Many women experience menopausal symptoms that affect their quality of life. Hormone replacement therapy (HRT) is the most effective form of treatment.
However, if you just take oestrogen then the lining of your womb (uterus) builds up. This increases your risk of developing cancer of the womb. Therefore, the oestrogen in HRT is usually combined with a progestogen hormone. The risk of cancer of your womb is completely reduced by adding in the progestogen. In many HRT products, the oestrogen and progestogen are combined in the same tablet; however, they can also be taken separately. If you have had a hysterectomy or have a contraceptive intrauterine system fitted, you do not need a progestogen.
How do I take hormone replacement therapy?
Different women prefer different methods of taking HRT. For example, some women prefer to wear a patch rather than taking tablets. Your doctor or practice nurse can give you information about the pros and cons of the different types of HRT.
If you start HRT when you are still having periods, or have just finished periods
You will normally be advised to use a 'cyclical combined HRT' preparation:
- Monthly cyclical HRT - you take oestrogen every day but progestogen is added in for 14 days of each 28-day treatment cycle. This causes a regular bleed every 28 days, similar to a light period. (They are not 'true' periods, as HRT does not cause ovulation or restore fertility. The progestogen causes the lining of your womb (uterus) to build up. This is then shed as a 'withdrawal' bleed every 28 days when the progestogen part is stopped.) Monthly cyclical HRT is normally advised for women who have menopausal symptoms but are still having regular periods.
You may switch to a continuous combined HRT (see below) if:
- You have been taking cyclical combined HRT for at least one year; or
- It has been at least one year since your last menstrual period.
If you start HRT a year or more after your periods have stopped
If your periods have stopped for a year or more, you are considered to be postmenopausal. If this is the case, you will normally be advised to take a 'continuous combined HRT preparation'. This means that you take both an oestrogen and a progestogen every day. The dose and the type of oestrogen and progestogen are finely balanced so that they usually do not cause a monthly bleed. However, you may have some irregular bleeding in the first 3-6 months after starting this form of HRT. You should see your doctor if this bleeding continues for more than six months after starting HRT, or if you suddenly develop bleeding after some months with no bleeding.
If you have had a hysterectomy
You will only need to take HRT that contains oestrogen. The progestogen is only added in to other types of HRT so that the lining of the womb does not build up and increase your risk of developing cancer of the womb. So, if your womb has been totally removed, progestogen is not needed.
If you have an intrauterine system (IUS) for contraception
You will only need to take HRT that contains oestrogen. This is because an IUS (sometimes called a hormone coil) already contains enough progestogen to stop the lining of your womb from building up. See separate leaflet called Intrauterine System for more information.
If you mainly have genital symptoms - for example, vaginal dryness or bladder symptoms
For vaginal dryness (atrophic vaginitis) you may choose to try some vaginal oestrogen cream or a pessary to help your symptoms. This alone may be enough to relieve symptoms in some women who would prefer this option or who cannot take other forms of HRT for some reason. However, in around one in ten women, this treatment is not enough to improve symptoms and HRT is needed to be taken as well.
What are the benefits of hormone replacement therapy?
HRT is a safe and effective treatment for most healthy women with symptoms, who are going through the menopause at the average age in the UK (about 51 years). The risks and benefits of HRT will vary according to your age and any other health problems you may have. Your doctor will be able to discuss any potential risks of HRT to you in detail.
Menopausal symptoms usually ease
This can make a big difference to quality of life in some women:
- HRT works to stop hot flushes and night sweats within a few weeks.
- HRT will reverse many of the changes around the vagina and vulva usually within 1-3 months. However, it can take up to a year of treatment in some cases.
- This means that HRT can:
- Improve symptoms of vaginal dryness.
- Improve discomfort during sexual intercourse as a result of this vaginal dryness.
- Help to reduce recurrent urine infections.
- Improve any increased frequency of passing urine.
- There is some evidence that HRT itself improves your mood and your sleep.
- HRT may also help to improve joint aches and pains.
- HRT improves symptoms of vaginal dryness and improves sexual function in many women.
- Many women notice that the texture of their hair and skin improves when taking HRT.
Reduced risk of 'thinning' of the bones (osteoporosis)
Women who take HRT have a reduced risk of osteoporosis and their risk of having fractures due to osteoporosis is also reduced. This risk reduces further the longer you take HRT.
Coronary heart disease
The evidence regarding HRT and cardiovascular disease is still controversial.
HRT does not increase the risk of heart disease when it is started in women aged under 60 years. In addition, it does not affect the risk of dying from heart disease.
There is some evidence that taking HRT, especially HRT with oestrogen alone, actually reduces the incidence of cardiovascular disease in women.
Other possible benefits
Some studies have shown a reduced risk of Alzheimer's disease and other types of dementia in women who take HRT. However, other studies have not shown this, so more work needs to be done in this area.
Some trials have also shown a reduction in risk of bowel cancer in women who take HRT. However, the evidence for this is still not completely clear.
What are the risks in taking hormone replacement therapy?
There has been a lot of media attention to the risks of taking HRT. This was after the results of some big studies about HRT were published between 2002 and 2004. These were the Women's Health Initiative study in the USA and the Million Women Study in the UK. These studies raised concerns over the safety of HRT, particularly over a possible increased risk of breast cancer with HRT and also a possible increased risk of heart disease. However, it is important that the results of the studies be looked at carefully. HRT can increase your risk of developing certain problems but this increase in risk is very small in most cases.
The risks of taking HRT are discussed below.
Clots in the veins (venous thromboembolism)
This is a blood clot that can cause a deep vein thrombosis (DVT). In some cases the clot may travel to your lung and cause a pulmonary embolism (PE). Together, DVT and PE are known as venous thromboembolism.
Women who take combined HRT as tablets have an increased risk of developing a clot. You are more likely to develop a clot if you have other risk factors for a clot. These include being obese, having a clot in the past and being a smoker.
This risk of clot is not present for women who use patches or gel at standard doses rather than tablets of HRT.
Note: you should see a doctor urgently if you develop a red, swollen or painful leg, or have shortness of breath and/or sharp pains in your chest.
You may have a small increased risk of breast cancer if you take combined (oestrogen and progestogen) HRT. This risk increases the longer you have used HRT. When you stop taking HRT, you have the same risk of breast cancer as someone who has not taken HRT.
The actual risk of breast cancer with taking HRT is actually very small. It equates to around one extra case of breast cancer per 1,000 women each year. This risk is similar to the risk of breast cancer in women who are obese, those women who have never had children and also those women who drink two to three units of alcohol each day. There is no increased risk of dying from breast cancer though.
Most of the studies done in this area have not actually shown an increased risk of breast cancer in women who take HRT for five years or less. Studies have also shown that women who take oestrogen-only HRT do not have an increased risk of breast cancer at all and may even have a lower risk of breast cancer (only women who have had their womb (uterus) removed (a hysterectomy) can take oestrogen-only HRT).
Women who take combined HRT have an increased risk of having an abnormal mammogram, as HRT increases the density of breast tissue. This is not the same as increasing the risk of breast cancer.
Note: there is no increased risk of breast cancer in women who take HRT under the age of 50 years.
Some studies have shown that there is a small increased risk of stroke in women taking either oestrogen-only or combined HRT. However, there is no increased risk of stroke in women who use the patch (or gel) rather than tablets.
HRT containing lower doses of oestrogen seems to be associated with a lower risk of stroke compared to those containing higher doses.
Cancer of the womb
There is an increased risk of womb (uterine) cancer due to the oestrogen part of HRT. However, by taking combined HRT containing oestrogen and progestogen, this risk reduces completely. This is the reason why progestogen is included in HRT. However, you should always see your doctor if you have any abnormal vaginal bleeding which develops after starting HRT. For example, heavy bleeding, irregular bleeding, or bleeding after having sex.
If you have had a total hysterectomy for whatever reason, you should only need to take oestrogen-only HRT.
Cancer of the ovary
It used to be thought there was a slightly increased risk of developing ovarian cancer if you use HRT but this has now been shown not to be the case.
Other points about risks
Your risk of developing the diseases mentioned above can depend on a combination of many factors. For example, your family history, and lifestyle factors such as smoking, obesity, diet, etc, also affect your risk of these conditions.
You can greatly reduce your risk of developing heart disease, stroke and many cancers by not smoking and by taking regular exercise and eating a healthy diet. These conditions become more common as we get older.
Note: women who take HRT at a younger age (under the age of 51 years) do not have any risks of HRT as they are receiving hormones that their bodies would otherwise be producing.
What about side-effects when taking hormone replacement therapy?
Side-effects are problems that are not serious but may occur in some women. They tend to go if you stop treatment. Side-effects with HRT are uncommon.
Side-effects may include the following:
- In the first few weeks some women may develop a slight feeling of sickness (nausea), some breast discomfort or leg cramps. These tend to go within a few months if you continue to use HRT.
- HRT skin patches may occasionally cause irritation of the skin.
- Some women have more headaches or migraines when they take HRT. This is usually reduced by using patches or gel rather than taking tablets.
A change to a different brand or type of HRT may help if side-effects occur. Various oestrogens and progestogens are used in the different brands. If you have a side-effect with one brand, it may not occur with a different one. Changing the delivery method of HRT (for example, from a tablet to a patch) may also help if you have side-effects.
So, should I take hormone replacement therapy, and for how long?
The benefits have to be balanced against the risks. Some of the risks associated with HRT increase the longer the time that you take HRT. You have to decide what is right for you, with advice from your doctor or nurse, depending on your circumstances and how your symptoms are affecting you.
As a general rule:
For short-term treatment of menopausal symptoms
If you are troubled with menopausal symptoms, the balance of risks and benefits is in favour of taking HRT (provided there are no reasons why you shouldn't take HRT).
- You should take the lowest dose which keeps symptoms away.
- Many women find that after 1-3 years the worst of the flushing-type symptoms have gone and they no longer need HRT to prevent them.
- In some women, the symptoms can return for a short time after stopping HRT. You may have to stop HRT to find out if you still have symptoms, but if you do still need it your symptoms will get worse rather than easing.
- If the genital symptoms such as vaginal dryness persist after stopping HRT, an option is to use, for example, an oestrogen cream or pessary in the vaginal area (see below).
If you mainly have genital symptoms such as a dry vagina
An option which may be advised by your doctor is to use, for example, a vaginal oestrogen cream or pessary. This gives the benefits of easing the symptoms but with less risk than using HRT tablets, patches, etc, as far less oestrogen gets into the bloodstream. In many women, this treatment may be needed long-term. Read about oestrogen for genital symptoms.
Some other points about hormone replacement therapy
- HRT does not act as a contraceptive. Therefore, if you are still having periods when you start HRT, or have only recently stopped having periods, you should still use contraception. Your doctor will advise when you no longer need to use contraception. But, as a general rule: contraception should be used to prevent pregnancy for one year after your last period if you are older than 50, or for two years after your last period if you are less than 50. See separate leaflet called Contraception for the Mature Woman, discussing contraception from 40 to the menopause.
- If you are taking HRT, you should have regular check-ups with your doctor. These are usually undertaken every year.
- At your review appointments, you should discuss your risks and benefits of taking HRT, as these may change over time. After some time, your doctor may also suggest stopping your HRT to see if you still need it.
- You should also be 'breast aware' and look out for any changes in your breasts. If you notice any lumps or problems that you are worried about, you should see your doctor. You should also attend your breast cancer screening mammogram when called.
What is tibolone?
Tibolone is a man-made hormone that can be used as an alternative to HRT. It has some oestrogen, progestogen and also some male hormone (androgen) effects. So, you just have to take this one tablet to have these hormone effects.
The following are some points about tibolone:
- It is effective in treating sweats and hot flushes.
- It reduces your risk of 'thinning' of the bones (osteoporosis).
- It may also improve your sex drive (libido).
- It is associated with a small increased risk of stroke.
- Most studies have shown a small increased risk of having womb (endometrial) cancer diagnosed in women who use tibolone.
- Tibolone may be associated with a small increased risk of breast cancer.
In younger women, the risks of taking tibolone are about the same as taking combined HRT. For women older than 60, the risks associated with taking tibolone may outweigh the benefits because of the small increased risk of stroke.
Further reading and references
Panay N et al; British Menopause Society & Women’s Heath Concern recommendations on hormone replacement therapy, May 2013
Menopause: diagnosis and management; NICE Guidelines (Nov 2015)
Kaunitz AM, Manson JE; Management of Menopausal Symptoms. Obstet Gynecol. 2015 Oct126(4):859-76. doi: 10.1097/AOG.0000000000001058.
No authors listed; Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov22(11):1155-74. doi: 10.1097/GME.0000000000000546.
Contraception for Women Aged over 40 Years; Faculty of Sexual and Reproductive Healthcare (August 2017)
Langer RD; The evidence base for HRT: what can we believe? Climacteric. 2017 Apr20(2):91-96. doi: 10.1080/13697137.2017.1280251. Epub 2017 Mar 10.
Information for women with Iatrogenic Premature Ovarian Insufficiency; European Society of Human Reproduction and Embryology, 2016
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