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6 Minute ReadEducation by Jo Waters
15.10.21 (Updated 23.01.23)
Whether you want to take Hormone Replacement Therapy (HRT) for your menopausal symptoms, or prefer natural alternatives like vitamins and supplements for menopause, it's good to have the whole treatment encyclopedia in front of you. In which case, here's an excellent start.
“While drugs can treat some of the individual symptoms of the menopause, HRT is really the only one that addresses all of them,” said Dr Nighat Arif, a GP and noon’s resident women’s health and menopause expert.
“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.”
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. There are now many different types of HRT and ways the body can absorb it.
Oestrogen HRT will compensate for the plummeting levels of the 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 off-label,” said Dr Arif.
Dr Arif says women suffering from menopause symptoms who want to go down the HRT route should tell their GP about their symptoms, say they’ve 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 emphasises.
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, says 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.
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."
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.
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.
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.
Everything you need to know about the menopause
Bioidentical, body identical or artificial - what type of HRT do you need?
The psychological fallout of the menopause, and how to treat it