HRT – benefits, side-effects and risks

Benefits of hormone replacement therapy

For the relief of symptoms (hot flushes, night sweats, dry skin, discomfort during intimacy due to dryness in the vagina, poor libido, dry skin and many others) – NOTHING BEATS HRT. While there are alternatives to HRT, it is simply true to state that nothing is as good / effective as HRT. For most symptomatic women, the use of HRT for five years or less is safe and effective.

Here is a list of some of the benefits:

  1. HRT abolishes hot flushes and night sweats: within two weeks of commencing treatment, sometimes sooner, HRT dramatically reduces and more often than not completely abolishes hot flushes and night sweats. No currently available alternative therapy is as effective for these symptoms.
  2. HRT improves quality of life: this has been shown by all research that has studied quality of life in the menopause, and the impact of HRT. This is important, since menopausal symptoms can impact negatively on quality of life, but are not life threatening. Women find that the eradication of muscle aches and pains, the improvement in mood, the better quality sleep, the perking up in libido and more – all contribute to an improvement in quality of life.
  3. HRT improves vaginal dryness and urinary symptoms: intimacy becomes more comfortable, and the desire for it also often improves. The nuisance of losing small amounts of urine when one coughs or plays a game of tennis is also reduced, as is the need to rush to the loo to empty the bladder.
  4. HRT reduces the risk of developing osteoporosis (brittle bones): while there are other treatments that reduce the risk of developing, or treat established osteoporosis, no treatment is as effective as oestrogen replacement.
  5. HRT reduces cardiovascular disease risk: a question mark has been put at the beginning of this statement because there is a degree of controversy and uncertainty. However, emerging evidence seems to suggest that HRT reduces the incidence of coronary heart disease if it is started within ten years of the menopause – which on the face of it makes sense: start therapy BEFORE potentially irreversible changes set in.
  6. HRT has additional (miscellaneous) benefits: HRT has a protective effect against connective tissue loss in tissues such as skin, bones, joints and mucous membranes. There may be a possible reduction in the long-term risk of Alzheimer's disease and all cause dementia in those women who take HRT. Most studies have demonstrated a reduction in risk of colorectal cancer with use of oral combined HRT.

Side effects of HRT

Common aspirin, taken by multitudes for the effective eradication of common symptoms such as a headache, causes side effects in a proportion of the populace, as does paracetamol – most, if not all, treatments have the potential for side effects. This is therefore to be expected and true too for HRT.

For some women their negative reaction to components of HRT is so severe that they are unable to take it, while for others the benefits of HRT outweigh the impact of the side effects. Quite often the side effects, such as headaches, bloatedness or breast fullness are transient and resolve once the woman settles on the HRT, usually within a couple of weeks. Sometimes it is necessary to change the type of HRT to minimize side effects. Here is a list of the more frequently experienced side effects:

  1. Side effects related to the hormone Oestrogen – breast tenderness, leg cramps, skin irritation, bloating, indigestion, nausea, headaches.
  2. Side effects related to the hormone Progesterone - premenstrual syndrome-like symptoms, fluid retention, breast tenderness, backache, depression, mood swings, pelvic pain.

There are effective ways of minimizing, or indeed even eradicating, these side effects. Thus nausea can be reduced by taking the HRT tablet at night with food instead of in the morning, or by changing from tablets to another type of HRT such as transdermal patches. While some women will complain that they put on weight as a result of taking HRT, in fact research has shown that HRT does not cause weight gain.

Weight gain in middle age (the so-called “middle-age spread”) is an undesirable reality, not caused by HRT. Researchers have found that, although women may put on some weight when they first start to take HRT due to a degree of reversible fluid retention, after a while their weight is the same as it was before treatment. Women whose energy levels and positive outlook on life following commencement of HRT find that they exercise more, and are therefore more likely to lose weight.

Irregular bleeding on HRT: Monthly sequential preparations should produce regular, predictable and acceptable period like bleeds. Erratic breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens (with no regular period like bleeds). If there is persistent irregular vaginal bleeding after six months of starting HRT, you will need to have further investigations. If you experience significant nausea or migraine headaches with oral preparations, patches can often be a better option. Progesterone related side-effects can often be minimised if the Mirena coil (intrauterine system) is used as the progesterone arm of HRT.

Risks associated with the use of HRT

At the Menopause Clinic London, we are great advocates of HRT. However, this does not blind us to the fact that HRT does carry risk for some women. We do not seek to minimize the risks, but rather to explain them as clearly as possible, and guide women to make informed choices.

Life choices are often about balancing risks against benefits, and it is arguably true that, based on current knowledge and the results of research, for the vast majority of women who need HRT the benefits far outweigh the risks. Current received wisdom says that women should take the lowest dose of HRT that controls their symptoms for the shortest duration of time possible.

That may seem obvious, self-evident and wise, but in reality there is no maximum duration of time for women to take HRT: for the woman who continues to have symptoms, HRT for life may be for them, and of course such women are kept under long term surveillance, with added benefits from such surveillance – regular mammograms, checks of blood pressure, regular blood tests that include measurement of cholesterol levels - the kind of surveillance that a women not on HRT is unlikely to receive.

It is also important to note that the risks from use of HRT are not the same for women younger than 50 (please visit www.prematuremenopausecliniclondon.co.uk for more information).

Here are some of the important risks of HRT

  1. Breast cancer

    The big C is a major worry for most women, and their physicians. It is therefore imperative that a detailed / extensive explanation of the risks is undertaken.

    In the mind of many a woman, the term “HRT” (hormone replacement therapy) immediately conjures up an image of the dreaded big C - breast cancer. Alas, this is also true for men, and indeed for healthcare professionals including general practitioners and even Gynaecologists. There is therefore an almost immediate antipathy to HRT – who wants to take a risk with a treatment that could give you cancer, especially a treatment that is often viewed as a “life-style” choice?

    However, the very fact of existence compels that risks are taken, some greater than others, some worthy while others are less so. It is therefore imperative that the extent of the risk of breast cancer associated with HRT is clearly understood, so that informed choices can be made.

    So, look at these figures, based on established research:

    • Among 1000 women, not on HRT, 23 will develop breast cancer over a 5-year period.
    • Among 1000 women given HRT that contains oestrogen and progesterone, 27 will develop breast cancer: an additional 4 women in a 1000 on HRT.
    • Among 1000 women given oestrogen-only HRT (because they do not have a womb, having had a hysterectomy), there is no increase in the number that develop breast cancer; indeed, most research shows the number to be lower.

    Please look at the illustrative diagram below for further clarity (adapted from www.womens-health-concern.org and www.thebms.org.uk)

    We make no comment as to whether an extra 4 women in a 1000 developing breast cancer while taking HRT is too high a risk, or in the greater scheme of life events, a risk worth taking. We leave it to each woman to weight up the risks against the benefits of HRT.

    Just for clarification:

    1. Women who have had a hysterectomy do not need a progestogen in their HRT regimen. The progestogen is given in women who have a uterus to protect against the development of cancer of the womb. All evidence points to the progestogen in HRT as the bogeyman responsible for the increased risk of breast cancer. Women without a womb, who are given oestrogen-only HRT, do not have an increase in the risk of developing breast cancer, and indeed all published data indicates that the risk in these women may be lower than in women not on HRT! (We are NOT advocating that women without a womb should take oestrogen-only HRT to prevent breast cancer!).
    2. Women with a womb could be given the same protection against the risk of breast cancer by having a Mirena coil inserted into the womb. This coil produces a progestogen locally, thus protecting the womb against the development of cancer, but theoretically while not increasing the risk of breast cancer. We say “theoretically” because there is no research evidence to confirm that the use of the Mirena coil in this way does reduce the risk of breast cancer in women are then given oestrogen only.
    3. Some HRT specialists seek to reduce the risk of breast cancer from progestogens by giving the progestogens every 3-4 months to induce shedding of the lining of the womb, thereby protecting the womb while reducing the exposure to the progestogens. Again, there is no definitive evidence that this approach protects against the risk of breast cancer.
  2. Venous thromboembolism (blood clotting): Oral HRT (combined oestrogen and progesterone or oestrogen only) increases the risk of venous thrombo-embolism (venous blood clots), pulmonary embolism (blood clot in lungs) and stroke. In one big study, over five years, less than 1 in 100 women taking HRT developed a blood clot in their lungs. However, this number was about twice the number of women who were not taking HRT. To put the issues into perspective, the risk is a lot lower than that associated with taking the contraceptive pill, or that associated with pregnancy. Research also shows that transdermal oestrogens (patches) are safer with respect to the risk of venous thrombo-embolism. At the Menopause Clinic London, we avoid oral HRT unless this is the woman’s preference in the face of full information. A past history of deep vein thrombosis, pulmonary embolism (blood clot on the lung) and stroke due to blood clot is a relative contra-indication to conventional HRT.
  3. Stroke: The risk of stroke appears to be increased in women taking oestrogen only or combined HRT. It does not appear to be significantly increased in women under 60 years old. To put matters into perspective, if 2 in 100 women not taking HRT have a stroke, then 3 in 100 women taking HRT will have a stroke. Transdermal oestrogen appears to be associated with a lower risk of stroke.
  4. Endometrial (womb lining) cancer: Oestrogen only HRT substantially increases the risk of endometrial cancer in women with a womb (uterus). The use of continuous combined HRT (both oestrogen + progesterone) or cyclical progesterone for at least twelve days every month eliminates this risk. It is also thought that insertion of the Mirena coil protects against endometrial cancer and allows oestrogen to be given without the need for additional progestogen – which could protect against the side-effects of progestogens, and could lower the risk of breast cancer associated with combined oestrogen-progestogen therapy.
  5. Heart disease: Women who are over 60 and take HRT more than 10 years after the menopause have an increased risk of heart disease. But the risk is small to begin with. Over five years, nearly 2 in 100 women taking HRT were at risk of heart disease, compared with 1.5 in 100 women not taking HRT. There is emerging evidence that commencing HRT early minimizes / reduces the risks of heart disease.
  6. Other risks: Evidence appears to suggest that taking HRT for a year or more could increase the risk of a woman developing gallbladder disease (gallstones). Current data on the role of HRT and the risk of ovarian cancer are still conflicting, with some research suggesting that HRT may slightly increase the risk, which disappears when HRT use is stopped.

When HRT should not be taken

HRT is not prescribed in the following conditions:

  • pregnancy and breast-feeding
  • undiagnosed abnormal vaginal bleeding,
  • venous thromboembolic disease (blood clots),
  • active heart disease,
  • current or past breast cancer,
  • current or past endometrial cancer,
  • other oestrogen dependent cancer,
  • active liver disease
  • uncontrolled high blood pressure.

Women who would like to consider HRT but have one of these conditions should seek specialist advice.

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Each woman’s experience of the menopause is unique and therefore a ‘one size fits all approach’ to managing the menopause is not effective.

We pride ourselves in providing individualised care and tailor our treatments to the patient’s unique circumstances.

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