Over the last two years there has been an increased demand for HRT from UK women. With the support of the Women’s Health Task Force for England and increased social media activity, women are feeling more confident to take HRT for menopausal symptoms and are now experiencing the benefits.

This article was included in issue 97 (summer 2023) of The Menopause Exchange newsletter.

Flushes and sweats
Vasomotor symptoms affect up to 80% of women in the menopausal years and last around seven years, although 20% of women may have symptoms for 15 years or more. Hot flushes and night sweats are most troublesome in the first few years after the last natural menstrual period. HRT is the most effective treatment, decreasing flushes and sweats by 77%. Women notice an improvement in hot flushes within four weeks of starting a standard dose of HRT, with maximum benefits achieved by three months. If the symptoms persist, the HRT dose can be increased but this should be discussed with a healthcare professional as refined carbohydrate, stress and/or anxiety, smoking, increased body mass index and alcohol may worsen flushes and sweats too.

Period changes
Women’s periods may initially become closer together when they’re in their 40s, so instead of having a period every 28 days this interval is reduced to 24 to 26 days. In the last couple of years before the menopause, the cycle can become more irregular with women missing periods. Taking a sequential HRT regimen with oestrogen daily and progestogen for 12 to 14 days of the month results in a more regular bleed again, often becoming lighter over time. Perimenopausal women who have the occasional period but would like a period-free HRT regimen, may be able to have a 52mg levonorgestrel intrauterine system fitted, along with using oestrogen replacement therapy.

Sleep patterns
Sleep patterns change as people get older. Flushes and night sweats can interrupt sleep, and around 60% of menopausal women complain of sleep disturbance. This may be difficulty getting to sleep or interrupted sleep with waking at the onset of a sweat or the need to pass urine. HRT may help if flushes and sweats at night are causing the sleep disturbance. Micronised progesterone in HRT is thought to aid sleep and has been shown in studies to shorten the time for women to fall asleep, lessen night-time wakening and increase total sleep time, while not being addictive or causing drowsiness the next morning.

Women taking HRT may also find their brain fog and therefore their loss of confidence improve if they have less disturbed sleep, but HRT is not recommended at any age to treat cognitive issues at the menopause or to prevent cognitive decline or dementia later in life.

Mood swings
HRT is thought to help mood swings in some women, but psychological options should be explored in those who fail to improve after taking HRT for three months. It is interesting to note that there is some evidence that oestrogens may increase the response to anti-depressants in menopausal women.

Skin changes
Two-thirds of menopausal women report skin changes, especially dry skin. Visible signs of dryness and wrinkles especially on the face contribute to a feeling of aging with a significant impact on quality of life. There is little data on the effect of HRT on hair quality during the menopause but skin hydration and collagen content of the dermis improve in women receiving HRT. Results on wrinkles are less certain.

Aches and pains
Fluctuating hormone levels at the time of the menopause can increase inflammatory changes and decreased lubrication in the joints. There is some evidence that HRT can reduce the incidence of osteoarthritis and may help menopausal joint pain and stiffness in some women. Other lifestyle changes, including rehydration, weight loss, regular physical exercise and simple pain relief, should also be tried to improve joint pain and associated symptoms.

Vaginal and urinary symptoms
About one in two postmenopausal women suffers from vaginal dryness, pain with sex, vulval irritation, urinary frequency and recurrent urinary tract infections. Low-dose local vaginal oestrogen in the form of pessaries, creams, gels and a vaginal ring markedly helps these symptoms and can be used long term.

Long-term effects
Using HRT purely to protect against heart disease, osteoporosis, cognitive decline or dementia isn’t currently recommended. Evidence suggests that HRT may benefit the cardiovascular system if it’s started around the time of the menopause. There is conflicting evidence about whether HRT provides some protection against dementia, with some observational studies suggesting a risk reduction but randomised controlled trials failing to find this benefit.

Bone density
HRT improves bone mineral density and has been shown to decrease fragility fractures while it is being taken but these fractures can increase once HRT is stopped. This benefit of HRT varies depending on the duration of its use and is recommended in women with primary ovarian insufficiency (menopause before the age of 40). HRT is often recommended for women with menopausal symptoms and reduced bone mineral density and in young women with osteoporosis. After the menopause, muscle mass and strength decline. Along with weight-bearing exercise, HRT may help to reduce any changes.

About the author
Dr Diana Mansour is a consultant in community gynaecology and reproductive healthcare at Newcastle upon Tyne Hospitals NHS Foundation Trust. She has been an associate clinical lecturer at Newcastle University since 1997.

Created Summer 2023
Copyright © The Menopause Exchange 2023

Tags: aches and pains, bone density, flushes & sweats, HRT, Long-term effects, menopausal symptoms, mood swings, period changes, skin changes, sleep patterns, Vaginal & urinary symptoms