Hormone replacement therapy (HRT)

There are some concerns about the risks of HRT, which are often exaggerated by the media. We hope this leaflet will give you the information you need to weigh up the benefits and risks of HRT for yourself.

What is the menopause?

The menopause is the time of your last period. It usually occurs in your early 50s, but can be earlier or occasionally slightly later.

What are the symptoms of menopause?

The symptoms you experience at the time of your menopause can start a few years before your last period. These are some of the common symptoms, but not everyone will experience these.

• Hot flushes

• Night sweats

• Vaginal dryness

• Changes in hair, skin, mood, and libido (sex drive).

Why am I experiencing the menopause?

The reason these symptoms occur is that oestrogen is not present in normal levels. Oestrogen is a hormone released by the ovaries, which is partly responsible for the menstrual cycle.

This happens because ovaries stop producing oestrogen at the time of the menopause, when they stop releasing eggs on a monthly basis. Replacing the oestrogen in the form of HRT will relieve these symptoms in a large number of patients.

Some patients are menopausal because of surgery, radiotherapy, or chemotherapy. These patients may benefit from HRT.

What is HRT?

HRT contains oestrogen, which prevents the symptoms described above. If you still have a uterus (womb) you will need to have another hormone called a progestogen within your HRT as well.

Do I need HRT?

For a small group of patients, HRT would be essential. This includes those who are experiencing premature (early) menopause. For the majority of patients who are going through the menopause naturally, HRT is a matter of personal choice.

The second hormone (progestogen) prevents the lining of your womb becoming very thickened, which can lead to abnormal cells developing. So, it is very important that if you have not had a hysterectomy (removal of the womb) then you must have progestogen within your HRT.

HRT has also been shown to reduce the likelihood of osteoporosis and bowel cancer.

Where does HRT come from?

The oestrogens used in HRT are taken from natural sources. Some are from wild yams and some from the urine of pregnant mares which are kept in very humane conditions. Please check with your doctor if you have a preference.

How is HRT given?

HRT is given in various ways. It can be given as a tablet, patch, gel, vaginal tablets, or as an implant. Tablets and patches are the most common.

Are there any alternatives to HRT?

Other treatments are available for treating the symptoms of the menopause, but generally they do not work as well as HRT.

• Some herbal remedies have been suggested, but there is no strong evidence to support their use. Some remedies can worsen symptoms. If you wish to consider this option, please speak to your doctor first.

• Some women may prefer to make dietary and lifestyle changes to help relieve their menopause symptoms.

What are the side effects of HRT?

Side effects from HRT are more common in the first few months of using it. The side effects often cause people to stop taking it before things have had a chance to settle down and for them to notice a significant improvement.

• Breast tenderness and engorgement. This is best treated using a well-fitted bra and simple painkillers. With time this tenderness should settle.

• Nausea (feeling sick and / or dizzy). This will usually settle with time.

• Bloating particularly in the second half of your cycle. This problem can continue, and may need a change in the type of HRT you are prescribed.

Will I put on weight?

It is very common to be put off HRT because of the fear of putting on weight. There has been a lot of research which has shown that at the time of the menopause women do put on some weight. Patients who have been started on HRT do not put on any more weight than patients not on HRT. The difference is that they have something to blame for their weight gain.

What are the risks of breast cancer?

Breast cancer risk causes a lot of anxiety in patients taking or about to take HRT.

• A large study showed that the risk of breast cancer in all women between the age of 50 and 70 is 45 in 1000.

• If HRT is taken for five years the risk of developing breast cancer increases to 47 in 1000 (an increase of two in 1000). There is an increase of six in 1000 if HRT is taken for ten years.

These risks are the risks of developing breast cancer. However, the risk of dying from the disease is no greater. This may be due to:

• earlier detection as patients self examine their breasts, or

• it may be that the oestrogen makes the tumours more treatable, when they occur.

Once HRT is stopped the risk of breast cancer may continue for up to 10 years. After this the risk returns to your background risk. Your background risk is the risk you have before you take any drugs that increase that risk.

You will need to have normal mammogram screenings, as any lady over the age of 50 will have. There is no need for additional breast screening if you are on HRT and under the age of 50.

For more information, please read Understanding the risks of breast cancer. This infographic has been produced by the Women's Health Concern and the British Menopause Society.

What about the risk of blood clots in my legs or lungs (thrombosis)?

• The risk of a blood clot developing in the legs of somebody not taking HRT is approximately one in 10,000 women per year.

• The risk of a clot developing in somebody on HRT is approximately three in 10,000 women per year. This is mainly in the first few months of taking the HRT. Once established on HRT (after one year) the risk is just above that for people not on HRT.

• The risk of thrombosis is lower with the patches or gel type HRT, compared with the tablet types.

What about the risks of coronary heart disease and stroke?

Studies have shown that women who take HRT may have increased risk of heart attack and stroke, particularly if they already have established heart disease.

• Studies show that between the ages of 50 and 70 an extra seven in 10,000 women per year will have a heart attack if they are on HRT.

• For strokes, an extra eight in 10,000 women per year will be affected. These figures are very small and work out to be less than 0.1% above the baseline rate for women who are not on HRT.

If you start HRT soon after your menopause, HRT can actually protect you against coronary heart disease. Stroke risk is also less if you use the patches or gel type HRT.

What about the risk of ovarian cancer?

• If you have already had your ovaries surgically removed, you do not need to worry about ovarian cancer.

• The same large study in America showed that patients who had hysterectomies but kept their ovaries and then took oestrogen alone for HRT, were at increased risk of ovarian cancer. The risk increased if they took the oestrogen for more than 10 years. Again, the figures are very small and work out to an extra four in 10,000 women per year.

• Preliminary observations suggest that women who take a combined oestrogen and progestogen HRT are not at an increased risk of ovarian cancer.

These figures frighten and confuse me, how can I make sense of them?

The extra numbers of women on HRT who experience these complications are in fact very, very small. The majority of women on HRT will not have these complications. For example, the risk of heart attacks:

• for women who do not take HRT, the risk of a heart attack is 30 in 10,000 per year, and

• for women who take HRT, the risk of a heart attack is 37 in 10,000 per year.

However, more than 9,960 women out of 10,000 do not suffer heart attacks whether they use HRT or not. It is important to keep these extra risks in perspective.

Further information

• British Menopause Society provide factsheets.

• British Menopause Society: Understanding the risks of breast cancer

• Daisy Network is a national support group for patients diagnosed with premature menopause.