Hormone replacement therapy (HRT) is safe and can ease various symptoms of the menopause and improve quality of life. Its long-term use has been shown to prevent osteoporosis and reduce the risk of heart disease. However, misconceptions or myths around HRT deter many women from seeking this treatment.
This article was included in issue 102 (Autumn 2024) of The Menopause Exchange newsletter.
HRT can cause breast cancer
The fear that HRT may cause breast cancer is perhaps the most common reason for women deciding not to use it. However, the evidence is reassuring. Recent studies show that women who take oestrogen on its own aren’t at an increased risk of breast cancer; there may even be a reduced risk. Combined oestrogen and progesterone may be associated with a very small increased risk of breast cancer but this is smaller than the risk associated with moderate alcohol consumption, obesity or smoking. There’s no evidence that HRT (oestrogen alone or with progesterone) increases deaths from breast cancer.
HRT can cause heart disease
There’s an increase in the risk of heart disease in women following the menopause. HRT started before the age of 60 has been shown to reduce this risk.
HRT is a contraceptive
HRT isn’t a contraceptive. Women can still conceive when taking it so should use additional contraception if they wish to avoid getting pregnant. Women who finish their periods after age 50 need to use additional contraception for one year. If their periods finish before age 50, they’ll need contraception for two years. Contraception is unnecessary in women over 55.
HRT delays the menopause
HRT will control the symptoms for as long as it’s taken, but it won’t delay the end of menopause symptoms or the natural cycle. In some women, the more troublesome symptoms last for a limited length of time and don’t return when HRT is stopped, but in others the symptoms are long-term and may still be present after stopping HRT.
HRT will cause weight gain
Body weight increases with age in men and women. In women, the menopause results in further weight gain that’s associated with increased fat around the waist. HRT doesn’t lead to an increase in weight gain, and some reports indicate that it may help reduce some of the weight gain related to the menopause.
HRT has the same risks as the oral contraceptive pill
The oral contraceptive pill usually contains a synthetic oestrogen and progestogen, which results in regular and light bleeds. However, it’s associated with an increased risk of blood clots, as well as high blood pressure and stroke. These risks are very small, especially in young women who aren’t overweight and don’t smoke. The hormones in modern HRT are natural or body-identical, which are associated with fewer side effects. The risks are further reduced if oestrogen is taken through the skin as patches or gels. This doesn’t lead to an increased risk of blood clots or strokes.
The diagnosis of the menopause needs a clinical examination and multiple blood tests
The diagnosis of the menopause is usually made on the basis of clinical history, including symptoms and changes in the cycle. Blood tests are unnecessary, unless the woman is under 40. Sometimes if the clinical picture isn’t clear, a blood test may be helpful to rule out other conditions such as an underactive thyroid or anaemia, which can cause similar symptoms.
HRT can only be prescribed once periods have stopped
Menopausal symptoms are often most troublesome in the one or two years when the woman may still be having a regular cycle. This stage is sometimes called the perimenopause. HRT can be safely prescribed at this stage and usually results in good symptom control.
Vaginal oestrogen is associated with the same risks as HRT tablets, patches or gels
Vaginal oestrogen is an effective treatment for the symptoms of urogenital atrophy. Oestrogen in this form works locally with only negligible absorption into the bloodstream, avoiding side effects or risks seen with systemic HRT. Women who take vaginal oestrogen don’t need additional progesterone and won’t have bleeding.
HRT can only be taken for five years
In the past, some doctors advised that HRT should be used for no more than five years because of safety concerns. But more recent studies confirm that long-term use of HRT is safe: the benefits outweigh any risks. HRT can be safely taken for as long as required, and there’s no arbitrary limit as to how long for. Indeed, the longer that HRT is taken, the greater the protection against osteoporosis and heart disease.
It’s essential to have vaginal bleeding with HRT
HRT is often given cyclically. This involves oestrogen every day with the addition of progesterone for 12 to 14 days every month, resulting in a light withdrawal bleed after each course of progesterone. A woman who wishes to avoid the bleed can take progesterone every day, but this is only suitable for women who are more than one year past the menopause. Another way to take HRT without having monthly bleeds is to have a Mirena contraceptive device fitted. This releases progesterone every day for five years and is particularly helpful for perimenopausal women who still need contraception.
About the author
Mr Mike Savvas is a consultant gynaecologist with a specialist interest in the menopause, at the London PMS and Menopause Centre.
Created Autumn 2024
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