Do you need HRT? Here’s what the menopause doctors say

Asha turns 60 this year, but says she has the hormones of a 26-year-old. When she went through the menopause at 47, she felt “dead from the neck down. My libido disappeared and I was plagued with hot flushes, night sweats and weight gain. Then a private menopause doctor prescribed me compounded bioidentical hormones to fit my exact profile and it changed my life…”

Asha’s experience is intriguing. As little as a decade ago, HRT – hormone replacement therapy – was pretty much out of the question. Studies in 2002 had linked it to breast cancer, and few women dared risk it. But it’s had something of a renaissance in the last few years since dozens of studies have provided evidence that HRT may be safer than previously believed.  Around 15 per cent of women aged 45 to 64 in England are currently prescribed HRT. 

But what of the women for whom HRT would be considered low-risk but don’t take it – with so many long-term health benefits, are they missing out? 

• What exactly is HRT?
• Signs you may need HRT
• Types of HRT
• What are the risks of HRT?
• Is HRT safe to take indefinitely?
• What are the effects of stopping HRT?
• Benefits of HRT
• Side effects of HRT
• Finding a hormone replacement doctor
• Can I get HRT without seeing a doctor?
• Can a doctor refuse to give HRT?

What exactly is HRT?

Hormone replacement therapy is medication, taken in the form of tablets, gels, patches, sprays, creams and pessaries, that contains oestrogen that our bodies stop making during menopause. HRT’s purpose is to tackle menopausal symptoms such as hot flushes, anxiety, low mood and vaginal discomfort. Your doctor will typically prescribe oestrogen along with progesterone or progestin (progesterone-like medication) to prevent growth of the lining of the uterus which increases the risk of endometrial cancer – unless you have had your uterus removed, in which case you’d take oestrogen on its own. A specialist doctor may also prescribe testosterone which can be effective at improving sexual wellbeing for postmenopausal women.

Signs you may need HRT

If you have moderate to severe hot flushes and night sweats, are experiencing uncomfortable vaginal symptoms, are at risk of osteoporosis and/or have been through early menopause or have oestrogen deficiency, you may benefit from HRT.

“First and foremost, HRT is for women who are either within the normal menopause age range of 45-55, who have menopausal symptoms, or are under the age of 45 and going through an early menopause,” says Kathy Abernethy, BMS menopause specialist and author of Menopause: The One Stop Guide. “Then there are women who are post-menopause who have still got ongoing symptoms - for about 10 to 15 per cent of women, their symptoms will last into their 60s.”

Types of HRT

There are various different types of HRT. Depending on your age, health and family health history, it’s essential to discuss the risks and which format is right for you with your GP or menopause doctor. Hormone replacement therapy is now available more cheaply thanks to a prescription prepayment certificate reducing a woman’s HRT costs to less than £20 a year.

Systemic hormone therapy

HRT can be systemic, meaning the drug travels through your bloodstream, and this comes in the form of a pill, gel, spray or skin patch. These typically contain a higher dose of oestrogen than local HRT and can be used to treat any common menopause symptoms.

Low dose vaginal HRT

This refers to vaginal oestrogen, which comes in cream, gel, pessary, or ring form, and is used to treat vaginal and urinary symptoms of menopause only. As it is a topical treatment, it minimises the amount of oestrogen absorbed by the body.

Vaginal oestrogen

As women become more prone to urinary tract infections with age, the use of vaginal oestrogen is highly recommended – especially if the risks associated with taking systemic HRT are putting you off, or it is too dangerous for you considering your health issues. “It can be really beneficial – in fact most of us could be using vaginal oestrogen forever,” says Abernethy.

Bioidentical hormone replacement therapy (rBHRT)

The term “bioidentical” refers to hormones in the HRT being chemically identical to those your body produces. It is sometimes referred to as “body-identical”, the difference being that body-identical HRT refers to regulated bioidentical hormones that have been the subject of numerous studies and are therefore deemed safer by experts.

Compounded bioidentical HRT (cBHRT) or ‘natural HRT’

Some private clinics offer personalised compounded bioidentical HRT to women, after taking samples of their blood and saliva to make a bespoke formulation. Marketed as being “more natural” than body-identical hormones, this is the type of custom-made hormone treatment taken by Asha at a cost of £400 every eight months. “These are tailored to me, my health and my lifestyle, and it’s the best money I’ve ever spent. I feel more vibrant, my skin looks better and I’m full of energy,” she says.

However, experts consider compounded biodentical HRT a major concern, and the British Menopause Society (BMS) warns against it, stating “cBHRT products are not recommended by the BMS. They are not evidence-based for effectiveness and safety”.  Indeed, neither Dr Elise Dallas, a specialist in menopause care at The London General Practice,  or Abernethy recommend cBHRT. “A private clinic will tell you that it’s made to measure just for you and has a little bit of oestrogen, of progesterone, of testosterone,” says Abernethy. “The problem with that is it’s not regulated, and we don’t know the risks”.

Natural hormone replacement therapy

“The term ‘natural’ in this context means the same as our own hormones,” says Abernethy. “And that’s exactly what conventional regulated bioidentical HRT does, mimicking what your body would have been producing during your reproductive years. In terms of HRT, we know that this seems to have fewer side effects and possibly fewer risks as well.”

The mirena coil

Apart from its contraceptive effects, the Mirena also provides the progestogen component of HRT, alongside oestrogen. A Mirena can minimise the unwanted effects of the PMS-type symptoms of the menopause. “Although it’s synthetic progesterone it releases so little and is very suitable for those that have might have bleeding problems at the end of their perimenopause,” says Dallas.

What are the risks of taking HRT?

HRT can slightly increase the risk of breast cancer. If you’ve had breast cancer, you’ll usually be advised not to take it. The increased risk is low: there are about five extra cases of breast cancer in every 1,000 women who take combined HRT for five years. But cancer risk from taking HRT depends on many different things, like the kind of HRT you take, your age and general health. The risk increases the longer you take it, and the older you are. It falls again after you stop taking it. There is little or no increase in the risk of breast cancer from oestrogen-only HRT, which you can take if you’ve had a hysterectomy to remove your womb.

The safety of HRT can also depend on other things, such as fitness levels, body mass index and how soon during or after menopause you start taking it. Factor in a woman’s family and personal medical history and her individual experience of menopausal symptoms, and it is clear that no one size fits all. 

“Drinking more than 14 units a week, being sedentary and having a BMI over 30 are bigger risk factors for developing breast cancer than being on HRT,” says Dr Dallas.

Is HRT safe to take indefinitely?

“The fact is, we don’t know if it’s safe to take indefinitely, because we don’t have the data for taking body identical HRT for 30 years,” says Dallas. “So, all we can say is that so far, for at least five years there has been no increase in breast cancer cases [among those taking HRT]. However, the evidence is pointing towards it being way more beneficial than not taking it, although we would always counsel women on an individual basis.” 

This is why it is vital to keep having your health checks if you are on HRT. “These are essential for looking at that person’s individual risk and whether they are generally fit and healthy. If there are no other risks, there is so far no reason why someone cannot continue taking it until the grave,” says Dallas.

“There’s no upper age at which you have to stop taking HRT, and there’s no maximum duration. However, if you’re on a combined HRT the risk of breast cancer, while small, increases with time,” says Abernethy. 

What are the effects of stopping HRT?

Menopausal symptoms can return, but furthermore it has an impact on long-term health conditions. “As soon as you stop taking it, your bones go back to their postmenopausal condition without oestrogen, meaning a high risk of breakage. What’s more, HRT is cardioprotective. Oestrogen is an anti-inflammatory, it prevents chronic inflammation and it’s been shown that chronic inflammation stimulates all chronic diseases, whether it be heart disease or the beginning of cancers. So, taking that oestrogen away means losing that protection,” says Dallas.

Benefits of HRT

HRT has been found to be associated with a small reduction in the risk of bowel cancer. It can also reduce muscle loss that commonly occurs after the menopause and can improve strength. It gives a woman better bone, cardiovascular, brain and skin health compared with a woman that does not take it. 

“Oestrogen is in every cell of our body, brains, hearts and bones, and it was found that heart attacks among women [who don’t take HRT] increased five times after menopause, because we lack oestrogen. We’re much more prone to osteoporosis and have a greater risk of brain disease once we lose our oestrogen protection. In many cases, the benefits of taking HRT outweigh the risks,” says Dallas.

Side effects of HRT

Common side effects of HRT include breast tenderness, muscle cramps, mood changes, headaches and nausea. These symptoms should subside after a few weeks, as your body gets used to it. Vaginal bleeding or spotting is common with HRT, but if you bleed heavily or it continues after six months, discuss this with your GP. You may also experience itchy skin or a mild rash, which may mean you need a different treatment. 

Finding a hormone replacement doctor 

Your GP can prescribe HRT. If you don’t have a sympathetic doctor, it is a good idea to get focused support from an expert, especially if you have challenging symptoms. The BMS website can help you find your nearest menopause specialist.

Can I get HRT without seeing a doctor?

The only HRT you can get as an over-the-counter medication from a chemist is vaginal oestrogen, subject to a consultation with a pharmacist. Known as Gina, this comes in the form of vaginal tablets that are a locally acting oestrogen HRT used to treat the symptoms of vaginal atrophy after the menopause – eg, vaginal soreness and urinary tract infections.

Can a doctor refuse to give HRT?

It’s not uncommon for women to be turned away by their GP when they ask for HRT. If you have a history of blood clots, are prone to migraines, have high blood pressure or have a family history of breast cancer, you should discuss the options with a menopause specialist.

You could also be turned away for being too old. If HRT is started within 10 years of the menopause or before the age of 60, it can protect you against osteoporosis and help prevent cardiovascular disease, as well as boosting your energy. If you start later than that, you may not get the same protection and there may be health risks.