Anon asked...

I’m considering starting hormone replacement therapy (HRT) for the menopause. What do I need to know about it? Can I stop taking it or will I have to stay on it forever? What are the risks?

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The Answer

What is HRT?

During the menopause your body stops making regular amounts of oestrogen. This means that the amount of oestrogen in the body reduces considerably, which can cause symptoms such as hot flushes.

Hormone replacement therapy (HRT) provides oestrogen to replace the lack of natural oestrogen produced by the body and alleviate the symptoms of the menopause.

We have more information about the menopause on our Ask The Expert

You must speak to your doctor if you want to start taking HRT as they will want to talk about your options, check your medical history and discuss the risks.

&This is important because HRT it is not suitable for some women, for example, if you have a history of high blood pressure, blood clots or breast, ovarian or womb cancer, among other conditions. It also comes with a variety of risks.

If you can take HRT you will usually start on a fairly low dose to see if it works. It can take a while to get your dose right: it might be a few weeks before you start to feel the benefits and your doctor will usually wait a few months to see how you go before adjusting your dosage.

Is it necessary to take both oestrogen and progesterone HRT?

The choice of HRT depends on your needs, medical risks and convenience.

Women with a uterus will need to take oestrogen and progesterone. Without progesterone, the womb lining can become abnormally thick. This is not cancer but can lead to cancer.

If you no longer have a uterus, for example, if you have had a hysterectomy, you can have oestrogen-only HRT, unless you suffer from endometriosis in which case you might need extra progesterone.

If you need oestrogen and progesterone, you will usually need oestrogen every day plus progesterone for the last 12 to 14days of your 28-day cycle. Or, you could use a combined oestrogen and progestogen medicine every day.

If you use oestrogen HRT patches, you may need to take additional progesterone tablets, although some patches – such as Evorel Conti, Femseven Sequi and Femseven Conti – combine both.

Does taking HRT mean I can’t get pregnant?

HRT does not provide contraception.

If you’re under 50 years old you could be fertile for two years after your last period. If you’re over 50 you could be fertile for up to a year after your last period.

Using oral contraceptives if you are older than 50 needs to be based on your individual medical history and potential health risks. You will need to discuss this with your doctor.

Your doctor may be able to perform some blood tests to check if you are fertile.

Side effects of HRT

As with all medicines, you will experience some side effects when you take HRT.

Read the patient information leaflet (PIL) that accompanies your medicine as this will have plenty of information for you.

Common side effects from taking HRT include:

  • Sensitive breasts or swelling
  • Headaches or migraines;
  • Leg cramps
  • Back pain
  • Tummy issues – including nausea, bloating, indigestion and pain
  • Depression or mood swings
  • Vaginal bleeding.

These usually pass within a few months. If they do not, you must contact your doctor.

Many women think taking HRT makes you put on weight. There is no evidence so far to support this, though you may gain weight due to the menopause.

Some types of HRT can also increase your risk of developing other more serious health issues. These include:

  • Breast cancer
  • Endometrial cancer
  • Ovarian cancer
  • Venous thromboembolism (or blood clots) such as deep vein thrombosis (DVT)
  • Stroke
  • Heart disease.

Recent research and health guidelines say that the risks are small and are usually outweighed by the benefits, but here they are in some more detail:

Risk of breast cancer

All HRT medications are known to increase your risk of breast cancer within one to two years of starting treatment.

Evidence shows that the longer you take HRT the greater your risk of developing breast cancer regardless of the age you started taking it. This increased risk disappears within five years of stopping HRT.

It’s important you attend your breast screenings. Be aware, however, that your breast tissue can become more dense with HRT use so it may be difficult to detect breast cancer via mammography.

Risk of endometrial (or womb) cancer

Oestrogen-only HRT can increase your risk of endometrial cancer which is why it is often only prescribed for women who do not have a womb.

Your risk very much depends on your dose and how long you have been taking HRT. Taking combined HRT (i.e. oestrogen and progestogen) reduces the risk.

Risk of ovarian cancer

Research around ovarian cancer and HRT have had mixed results.

Specialists think oestrogen-only HRT carries a small increased risk of ovarian cancer. HRT that has combined oestrogen and progesterone – if used for a while – is also associated with a small increased risk of ovarian cancer. This increased risk disappears within a few years of stopping the HRT.

Risk of blood clots

Venous thromboembolism is when a blood clot forms in the vein. These are known as deep vein thrombosis (DVT) and they usually form in the leg, though they can develop elsewhere.

It can sometimes break loose and travel to the lungs. This is known as a pulmonary embolism (PE).

Women who take HRT are thought to be more at risk of developing blood clots, particularly in your first year of taking it. It’s worth noting, however, that current health guidelines suggest this risk is only associated with HRT tablets, not patches or gels.

This risk is usually low unless you have a family history of DVT, PE, obesity, severe varicose veins or if you have a personal history any of these health issues. Your doctor will carefully take your past medical history into account before prescribing any HRT products.

Trauma, or long periods of immobility, such as prolonged bed rest or a hospital stay, can increase your risk of developing blood clots. If you are having major surgery your doctor may ask you to stop the HRT four to six weeks before surgery.

Risk of stroke

The risk of stroke increases with age so the older you become the greater your risk of having a stroke. HRT only slightly increases this risk.

Risk of heart disease

There is very little data on the risk of heart disease in women who start taking HRT soon after the menopause, but those who start taking HRT 10 years or more after starting the menopause are at greater risk of coronary heart disease.

You must see your GP if you are thinking about re-starting HRT to consider the risks.

How to stop taking HRT safely

There’s no limit about how long you can take HRT for so it is important to discuss stopping the medication with your doctor. Many women stop taking HRT after about five years or when their symptoms are no longer a problem.

You can stop HRT immediately, but it is recommended that you gradually reduce your dose over two or three months, especially if you are on a higher dose of oestrogen, to prevent the menopausal symptoms returning.

If you’re taking a low dose of oestrogen the gradual reduction may not be required. On stopping, many women have a return of their menopausal symptoms but these are often mild and resolve in time with no treatment.

If your symptoms are severe when you stop then you need to discuss this matter with your GP who may prescribe a low dose HRT. Your doctor will need to consider your individual risk.

After stopping many women experience bladder and vaginal symptoms. These can be controlled with creams or pessaries that contain a very low dose oestrogen. These still pose the risks associated with the use of HRT but to a much lower extent because very little oestrogen is absorbed into your bloodstream.

Alternatives to HRT

If you are reluctant to take HRT, there are other ways to manage symptoms of the menopause. These include:

  • Ensuring you exercise regularly
  • Cut down on caffeine
  • Maintain a healthy diet including cutting down on spicy food and alcohol
  • Try antidepressants – certain types can help you with hot flushes and night sweats, although they haven’t had clinical trials for this use.

Many women are also interested in bio-similars, which are medicines that mimic natural oestrogen. The NHS does not recommend these, however, as it is not clear how safe or effective they are (they are not regulated and there is little research).

Answered by our Health at Hand pharmacist.

Further Reading

Hormone Replacement Therapy

From pregnancy to puberty – how hormones affect mood swings

Health in your 40s and 50s