long you take HRT, and it falls after you stop taking it. Taking bioidentical progesterone (otherwise known as micronised progesterone) has been shown to have the least risk.
- Young women (under 51 years) taking HRT do not have a greater risk of breast cancer5
- Taking oral oestrogen HRT can very slightly increase your risk of blood clots
- There is no increased risk with transdermal oestrogen HRT (patches or gels)
- With micronised progesterone, there is no risk.2
Heart disease and strokes:
- When HRT is started before the age of 60 years, it does not significantly increase the risk of cardiovascular disease (including heart disease and strokes) and may actually reduce your risk.
- Taking oestrogen HRT tablets is associated with a slight increase in the risk of stroke, but the risk of stroke for women under age 60 is generally very low. This means the overall risk is still small and taking oestrogen as a patch or gel eliminates this risk.6
As you can see, the type of HRT you are on can have different benefits and risks. HRT containing micronised progesterone or in the form of the hormonal coil has been shown to be linked with a lower risk of breast cancer, heart disease and blood clots compared to other synthetic progesterone. The hormonal IUS has the added benefit of being contraception too.
There is good evidence showing that an oestrogen patch or gel with a micronised progesterone is the best option for many people, including those with a risk of cardiovascular events. However, the right HRT regime will vary from person to person. The good thing is, you don’t have to weigh up this decision alone - Babylon offers high-quality, 24/7 comprehensive health care and one of our providers can assist you in navigating your choices. Let us help:
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- HRT, NHS choices, Reviewed September 2019
- Benefits and Risks, NHS choices, Reviewed September 2019
- FSRH statement: we welcome reclassification of Gina 10microgram vaginal tablets, Issued July 2022
- BMS & WHC’s 2020 recommendations on hormone replacement therapy in menopausal women, British Menopause Society, Updated March 2021.
- Does hormone replacement therapy (HRT) increase cancer risk? Cancer Research UK, Reviewed March 2021
- Benefits and risks of HRT, NICE, Updated December 2019.