Hormone replacement therapy (HRT) is the most effective treatment for menopausal symptoms, in particular for younger women at the onset of the menopause, suggests a new review published today (19 December) in The Obstetrician & Gynaecologist (TOG).
The review highlights that menopausal symptoms, including hot flushes and night sweats are common, affecting around 70% of women for an average of 5 years but may continue for many years in about 10% of women.
Every woman experiences the menopause differently; some experience one or two symptoms mildly while others have more severe symptoms. Menopausal symptoms can be debilitating and can adversely affect a woman’s quality of life.
HRT is a medical treatment for the menopause. It provides low doses of the hormone estrogen, with or without progestogen, which a woman no longer produces.
The review notes that the risk-benefit ratio of HRT has always been debated and discusses previous studies examining the effects of HRT.
The Women’s Health Initiative Study in 2003 examined the effect of HRT on healthy postmenopausal women with a particular interest in cardiovascular outcomes. The study reported an increase in breast cancer, stroke and venous thromboembolism. Consequently, an 80% reduction in HRT use was reported. However, the re-analysis in 2007 demonstrated that giving HRT to women within 10 years of the menopause was associated with fewer risks and a reduction in cardiovascular problems.
Some women can use menopausal hormone therapy (MHT) to help control the symptoms of menopause. MHT, which used to be called hormone replacement therapy (HRT), involves taking the hormones estrogen and progesterone. (Women who don’t have a uterus anymore take just estrogen.)
MHT can be very good at helping with moderate to severe symptoms of the menopausal transition and preventing bone loss. But MHT also has some risks, especially if used for a long time.
MHT can help with menopause by:
Reducing hot flashes, night sweats, and related problems such as poor sleep and irritability
Treating vaginal symptoms, such as dryness and discomfort, and related effects, such as pain during sex
Slowing bone loss
Possibly easing mood swings and mild depressive symptoms (MHT is not an antidepressant medication - talk to your doctor if you are having signs of depression.)
For some women, MHT may increase their chances of:
Gall bladder disease
The Million Women Study in 2001 suggested that HRT use increased the risk of breast cancer significantly and the Cochrane Collaboration systematic review identified an increased risk of similar conditions.
However, the authors of the TOG review highlight that such studies failed to address the effect of HRT in symptomatic younger postmenopausal women and have not addressed the benefits of HRT given at the window of opportunity, for example, administrating HRT for symptom relief during the early phase of the menopausal transition.
Additionally, the review advises that any woman with relative contraindications should be offered the option of discussing this further with a menopause specialist. Women with premature ovarian sufficiency should be strongly advised to consider taking HRT until the average menopausal age of 51.4 years, state the authors.
The authors conclude that doctors should not be concerned about discussing the risks and benefits of HRT with women who have menopausal symptoms, or be hesitant to offer a trial of appropriate treatment. They also emphasise that HRT is a patient choice.
What is hormone replacement therapy?
HRT is a treatment used to augment the body’s natural hormone levels, either in the form of estrogen-alone therapy (ET), for women who have had a hysterectomy (or surgical menopause) or as estrogen with progesterone therapy (EPT), for women who experience menopause naturally at midlife.
Why replace hormones?
In addition to thickening the lining of the uterus to prepare it for egg implantation, estrogen - in tandem with progesterone - serves many functions. It helps the body to process calcium (important for the strengthening of bone), aids in maintaining healthy cholesterol levels, and keeps the vagina healthy. With the onset of menopause, however, the amount of natural estrogen and progesterone the ovaries produce drops sharply. That, in turn, can lead to such symptoms as hot flashes, night sweats, vaginal dryness, painful intercourse, mood changes, and sleep problems. It also can boost the risk of osteoporosis. By replenishing the body’s estrogen supply, HRT can help relieve menopause symptoms and guard against osteoporosis.
When is estrogen therapy alone appropriate?
Estrogen alone is generally prescribed for women undergoing surgical menopause (the result of a hysterectomy).
When is estrogen/progesterone therapy appropriate?
The combination of estrogen and progesterone is for women who still have a uterus (that is, those who have not had a hysterectomy). For women undergoing menopause naturally, taking estrogen alone can increase the risk of developing cancer of the endometrium (the lining of the uterus). That’s because during the reproductive years, endometrial cells are discharged during menstruation, but when menstruation ceases and the endometrium is no longer shed, the addition of estrogen can cause an overgrowth of uterine cells, which, in turn, can lead to cancer. Adding progesterone (in the form of progestin, a synthetic version of the hormone) lessens the risk of endometrial cancer by causing the endometrium to shed each month.
Who should consider HRT?
Women with moderate to severe menopausal symptoms, as well as those with a family history of osteoporosis, are candidates for hormone replacement therapy.
Shagaf Bakour, Honorary Senior Lecturer and Consultant Obstetrician and Gynaecologist at City Hospital, Birmingham, and co-author of the review said:
“Women are sometimes concerned about the increased risk of breast cancer related to HRT. However, this risk is much lower than that associated with other factors such as obesity, alcohol consumption and later maternal age.
“HRT is the most effective treatment for symptoms of the menopause and when HRT is individually tailored, women gain maximum advantages and the risks are minimised.
“There are various types and regimens of HRT and healthcare professionals will be able to advise on the suitability of HRT to any woman.”
Jason Waugh, TOG Editor-in-chief added: “The use of HRT is an individual decision, which a woman can only make once she has been given correct information and advice from healthcare professionals.
“If women have any concerns about menopausal symptoms or HRT, they should talk to their doctor who will be happy to discuss treatment options further.”
The Obstetrician & Gynaecologist (TOG) is published quarterly and is the Royal College of Obstetricians and Gynaecologists’ (RCOG) medical journal for continuing professional development. TOG is an editorially independent, peer reviewed journal aimed at providing health professionals with updated information about scientific, medical and clinical developments in the specialty of obstetrics and gynaecology.
To view further information about the 2013 British Menopause Society & Women’s Health Concern recommendations on hormone replacement therapy, please click here.
For patient information about the use of HRT to treat symptoms of menopause, please visit Women’s Health Concern. For healthcare professionals, please visit the British Menopause Society.
You should not use menopausal hormone therapy (MHT) if you:
May be pregnant
Have problems with vaginal bleeding
Have had certain kinds of cancers (such as breast and uterine cancer)
Have had a stroke or heart attack
Have had blood clots
Have liver disease
Have heart disease
If you choose MHT, experts recommend that you:
Use it at the lowest dose that helps
Use it for the shortest time needed
S H Bakour, J Williamson. Latest evidence on using hormone replacement therapy in the menopause. The Obstetrician & Gynaecologist 2014; http://onlinelibrary.wiley.com/doi/10.1111/tog.12155/