Hormone replacement therapy
What is hormone replacement therapy and why is it used?
As women go through menopause, production of the female sex hormones (oestrogen and progesterone) is dramatically reduced, resulting in low levels of these hormones in the body. This means that many women experience unpleasant symptoms as a result of the decreased levels of these hormones, particularly oestrogen.
Hormone replacement therapy (HRT), also known as hormone therapy (HT), is prescribed by your doctor and replaces the body’s female sex hormones, oestrogen and progesterone.
There is an increasing range of alternative treatments for menopause symptoms available, but so far there is little good evidence that they are effective. Herbal medicines can have adverse effects and can also interact with other medicines. HRT that is available on prescription from your doctor therefore remains the most accepted treatment for relieving the symptoms of menopause that many women find troublesome.
How can HRT help me?
HRT helps treat 2 troublesome symptoms of menopause — hot flushes and night sweats. It may also help with insomnia, mood swings, a dry vagina and muscle aches and pains. HRT helps maintain bone density and it reduces the risk of fractures due to osteoporosis (a condition that makes bones weak and brittle). However, other medicines are available for the treatment and prevention of osteoporosis.
Does HRT have any risks?
Several major studies, including the Women’s Health Initiative (WHI) study and the Million Women Study have reported on the effects of HRT on long-term health. The main risks to consider are blood clots, stroke, cardiovascular disease, breast cancer and gallbladder disease.
The risk of breast cancer is increased when combined HRT is used for 4 to 5 years. There is a greater risk of breast cancer with combined HRT than with oestrogen alone.
The effect of HRT on the risk of heart disease is complicated. Outcomes are affected by: when HRT is started; how long you take HRT; and whether there is any underlying heart disease.
HRT increases the risk of stroke, and the risk increases with increasing age. However, stroke is uncommon in otherwise healthy women younger than 60 years with normal blood pressure.
Oral HRT increases the risk of having a blood clot. The risk is further increased with increasing age and when there are other risk factors, such as obesity and smoking. However, the risk is low in healthy women younger than 60 years.
HRT is associated with an increased risk of cholecystitis — inflammation of the gallbladder. The risk may be reduced by using skin patches rather than oral HRT.
Overall, using HRT for up to 5 years is considered safe and effective for most women.
Weighing up whether or not to take HRT
It is worth discussing the risks and benefits of HRT with your doctor. He or she will be able to advise you on whether HRT is right for you. If the symptoms of menopause are not really bothering you, you may not wish to consider taking HRT at all.
You should be aware that HRT is not a ‘quick fix’ solution to the challenge of menopause, but only one aspect of its overall management. You should make sure you take regular exercise, eat a varied diet low in fat and high in fruits and vegetables, and make time for relaxation.
HRT is not the same as birth control pills and it will not stop you from falling pregnant. If you are still getting your periods, even if they are not regular, you should discuss with your doctor whether or not you still need to use contraception.
What does HRT involve?
HRT can be given in various ways and there are many different formulations and combinations of hormones available. Depending on your medical history your doctor may suggest one of the following.
Cyclic combined treatment
This is usually given if you are still getting periods or have not yet had a full year without periods. It involves daily oestrogen and 10–14 days per month of progestogen, a synthetic formulation of progesterone. Because cyclic combined HRT mimics your normal menstrual cycle, you may continue to have regular bleeding — like a period.
Continuous combined treatment
This is usually prescribed for women who have had more than a full year without periods. It involves oestrogen and progestogen daily, every day, but the dose of progestogen is lower than for cyclic HRT. You should not experience bleeding with this treatment after therapy is established, which may take 3-6 months.
Continuous oestrogen alone
Treatment with oestrogen alone is normally reserved for women who have had a hysterectomy (removal of their uterus), because oestrogen without the balancing effect of a progestogen has been associated with an increased risk of cancer of the endometrium (lining of the uterus). It is sometimes called ‘unopposed oestrogen replacement therapy’.
Tibolone (e.g. Livial) is an alternative to traditional HRT for women who have gone through the menopause. It acts like oestrogen on some body tissues, but like progesterone and testosterone on others. Tibolone is said to cause less breast tenderness than some other HRT medications do and may help women with a loss of sex drive. Tibolone does not cause period-like bleeding when used in women after the menopause. However, doctors do not recommend tibolone if you are still having your periods. Tibolone is not recommended for women who have a personal history of breast cancer. It is recommended that you discuss the risks and benefits of this medicine with your doctor.
How long will I need to take HRT?
For the relief of menopause symptoms, doctors usually suggest taking the lowest dose of HRT for the shortest amount of time necessary to control your symptoms. However, it depends on your individual needs. It is now recommended that HRT be used for short-term (2 to 5 years) treatment of menopausal symptoms, as this length of treatment is not associated with an increased risk of breast cancer. Longer term use is possible if you and your doctor believe that the benefits outweigh the risks. Talk to your doctor about the benefits and risks of long-term HRT, and whether or not long-term HRT is suitable for you.
How is HRT taken?
There are several different ways of taking HRT. Your doctor will choose the best one for you based on your medical history and potential for side effects. However, you may need to try different combinations before you find one that suits you.
These are still the most popular and widely available method of HRT. There are several combinations of HRT tablets, and there are also several dosage ‘strengths’ to suit different women.
HRT can be given as an oestrogen tablet for 14 days followed by a combined oestrogen and progestogen tablet for the next 14 days (e.g. Femoston). Alternatively both hormones may be combined into a single tablet (e.g. Angeliq 1/2, Kliovance, Kliogest, Premia 2.5 Continuous, Premia 5 Continuous).
There are also packs of tablets with a set number of oestrogen tablets which are followed by combined tablets then by oestrogen tablets again for a 28-day cycle (e.g. Trisequens). Most tablets come in easy-to-follow calendar packs.
Transdermal skin patches
These are applied every 3–4 days (e.g. Estraderm, Estradot) or every 7 days (e.g. Climara, Femtran). They are applied to your skin and release the hormones into your body slowly over time.
Most patches contain oestrogen only but combination oestrogen/progestogen products are available, either in one patch (e.g. Estalis Continuous) or in separate patches which may be supplied in the same pack but are applied at different times of the month (e.g. Estalis Sequi, Estracombi).
The patches come in varying strengths, and need to be replaced once or twice a week depending on the product. They may have fewer side effects than tablets because the dose of oestrogen is lower, but some women may find them irritating to the skin.
Oestrogen patches are often a good choice for women who find they experience side effects such as nausea from oestrogen tablets.
Progestogen is available on its own in tablet form (e.g. Primolut N) for use with oestrogen therapy, usually in the last 14 days of the cycle in women who have not had a hysterectomy.
Progestogen-releasing intra-uterine device (IUD)
Progesterone can also be delivered directly into the endometrium using an IUD that releases levonorgestrel (Mirena). This is a suitable alternative for women who cannot tolerate progestogen tablets.
Oestrogen is available on its own in tablet form (e.g. Estrofem, Ogen, Ovestin, Premarin, Progynova or Zumenon).
Oestrogen gel (Sandrena) is available in sachets and is helpful for women who cannot tolerate tablets and who do not want to wear a patch. It is rubbed onto the skin once daily.
These include oestrogen creams (e.g. Ovestin), or pessaries (e.g. Ovestin Ovula, Vagifem) and are usually prescribed if you are getting localised (confined to one area) menopausal symptoms such as a dry vagina or bladder problems and do not want to take systemic (general) treatment.
Bio-identical hormones (‘troches’)
So-called bio-identical hormones in the form of lozenges or ‘troches’ that are dissolved in the mouth are composed of a mix of hormones, such as different types of oestrogens and sometimes testosterone. There is no scientific data to support the safety or effectiveness of bio-identical hormones in relieving menopause symptoms, and their use is not supported by the Australian Menopause Society or the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
Before starting HRT
You should have a full gynaecological examination and blood pressure check. Your doctor may also suggest an HPV cervical cancer screening test (these have replaced Pap smears) and a mammogram, or a bone density scan if you are considered at particular risk of developing osteoporosis.
What are the side effects of HRT?
Some women experience side effects as a result of taking HRT. These include breast enlargement and tenderness, abdominal bloating and fluid retention, nausea and headaches. HRT does not cause weight gain in the long term.
Side effects may pass with time, or your doctor may need to change the dose or change to another method of treatment. If you are getting unusual bleeding, you should see your doctor straight away.
Who should not take HRT?
You may not be able to take HRT if you have, or have had, the following:
- breast cancer;
- liver or gall bladder disease;
- high blood pressure that is not well controlled, stroke or some types of heart disease;
- thrombosis (blood clot);
- some gynaecological conditions, including endometriosis, large fibroids, endometrial cancer and unexplained vaginal bleeding;
- systemic lupus erythematosus (SLE);
- diabetes mellitus;
- severe kidney disease;
- a high level of triglycerides (type of fat) in your blood.
Your doctor can give you specific advice about these conditions and the use of HRT.
Your doctor will also be able to inform you fully about the risks and benefits of HRT and address any concerns you have. The more you understand, the easier it should be to make informed decisions.
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3. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of the menopause , November 2011. http://www.ranzcog.edu.au/component/content/article/270-revised-statement-guidelines/469-management-of-the-menopause-c-gyn-9.html (accessed Sep 2012).
4. Menopause (revised June 2009). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2012 Jul. http://online.tg.org.au/complete/ (accessed Sep 2012).