Hormone Replacement Therapy for Women: Who Needs It?

Menopause marks the end of menstruation in a woman’s life. It occurs because a woman stops ovulating (releasing a mature egg once monthly), and her ovaries no longer produce estrogen (one of the female sex hormones).

Menopause means ‘the last period’. It is a natural event that marks the end of the reproductive years, just as the first menstrual period during puberty marks the start.

Many women, although not all, experience uncomfortable symptoms before and after menopause, including hot flashes, night sweats, sleep disturbance, and vaginal dryness. These symptoms and physical changes can be managed in various ways, including lifestyle changes such as healthier eating and increased exercise, and hormone replacement therapy (HRT).

Hormone Replacement Therapy (HRT): What is it?

HRT, also known as hormone therapy (HT) or menopausal hormone therapy (MHT), is medication containing the hormones that a woman’s body stops producing after menopause. HRT is used to treat menopausal symptoms.

While HRT reduces the likelihood of some debilitating diseases such as osteoporosis, colorectal (bowel) cancer, and heart disease, it may increase the chances of developing a blood clot (when given in tablet form) or breast cancer (when some types are used long-term).

‘Premature menopause’ is when the final menstrual period occurs before a woman is 40. ‘Early menopause’ is when the final menstrual period occurs before a woman is 45. For women who experience premature or early menopause, HRT is strongly recommended until the average age of menopause (around 51 years), unless there is a particular reason for a woman not to take it.

Menopause symptoms and HRT

Menopause symptoms that may be relieved by HRT include:

• hot flushes and night sweats;
• vaginal dryness;
• thinning of vaginal walls;
• vaginal and bladder infections;
• mild urinary incontinence;
• aches and pains;
• insomnia and sleep disturbance;
• cognitive changes, such as memory loss;
• reduced sex drive;
• mood disturbance;
• abnormal sensations, such as ‘prickling’ or ‘crawling’ under the skin;
• palpitations;
• hair loss or abnormal hair growth;
• dry and itchy eyes.

Other therapies, including vaginal estrogen products, antidepressants, or other medications, may be used depending on the symptoms and risk factors. Seek advice from a doctor.

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Added benefits of HRT

HRT reduces the risk of various chronic conditions that can affect postmenopausal women, including:

1. diabetes – taking HRT around the time of menopause reduces a woman’s risk of developing diabetes;
2. osteoporosis – HRT prevents further bone density loss, preserving bone integrity and reducing the risk of fractures, but it is not usually recommended as the first choice of treatment for osteoporosis, except in younger postmenopausal women (under the age of 60);
3. bowel cancer – HRT slightly reduces the risk of colorectal cancer (bowel cancer);
4. cardiovascular disease – HRT has been shown to reduce cardiovascular disease markers when used around the time of menopause.

Side effects of HRT

HRT needs to be prescribed for each woman individually. Some women experience side effects during the early stages of treatment, depending on the type and dose of HRT. These side effects will usually settle within the first few months of treatment and may include:

• breakthrough bleeding;
• breast tenderness;
• bloating;
• nausea.

HRT does not cause weight gain

Weight gain at menopause is related to age and lifestyle factors. An increase in body fat, especially around the abdomen, can occur during menopause because of hormonal changes, although exactly why this happens is not clear. Normal age-related decreases in muscle tissue, and a decrease in exercise levels, can also contribute to weight gain.

Most studies do not show a link between weight gain and HRT use. If a woman is prone to weight gain during her middle years, she will put on weight whether or not she uses HRT.

Some women may experience symptoms at the start of treatment, including bloating, fluid retention, and breast fullness, which may be misinterpreted as weight gain. These symptoms usually disappear once the therapy doses are changed to suit the individual.

Contraception and HRT

HRT is not a form of contraception. The treatment does not contain high enough levels of hormones to suppress ovulation, so pregnancy is still possible in women in perimenopause (the time of hormonal instability leading up to menopause).

Periods can be erratic in perimenopause, and egg production will be less frequent, but can still occur until menopause. For women younger than 50, contraception is recommended for at least two years after the final period. For women aged 50 and above, contraception is recommended for at least one year after their final period.

Long-term use of HRT

It is currently believed that, overall, the risks of long-term (more than five years) use of HRT outweigh the benefits. HRT should not be recommended for disease prevention, except for women under 60 years of age with a substantially increased risk of bone fractures, or in the setting of premature menopause.

No alternative therapy has yet been clinically proven to reduce a menopausal woman’s risk of osteoporosis, including the use of soy products, phytoestrogens (plant estrogens), and herbal medicines.

Women with liver disease, migraine headaches, epilepsy, diabetes, gall bladder disease, fibroids, endometriosis, or hypertension (high blood pressure) need special consideration before being prescribed HRT. In these situations, HRT is often given through the skin (transdermally).

Despite the risks of long-term use, in women with severe and persistent menopausal symptoms, HRT is the only effective therapy.

Women with premature or early menopause are prescribed HRT long-term because of their increased risks of earlier onset of heart disease, osteoporosis, and some neurological conditions compared to women undergoing menopause around the age of 50 years. Seek specialist advice; regular check-ups are recommended.

Other treatments for menopausal symptoms

Studies have shown that some prescription medications can reduce hot flashes and sweats. These treatments may be an option if HRT cannot be used for health or other reasons, and should be discussed with a doctor.

The herbal medicine, black cohosh, may take the edge off hot flushes and sweats, but there is no data to support long-term use. There is also a rare liver condition that may be associated with the use of black cohosh.

Other complementary and alternative medicines have not been shown to be effective for menopausal symptoms when compared with ‘dummy’ or placebo treatment in research studies.

Commercially available vaginal moisturizers (such as Replens) may reduce vaginal dryness if used regularly. Consult a doctor about what will work best for you.

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