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Whether you want to take Hormone Replacement Therapy (HRT) for your menopausal symptoms, or try individual drug treatments for isolated symptoms, help is available.
Individual drug treatments for symptoms include antidepressants for depression, vaginal moisturisers and lubricants for dry vagina and painful sex, drugs such as clonidine which is normally used to treat blood pressure but is also used for hot flushes, and painkillers for muscle pain and aching joints.
“While drugs can treat some of the individual symptoms of the menopause, HRT is really the only one that addresses all of them,” said GP and womens health expert Dr Nighat Arif.
“However, HRT is not a silver bullet for the menopause, it’s just a part of the jigsaw that we make to treat the big change in life. Every woman is unique and will have her own individual problems. But my own view is that life is short, and HRT gives you your life and joy back.”
What is HRT?
Menopause is caused by a hormone deficiency; HRT replenishes the hormones your body is no longer making in sufficient quantities. The three main sex hormones that dramatically reduce at the time of the menopause are oestrogen, progesterone, and testosterone.
Oestrogen HRT will compensate for the plummeting levels of the oestrogen hormone, which is a lubricant for blood vessels, vital for building new bone, cognitive function and for producing collagen (the scaffolding of skin). Progesterone will protect the lining of the womb against endometrial cancer. Testosterone gel is often prescribed as an add-on to HRT to help restore sex drive, sexual arousal, and ability to orgasm, but also to help with joint pains, memory, and fatigue, particularly in women who have had a surgical menopause after hysterectomy.
“HRT is available on NHS GP prescription to treat menopausal symptoms, although this does not include testosterone gel routinely, as it is not licensed for use in women, and only prescribed privately,” said Dr Arif.
How to ask for HRT
Dr Arif says women suffering from menopause symptoms who want to go down the HRT route should tell their GP about their symptoms, and state that they have read the NICE Guideline on Menopause from 2015. This says that women with menopausal symptoms should be treated with HRT as a first line even if their symptoms are just psychological and not physical.
“If you are diagnosed with menopause then the first offer of treatment you should get is HRT,” Dr Arif emphasised.
Does HRT raise your risks of breast cancer and blood clots?
A lot of the confusion and negative publicity about HRT stems from research published in 2002/2003, which scared millions of women off the treatment. The Women’s Health Initiative (WHI) in the USA and the Million Women Study in the UK in 2003 both raised concerns about HRT’s safety. These centred on an increased risk of breast cancer with combined progestogen and oestrogen HRT, and blood clots, raising the risk of stroke and heart attack. The WHI trial was even halted early, so great were the risks thought to be.
“GPs were told by the Medicines and Healthcare Regulatory products Agency (the UK’s drugs safety watchdog) that they should take patients off HRT because of the higher risk of breast cancer and clots, and we had to listen to that,” explained Dr Arif. “It made a lot of doctors scared to prescribe it and if they did, warnings would flash up on their computer screens. But the data was never easy to decipher or that clear cut.”
Later analyses of the studies showed that both were flawed: they weren’t double blinded (so people knew what they were taking), and the studies were done in older women in their 60s and didn’t consider the background risks that older women have of clots and breast cancer due to their age, said Dr Arif.
“Neither did they consider other risk factors such as smoking, drinking alcohol, family history and being obese. For example, having a BMI of 32 gives you a 50 percent increased risk of breast cancer, and all women have a background risk of 1 in 8 for developing breast cancer during their lifetime, but this wasn’t considered, and any cases of breast cancer or clots were just blamed on HRT. By then the damage was done and a massive panic had been created.”
Dr Arif said another source of confusion is people wrongly believe that HRT uses the same artificial hormones as the combined contraceptive pill (with its association with increased risk of blood clots) which suppresses hormone release to prevent pregnancy.
Publication of the NICE Guideline on Menopause in 2015 was a real turning point though, as the independent body analysed all the evidence and came out with clear advice that said HRT is safe if given transdermally (through the skin) and started before the age of 60. “This has given doctors confidence to prescribe it again,” said Dr Arif.
HRT has also moved on in the last twenty years. Older studies are based on HRT which used artificial hormones and chemicals in its formulation, but newer types, such as body identical hormones, are made from yams and root vegetables. There are natural, and can be given through the skin as a gel, patch or spray. “Studies have shown that, with this type of HRT, your background risk of breast cancer or clots does not increase,” explained Dr Arif. “If HRT is given through the skin, it doesn’t go into the bloodstream or fat cells and doesn’t go into the liver and affect clotting.’”
Oestrogen HRT can also be delivered vaginally, and this has a localised effect, treating vaginal atrophy (where the skin of the vagina becomes dry and shrinks) and it also doesn’t raise the risk of breast cancer and strokes.
“Even with oral HRT the risk is very small, and I still prescribe it to some patients after careful counselling with them about the risks v benefits as I would with any medication.”
How long can you take HRT for?
The NICE Menopause Guideline is very clear on this, stating women should be prescribed the lowest dose of HRT, but for “as long as the woman needs it.”
“Some GPs such as myself believe menopause is a hormone deficiency disease and therefore women should remain on it for as long as they have symptoms,” said Dr Arif, “but we don’t have the studies to back this up: we’re making a clinical judgement based on our experience.”
If women feel they might no longer need it, added Dr Arif, “they can stop it for a while and if their symptoms don’t return, they might feel they can discontinue it. But if symptoms do return, they may want to go back on it.”
Does HRT give you protection against long-term health conditions?
HRT is protective against the fragility fractures caused by osteoporosis when you are taking it. The NICE Menopause Guideline says HRT with oestrogen alone is associated “with no risk of – or at least a reduced risk of – coronary heart disease”.
HRT is being investigated to see if it protects against dementia, but currently there’s not enough evidence to recommend it for this purpose. “More women than men develop dementia and there’s a theory that this could be due to the lack of oestrogen in the brain,” said Dr Arif.
Can I still take HRT if I have risk factors for heart disease such as high blood pressure?
The NICE guideline says having risk factors for heart disease (such as high blood pressure and raised cholesterol) doesn’t mean women can’t have HRT, so long as their risk factors are being optimally managed. However, HRT is not generally recommended for women with a history of strokes or blood clots.
Can women who have had breast cancer take HRT?
Cancer Research UK says it does not recommend women who have had breast cancer take HRT as it increases the risk of breast cancer returning, although some doctors will prescribe it to women who have severe symptoms. Oestrogen creams, pessaries and rings may help with vaginal dryness and are safe as minimal amounts of oestrogen are absorbed.
What other drugs can I take?
Drugs such as Dixarit (a vasodilator drug which dilates blood vessels) and gabapentin (an epilepsy drug also used to treat pain conditions) can help with hot flushes, and antidepressants such as venlafaxine (Exefor) with depression. Drugs called bisphosphonates (Alendronate) can prevent or slow down bone thinning.
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