What is hormone replacement therapy?

Hormone replacement therapy (HRT) is widely used by women who want to manage their menopausal symptoms.

HRT effectively treats hot flushes, vaginal dryness and other distressing menopausal symptoms. Most menopausal women are also less tired, have greater mental focus and energy, improved mood and heightened libido, all of which continue for as long as they have HRT.

Hormone replacement also preserves bone architecture and strength. Women who start HRT in their peri-menopausal years appear to have a lower risk of fractures in later life.

Some studies also suggest women who have HRT during peri-menopause have a slightly lower risk of dementia.

Is HRT safe?

Recent research shows having HRT for five or more years might negatively affect our health, particularly with respect to heart disease and breast cancer.

If you are considering hormone replacement, start it in the critical window before or around the time of the menopause. Doing so reduces the risk of heart disease. The magnitude of this effect, however, is small compared to other ways of preventing heart disease, such as lowering “bad” cholesterol levels and blood pressure or quitting smoking.

If you start HRT late – more than 10 years after reaching the menopause – it can increase your risk of heart disease. This is because the receptors through which estrogen would normally signal its protective effect(s) have long-since disappeared.

Certainly, women with or at risk of heart disease or clotting shouldn’t undergo HRT, as it may be detrimental.

The other concern with HRT is the suggestion that it may slightly increase the risk of breast and ovarian cancer. Again, this alleged risk is very small compared to smoking, eating or drinking too much.

Nonetheless, those with family histories of breast cancer or other conditions linked with breast cancer should consider non-hormonal methods to manage menopausal symptoms.

Women should avoid using HRT for more than 10 years, as many benefits seem to disappear after this time, while risks increase.

Forms of HRT

HRT is delivered via oral, transdermal or vaginal routes.

Women who haven’t had hysterectomies are usually given a ‘combined’ regimen, in which estrogen is combined with progesterone. You can have this combined hormone therapy on a cyclical basis, as you would on the contraceptive pill, or on a continuous, daily schedule.

Women who have had hysterectomies can take daily doses of estrogen without progesterone.

Generally, the dose is determined by why you’re starting HRT. To control unwanted menopausal symptoms, the lowest effective dose is preferable. Low doses also reduce the chances of experiencing side-effects such as breast tenderness or intermittent vaginal bleeding.

Vaginal symptoms such as dryness, itching, discomfort and painful intercourse are a frequent complaint of post-menopausal women.

Treating these symptoms with oral HRT isn’t always necessary.

Some women use estrogen creams, pessaries, tablets or an oestradiol-releasing ring to avoid excessive or unnecessary exposure to hormones inside their body. These are safe and can be effective in some women, especially if started early in the peri-menopausal period.

Women can also use lubricants or increase foreplay prior to sex to increase natural lubrication if they don’t want to use hormone replacement therapy.

Benefits and risks

Potential benefits:

  • Prevent and treat menopausal symptoms including hot flushes, vaginal dryness, pelvic floor discomfort, sleeplessness and tiredness, lethargy, and low mood
  • Significantly lower risk of thin, weak bones (osteoporosis) and increased risk of fracture
  • Slightly reduce risk of heart attack, stroke, cognitive decline and dementia
  • Slightly reduce risk of colon cancer and age-related vision loss associated with macular degeneration

Potential risks:

  • Slightly increase risk of breast and ovarian cancer
  • Slightly increase risk of heart attack and stroke (if you begin HRT well after the menopause or if you have heart disease)
  • Intermittent vaginal bleeding
  • Increase risk of gallstones, especially if overweight

Bioidentical hormone replacement therapy

Some claim bioidentical hormone replacement therapy is superior because it uses hormones chemically identical to those found in our bodies.

Women can have compounded troches or lozenges of bioidentical hormones tailor-made based on their individual symptoms and blood tests.

There isn’t any current evidence, however, to suggest bioidentical hormones have any special advantages over those used in conventional HRT.

Most compounded preparations haven’t been through clinical trials big enough to confirm their relative safety.

Natural alternatives to HRT

A number of natural alternatives to HRT have proven popular for managing menopausal symptoms:

  • plant-derived isoflavones (from soy, clover, flax, hops or other sources) bind and partially activate estrogen receptors – so-called phytoestrogens. Foods naturally high in phytoestrogens such as tofu, tempeh, soy milk, flaxseed and linseed, don’t effectively treat menopausal symptoms, but high dose supplements are widely available.
  • herbs such as tribulus terrestris and Vitex increase natural hormone levels by inhibiting enzymes in our livers that metabolize estrogen.
  • other herbal products including Black Cohosh (or cimicifuga) are promoted as offering hormone-free relief for menopausal symptoms, though they probably act by modifying serotonin levels.

On the whole, small clinical trials with these supplements have failed to confirm replicable benefits, although some women will experience improvements in some menopausal symptoms.

More selective non-hormonal solutions to menopausal symptoms, including gabapentin, selective serotonin reuptake inhibitors (SSRIs) and clonidine, are available on prescription.

Overall, however, conventional HRT is far more effective for relieving menopausal symptoms.

No data exists for which HRT formulation is the best. In most comparisons the benefits turn out to be roughly the same, so women should choose the one that works best for them.

 

Last Reviewed 29/Oct/2016

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Dr Merlin Thomas

Professor Merlin Thomas is Professor of Medicine at Melbourne’s Monash University, based in the Department of Diabetes. He is both a physician and a scientist. Merlin has a broader interest in all aspects of preventive medicine and ageing. He has published over 270 articles in many of the worlds’ leading medical journals