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Menopause and HRT

menopause and hrt

Strictly speaking, the menopause is your last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. Women are said to have gone through the menopause (be postmenopausal) when they have not had a period at all for one year.

What causes the menopause?

  • A natural menopause occurs because as you get older, your ovaries stop producing eggs and make less oestrogen (the main female hormone). There are certain things that may cause an early menopause. For example:
  • If you have surgery to remove your ovaries for some reason, you are likely to develop menopausal symptoms straight away.
  • If you have radiotherapy to your pelvic area as a treatment for cancer.
  • Some chemotherapy drugs that treat cancer may lead to an early menopause.
  • If you have had a hysterectomy (removal of the uterus) before your menopause. Your ovaries will still make oestrogen. However, it is likely that the level of oestrogen will fall at an earlier age than average.
  • An early menopause can run in some families.
  • In some women who have an early menopause, no cause can be found.

What are the possible symptoms and problems of the menopause?

The menopause is a natural event. Every woman will go through it at some point. You may have no problems. However, it is common to develop one or more symptoms which are due to the low level of oestrogen.

Short-term symptoms

These short-term symptoms only last for a few months in some women.

Hot flushes occur in about 3 in 4 women. A typical hot flush lasts a few minutes and causes flushing of your face, neck and chest. You may also perspire (sweat) during a hot flush. Some women become giddy, weak, or feel sick during a hot flush. Sweats commonly occur when in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and night clothes.

Other symptoms may develop, such as headaches, tiredness, being irritable, difficulty sleeping, depression, anxiety, aches and pains, loss of libido (sex drive), and feelings of not coping as well as before.

Changes to your periods. The time between periods may shorten in some women around the menopause; in others, periods may become further apart, perhaps many months apart. It is also common for your periods to become a little heavier around the time of the menopause.

Longer-term changes and problems

Skin and hair. You tend to lose some skin protein (collagen) after the menopause. This makes the skin drier, thinner and more likely to itch.

Genital area. Lack of oestrogen tends to cause the tissues in and around the vagina to become thinner and drier.  The vagina may shrink a little, and expand less easily during sex.

You may experience some pain when you have sex. Your vulva (the skin next to your vagina) may become thin, dry, and itchy.

As you become older, you gradually lose bone tissue. Your bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss, then you have osteoporosis. If you have osteoporosis, you have bones that will break more easily than normal, especially if you have an injury such as a fall.

Your risk of cardiovascular disease (disease of the heart and blood vessels), including heart disease and stroke, increases after the menopause. Again, this is because the protective effect of oestrogen is lost.

Do I need any tests to see if I am going through the menopause?

Your doctor can usually diagnose the menopause by your typical symptoms. Hormone blood tests are not usually needed to confirm that you are going through the menopause. However, they may be helpful in some cases. For example, if your doctor suspects that you are going through an early menopause, or if you have had a previous hysterectomy (and so are no longer having periods).

Do I need treatment for the menopause?

Many women do not have symptoms severe enough to require treatment. Only about 1 in 10 women sees a doctor because of her symptoms. There are treatments other than HRT for menopausal symptoms. As a rule, they are not as effective as HRT, but may help relieve some symptoms

What is hormone replacement therapy?

All types of HRT contain an oestrogen hormone. If you take HRT it replaces the oestrogen that your ovaries no longer make after the menopause.

HRT is available as tablets, skin-patches, gels, nasal spray or implants. There are several brands for each of these types of HRT. All deliver a set dose of oestrogen into your bloodstream.

However, if you just take oestrogen then the lining of your uterus (womb) builds up. This increases your risk of developing cancer of the uterus. Therefore, the oestrogen in HRT is usually combined with a progestogen hormone. The risk of cancer of your uterus is very much reduced by adding in the progestogen. In many HRT products, the oestrogen and progestogen are combined in the same tablet, patch, implant, etc but they can also be taken separately.

How do I take hormone replacement therapy?

If you start HRT when you are still having periods, or have just finished periods

You will normally be advised to use a 'cyclical combined HRT' preparation. There are two types:

Monthly cyclical HRT - you take oestrogen every day, but progestogen is added in for 14 days of each 28-day treatment cycle. This causes a regular bleed every 28 days, similar to a light period. (They are not 'true' periods, as HRT does not cause ovulation or restore fertility. The progestogen causes the lining of the uterus to build up which is then shed as a 'withdrawal' bleed every 28 days when the progestogen part is stopped.) Monthly cyclical HRT is normally advised for women who have menopausal symptoms but are still having regular periods.

Three-monthly cyclical HRT - you take oestrogen every day and then you also take progestogen for 14 days, every 13 weeks. This means that you have a bleed every three months. This is normally advised for women who have menopausal symptoms but are having irregular periods.

You may switch to a continuous combined HRT if you have been taking cyclical combined HRT for some time but are now over the age of 54.

If you start HRT a year or more after your periods have stopped

If your periods have stopped for a year or more, you are considered to be postmenopausal. If this is the case, you will normally be advised to take a 'continuous combined HRT preparation'. This means that you take both an oestrogen and a progestogen every day. The dose and type of the oestrogen and progestogen are finely balanced so that they usually do not cause a monthly bleed. However, you may have some irregular bleeding when you start taking this form of HRT.

If you mainly have genital symptoms

You may choose to try for example, some vaginal oestrogen cream or a pessary to help your symptoms. This alone may be enough to relieve symptoms in some women who would prefer this option or who cannot take other forms of HRT for some reason.

What are the benefits of hormone replacement therapy?

  • Menopausal symptoms usually ease
  • HRT tends to stop hot flushes and night sweats within a few weeks.
  • HRT will reverse many of the changes around the vagina and vulva usually within 1-3 months.
  • If you are anxious, irritable, depressed, etc, at the same time as having menopausal symptoms, these symptoms may also ease if symptoms such as hot flushes or a dry vagina are eased.

If you take HRT long-term (several years or more)

  • Taking either estrogen-only or combined HRT may reduce your risk of osteoporosis.
  • HRT is also thought to produce a small reduction in your risk of developing colorectal (bowel) cancer.

What are the risks in taking hormone replacement therapy?

  • Venous thromboembolism
  • Breast cancer
    • You may have a small increased risk of breast cancer if you take HRT.
  • Stroke
    • Some previous big studies, have shown that there is a small increased risk of stroke in women taking either oestrogen-only or combined HRT.
  • Coronary heart disease
    • It is the usual cause of angina and heart attacks. So far, studies have shown that oestrogen-only HRT does not seem to increase your risk of coronary heart disease.
  • Cancer of the uterus (womb)
    • There is an increased risk of cancer of the uterus due to the oestrogen part of HRT. By taking combined HRT containing oestrogen and progesterone, this risk reduces significantly.
  • Cancer of the ovary
    • There is a slightly increased risk of developing this cancer if you use oestrogen-only HRT or combined HRT. This risk decreases after you stop HRT.
  • Dementia
    • If you start HRT after the age of 65, it is not thought to protect against dementia. Also, combined HRT may increase the risk of dementia in women over the age of 75 years.

HRT may not advised in the following cases:

  • If you have a history of endometrial (womb) cancer, ovarian cancer or breast cancer.
  • If you have a history of blood clots (a DVT or a PE).
  • If you have a history of heart attack, angina or stroke.
  • If you have uncontrolled high blood pressure.
  • If you are pregnant.
  • If you have severe liver disease.
  • If you have an undiagnosed breast lump.
  • If you are being investigated for abnormal vaginal bleeding.

What about side-effects when taking hormone replacement therapy?

Side-effects with HRT are uncommon.

  • In the first few weeks some women may develop slight nausea (feeling sick), some breast discomfort or leg cramps. These tend to go within a few months if you continue to use HRT.
  • HRT skin patches may cause irritation of the skin.
  • Some women have more headaches or migraines when they take HRT.
  • Dry eyes (lack of tears) are also thought to be more common in HRT users.

What is tibolone?

Tibolone is a man-made hormone that can be used as an alternative to HRT. It has some oestrogen, progestogen and also some androgen (male hormone) effects. So, you just have to take this one tablet to have these hormone effects.

It is effective in treating sweats and hot flushes. It reduces your risk of osteoporosis. It may also improve your libido (sex drive). It is associated with a small increased risk of stroke. Most studies have shown a small increased risk of having endometrial (womb) cancer diagnosed in women who use tibolone.


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