Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP

The real facts about menopause and HRT – based on the real evidence

The real facts about menopause and HRT – based on the real evidence – and why we ALL need to be rebranding the menopause as a “female hormone deficiency”

Dr Louise Newson BSc(Hons) MBChB(Hons) MRCP FRCGP

For decades, the menopause has been a taboo and there has been a huge amount of misinformation and misconceptions about treatment options, especially hormone replacement therapy (HRT). This has resulted in women’s health being far worse than it could be otherwise. If more women were given the right advice and treatment based on the available evidence, then women’s health would improve and health costs to the NHS would also dramatically reduce.

The menopause occurs usually when a woman runs out of eggs so her associated hormone levels decline and her periods stop. The average age is 51 years but it is common in younger women too – around 1 in 100 women under 40 years have an early menopause. The menopause can occur earlier in women who have their ovaries removed in an operation or have a hysterectomy. Also, some treatments for cancer (such a radiotherapy, chemotherapy and some medication) can lead to a menopause occurring even younger. Women can be perimenopausal for many years before their periods actually stop – the perimenopause is when hormone levels start to decline and menopausal symptoms begin.

The life expectancy of women has increased over the past century, so women now often spend at least one-third of their lives being postmenopausal.  Once a woman’s periods have stopped then her hormone levels will always be low, regardless of whether or not she experiences symptoms – she will have a female hormone deficiency. There are health risks of the menopause as women have an increased future risk of heart disease, osteoporosis, type 2 diabetes, as a result of low hormone levels that occur.

The most common menopausal symptoms are vasomotor symptoms (ie hot flushes and night sweats). Other symptoms include mood changes, memory loss, vaginal dryness and soreness, reduced libido, sleep disturbances, joint pains and muscle stiffness1,2. These symptoms can be non-existent, last for a few years, or even decades. Around 75% of menopausal women experience symptoms, with around one third of these experiencing severe symptoms3.

Many women and healthcare professionals are worried about the perceived risks of taking HRT. Much of the negativity regarding HRT stems from the misinterpretation of the Women’s Health Initiative (WHI) study in 2002, which led to a worldwide reduction in HRT use4. The results of this study were leaked to the press early, before they had been properly analysed. The subsequent sub-analysis of this study showed that women taking HRT are healthier and have less diseases than those women not taking HRT5.

There are numerous potential benefits to be gained by women taking HRT. Symptoms of the menopause such as hot flushes, mood swings, night sweats, and reduced libido improve.  Numerous studies have shown that shown that when take HRT they have a lower future risk of osteoporosis, type 2 diabetes, osteoarthritis and also death from all causes6.

Most women and healthcare professionals are concerned about the possible risks of breast cancer in women taking HRT. However, the risk is far lower than many realise. Women who take estrogen only HRT (women who have had a hysterectomy) actually have a lower of breast cancer than women not taking HRT. Women who take estrogen and a progestogen may have a small increased risk of breast cancer. However, this increased risk is a similar magnitude to the risk of breast cancer for women who are drinking a glass or two of wine each night (so if there is a risk then this risk is very low). To put this into perspective, women who are obese are ten times more likely to develop breast cancer.

Reluctance of doctors and nurses to prescribe HRT is denying many women adequate and effective symptom relief and increasing their future risk of significant conditions.  It is so important that women are given accurate, evidence-based information so they can have receive the right treatment for their perimenopause and menopause. This will then have a positive effect on their future health.

Ten Tips:

• The benefits of HRT outweigh the risks for most women

• HRT is much safer than many people realise. NICE Menopause Guidance provides evidence and reassurance

• HRT should be recommended routinely to the majority of perimenopausal and menopausal women

• Women who take HRT have a lower risk of heart disease, osteoporosis, diabetes and dementia

• There is no limit to length of time taking HRT – women can take HRT for ever

• Body identical HRT (same molecular structure as a woman’s hormones) is the optimal type of HRT

• Oestrogen through the skin as a patch, gel or spray has no risk of clot and a lower risk of breast cancer

• Micronised progesterone is safer than older types of progestogens

• Testosterone is a female hormone that can improve libido, mood, energy and concentration

• Testosterone can be especially beneficial in young women and those women who have had a surgical menopause

References
1. National Institute for Health and Care Excellence. NICE guideline NG23 – Menopause: diagnosis and management 2015 [May 2017]. Available from: https://www.nice.org.uk/guidance/ng23
2. Baber RJ, Panay N, Fenton A, Group IMSW. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016;19:109-50
3. Hamoda H, Panay N, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal women. Post Reproductive Health 2016;22:165-83
4. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321-33
5. Manson JE, Aragaki AK, Rossouw JE et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. JAMA. 2017; 318(10):927-938
6. Boardman HM, Hartley L, Eisinga A, Main C, Roque i Figuls M, Bonfill Cosp X, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015:CD002229

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