The following information will be of interest to women who want to understand the symptoms of the menopause and HRT.
What is the menopause?
Strictly speaking, the menopause is the last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. It is often called the 'change of life'. It occurs because as you get older your ovaries make less oestrogen (the main female hormone). The average age of the menopause in the UK is 51. However, it may be sooner or later than this. Early menopause (occurring in your 30's or early 40's) can run in families.
If you have had a hysterectomy (removal of the uterus) before your menopause
Your ovaries will still make oestrogen. However, it is likely that the level of oestrogen will fall at an earlier age than average. As you do not have periods after a hysterectomy, it may not be clear when you are in 'the menopause'. However, you may develop some typical symptoms (see below) when your level of oestrogen falls.
If you have your ovaries removed
You are likely to develop menopausal symptoms straight away.
What are the possible symptoms and problems of the menopause?
The menopause is a natural event. You may have no problems. However, it is common to develop one or more symptoms which are due to the low level of oestrogen.
Short term symptoms
- Hot flushes occur in about 3 in 4 women. A typical hot flush lasts a few minutes and causes flushing of your face, neck, and chest. You may also perspire (sweat) during a hot flush. Some women become giddy, weak, faint, or feel sick during a hot flush. The number of hot flushes can vary from every now and then, to fifteen or more times a day. Hot flushes tend to start just before the menopause, and typically persist for 2-3 years.
- Sweats commonly occur when you are in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and night clothes.
- Other symptoms may develop such as headaches, tiredness, palpitations, being irritable, difficulty sleeping, depression, anxiety, aches and pains, loss of libido (sex drive), and feelings of not coping as well as before. It can be difficult to say whether these symptoms are due to the hormone changes of the menopause. For example, you may not sleep well or become irritable because you have frequent hot flushes, and not directly because of a low oestrogen level. Also, there may be other reasons why these other symptoms develop. For example, depression is common in women in their 'middle years' for various reasons.
Long term changes and problems
- Skin and Hair. You tend to lose some skin protein (collagen) after the menopause. This makes the skin drier, thinner, and more likely to itch.
- Genital area. Lack of oestrogen tends to cause the tissues in and around the vagina to become thinner and drier. These changes can take months or years to develop.
- The vagina may shrink a little, and expand less easily during sex. You may then have some pain when you have sex.
- Your vulva (the skin next to your vagina) may become thin, dry, and itchy.
Osteoporosis after the menopause
As you become older, you gradually lose bone tissue. The bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss, then you have osteoporosis. If you have osteoporosis you have bones that will break more easily than normal, especially if you have an injury such as a fall.
Women lose bone material more rapidly than men especially after the menopause when the level of oestrogen falls. Oestrogen helps to protect against bone loss. By the age of 70 some women have lost 30% of their bone material. In the UK, about half of women over the age of 50 will fracture a bone, many as a result of osteoporosis.
However, not all women develop osteoporosis after the menopause. Osteoporosis is more likely to develop if you have, or have had, one or more 'risk factors'. The following situations are risk factors for developing bone loss and osteoporosis. If you:
- are a woman who had your menopause before the age of 45.
- have already had a bone fracture after a minor fall or bump.
- have a strong family history of osteoporosis.
- have a body mass index (BMI) of 19 or less. (That is, you are very underweight.) For example, if you have anorexia nervosa. In this situation the level of oestrogen is often low for long periods of time and, combined with a poor diet, can affect the bones.
- are a woman and your periods stop for a year or more before the time of your menopause. This can happen for various reasons.
- have taken, or are taking, a steroid medicine (such as prednisolone) for three months or more. A side-effect of steroids is to cause bone loss.
- smoke
- lack calcium and/or vitamin D (due to a poor diet and/or little exposure to sunlight.)
- have never taken regular exercise, or have led a sedentary lifestyle (particularly during your teenage years).
- have, or had, certain medical conditions that can affect the bones. For example, an overactive thyroid, Cushing's disease, and any condition that causes poor mobility.
What is HRT (hormone replacement therapy)?
All types of HRT contain an oestrogen hormone. If you take HRT it replaces the oestrogen that your ovaries no longer make after the menopause.
HRT is available as tablets, skin-patches, gels, nasal spray, or implants which are put under the skin. There are several brands for each of these types of HRT. All deliver a set dose of oestrogen into the bloodstream.
However, if you just take oestrogen then the lining of the uterus builds up. This increases the risk of developing cancer of the uterus. Therefore, the oestrogen in HRT is usually combined with a progestogen hormone. The risk of cancer of the uterus is very much reduced by adding in the progestogen. In many HRT products, the oestrogen and progestogen are combined in the same tablet or patch, but they can be taken separately. If you have had a hysterectomy, you do not need a progestogen.
An option to ease symptoms just in the vaginal area is to use a cream, pessary, or vaginal ring that contains oestrogen.
How do I take HRT?
Different women prefer different methods of taking HRT. For example, some women prefer to wear a patch rather than take tablets. You doctor or practice nurse can give you information about the pros and cons of the different types of HRT. In general:
If you start HRT when you are still having periods, or have just finished periods
You will normally be advised to use a 'sequential combined HRT' preparation. This means you take oestrogen every day, but you add in the progestogen for 12-14 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 the uterus to build up which is then shed as a 'withdrawal' bleed every 28 days when the progestogen part is stopped.)
If you continue with HRT for more than 2-3 years, you may wish to switch to a 'continuous combined HRT preparation' which usually causes no bleeding (see below).
If you start HRT a year or more after your periods have stopped
You will normally be advised to take a 'continuous combined HRT preparation'. This means you take both an oestrogen and a progestogen every day. The dose and type of the oestrogen and progestogen are finely balanced so that they usually do not cause a monthly bleed. However, even with these types of HRT some women still get spotting or mild irregular bleeds.
What are the benefits of HRT?
Menopausal symptoms usually ease
- HRT tends 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.
- If you are anxious, irritable, depressed, etc, because of menopausal symptoms, these may also ease if the symptoms such as hot flushes or dry vagina are eased. Therefore, you may have a 'knock on' effect on your general wellbeing after starting HRT.
If you take HRT long-term (several years or more):
It helps to protect against osteoporosis and bowel cancer. However, the protective effect is small. Studies have shown that if 1,000 healthy women who take HRT are compared to 1,000 healthy women who do not take HRT, in those who take HRT, over a 10 year period there will be about:
- Five fewer women who develop a hip fracture. This is because you are less likely to develop osteoporosis, and therefore less likely to fracture a bone.
- Six fewer women who develop cancer of the bowel (colon). It is not clear how HRT reduces the risk of developing this cancer.
What are the risks in taking HRT?
If you take HRT, compared to women of the same age who do not take HRT, you have a small increased risk of developing the following.
- A blood clot in a blood vessel. This can cause a DVT (deep vein thrombosis) and the clot may travel to the lung (pulmonary embolism). In women in their 50's, over a five year period:
- about 3 in 1000 women who do not use HRT are likely to have a serious blood clot.
- about 7 in 1000 women who do use HRT are likely to have a serious blood clot.
The increased risk of having a blood clot is mainly within the first year or so of starting HRT. See a doctor urgently if you develop a red, swollen or painful leg, or have sharp pains in your chest.
- Cancer of the breast. For women aged 50 who do not use HRT, about 45 in 1000 will develop breast cancer before they are 70. However, if you take HRT it increases your risk of developing this cancer. The increased risk is small for the first 1-2 years of using HRT, and then gradually increases the longer you use it. For example, studies have shown that for every 1000 women who take HRT for 10 years, there are:
- about 19 extra cases of breast cancer in those who take combined oestrogen/progestogen HRT.
- about 5 extra cases of breast cancer in those who take oestrogen-only HRT.
However, if you use HRT and then stop taking it, your risk of developing breast cancer falls back to the normal risk within a few years of stopping treatment.
- Stroke. There is a small increased risk. Over a five year period:
- about 3 in 1000 women in their 50's who do not take HRT will have a stroke.
- about 4 in 1000 women who do take HRT will have a stroke.
Stroke becomes more common with increasing age. Over a five year period: - about 11 in 1000 women in their 60's's who do not take HRT will have a stroke.
- about 15 in 1000 women who do use HRT will have a stroke.
- Heart disease. A recent research study suggested that HRT may cause a slight increased risk of developing heart disease. The research study looked at one type of HRT. So, although the picture is still unclear for other brands, it is likely that there is a small increased risk for all types of HRT. The study estimated that in every 10,000 HRT users, there is an extra 8 heart 'events' (heart attack, etc) per year compared to 10,000 non-users.
- Cancer of the uterus (womb). The increased risk is much reduced by taking the progestogen part of the HRT. This is the reason why progestogen is included in HRT. 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.
- Cancer of the ovary. There is a slight increased risk of developing this cancer if you use oestrogen-only HRT for more than 5 years.
- Dementia. HRT users may have a slightly increased risk of developing dementia.
So, there is a small but definite increased risk of serious illness when using HRT.
Note: your risk of developing the diseases mentioned above depend on many factors. For example, your family history, and lifestyle factors such as smoking, obesity, diet, etc. You can greatly reduce your risk of developing heart disease and stroke by not smoking, taking regular exercise, and eating a healthy diet. These conditions become more common anyway with advancing age. But, if you take HRT this is now another factor to consider.
What about side-effects when taking HRT?
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. Always read the page that comes with the packet which gives a full list of possible side-effects. They include the following.
- In the first few weeks some women develop slight nausea (feeling sick), some breast discomfort, or leg cramps. These tend to go within a few months if you continue to use HRT.
- HRT skin patches may cause irritation of the skin.
- Some women have more headaches or migraines when they take HRT.
- Dry eyes (lack of tears) are also thought to be more common in HRT users.
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.
So, should I take HRT, and for how long?
The benefits have to be balanced against the risks. You have to decide what is right for you, with advice from your doctor or nurse, depending on your circumstances. 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 probably in favour of taking HRT. You may be happy to accept the small risk of taking HRT for 1-3 years to be free of these symptoms. 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. If the genital symptoms such as vaginal dryness persist after stopping HRT, an option is to use an oestrogen cream or pessary in the vaginal area (see below).
For healthy women without symptoms and a menopause at around 50 or over
HRT is usually not advised as there is little to be gained, and even the small risks of HRT are then unacceptable.
If you just have genital symptoms such as a dry vagina
An option which may be advised by your doctor is to use 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 less oestrogen gets into the bloodstream.
What about taking HRT to help prevent osteoporosis
A few years ago HRT was widely used to prevent osteoporosis. However, recent research has shown that there are potential serious health risks with taking HRT (described above). So, we now know that the balance of risks and benefits is usually not in favour of taking HRT to prevent osteoporosis for most women.
However, if you have an early menopause, HRT may be advised until you are aged 50. This is to help to prevent osteoporosis (and ease menopausal symptoms if they occur). You have an increased risk of developing osteoporosis if you have an early menopause. The health risks of taking HRT are not thought to apply, or be very small, until you reach the usual age of menopause (about aged 50).
Some other points about HRT
- 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.
- You should not take HRT if you have severe liver disease, or cancer of the uterus or breast.
- If you have had a previous blood clot in a vein, or have a family history of a blood clotting problem, you may be advised not to take HRT until certain blood tests are checked.
©EMIS and PIP 2006
