Introduction
I see approximately 100 female patients a year for hormone therapy treatment, also known as HRT. Women considering HRT tend to get their information from a variety of sources. Some women already have an idea about what they want, but others have misconceptions which probably reflects the regular media exposure that HRT attracts. As an experienced clinician running a specialist clinic at St. Mary’s Hospital for reproductive endocrine problems, Imperial College Healthcare, I want to talk about the five most important things that you should know about HRT before beginning treatment or being referred, as well as discuss some of the contentious issues and latest developments in this field.
1. HRT has positive effects.
Menopausal hot flushes are a common symptom of menopause which normally wears off with time. However, a few women experience ongoing hot flushes, which can profoundly affect everyday activities, sleep and quality of life. In 2004, a concluded that HRT provides effective long-term relief from hot flushes. HRT can also reduce age-related thinning of bones which may eventually cause osteoporosis. Everyone will experience a steady drop in the density (‘thickness’) of their bones each year, from middle age onwards. Women with problems of low oestrogen, menopause before the age of 40 years (premature menopause), or women with osteoporosis, could benefit from HRT.
2. HRT (like all medications) has drawbacks.
HRT prolongs your lifetime exposure to oestrogen, a hormone which makes blood sticky and regulates the breasts and ovaries. It is therefore unsurprising that HRT slightly increases the risk of blood clots (thrombosis), breast cancer and ovarian cancer. The key thing to consider is your ‘baseline risk’ i.e. how likely are you to experience these harmful effects without HRT? For instance, non-smokers without obesity or a previous or family history of blood clots start off with a very low risk, so HRT increases your absolute risk of blood clots marginally. However, if you start off with all of these risk factors, your chance of getting a blood clot becomes higher.
3. HRT may have additional benefits beyond its immediate benefits.
Some women experience improved mood and well-being on HRT. The published evidence in this area is more patchy because it’s hard to record empirically, and we certainly need more research performed on this topic. Nevertheless, a recent study showed that going through the menopause doubles the risk of depressive symptoms. Furthermore, a minority of women experience improvements in cognition (ability to think about things). We do not know if HRT has any effect on future dementia onset, though this is currently an area of interest.
4. HRT comes in lots of different forms.
There is a myriad of HRT preparations available, which means we can normally find something that suits each patient. Some women prefer tablets, but others like having a skin (transdermal) patch. Some women like a cyclical preparation which gives monthly bleeds. But others prefer a continuous preparation which does not give withdrawal bleeds at all. And there are different strengths of HRT, along with different types of hormone within the HRT. The immense choice of HRT reflects that a bit of trial and error is sometimes needed to find something that works well, as well as the importance of selecting a specialist who is able to accommodate your wishes and work with you on the various options.
An HRT patch
5. There is no hard and fast rule about how long or at what age you can take HRT, as long as the benefits outweigh the risks.
I do see patients whose GP is uncomfortable prescribing HRT because they are older than 60; GPs do a fantastic job, and I think it is understandable that they should be cautious. However, I firmly believe there is a place for HRT in the minority of women with severe menopausal symptoms, provided that the potential risks for each patient are explored and discussed. I have a small number of patients in their 70s, who are still employed, fit and active, and find dramatic improvement in symptoms when taking HRT.
Recent developments in HRT
First of all, news claiming ‘new study reveals that HRT does X’ should not trigger automatic panic. HRT has well-known potential risks which I have discussed - there is a steady stream of studies on this topic which often provide a bit more information about these risks, and make the news due to the huge public interest in HRT. However, I am aware that being continually bombarded with ‘new information’ about HRT can worry patients taking it or considering it. So, the best policy is to speak with your doctor at your next review, and see what they think.
A pioneering study at Imperial College London that I am involved with has revealed that Neurokinin B (NKB) antagonists could be a new class of medication to treat menopausal hot flushes. This study is fairly advanced and is currently
. During the menopause, levels of neurokinin B rise in the hypothalamus (part of the brain). We think that NKB then activates thermoregulatory (temperature regulating) parts of the brain to trigger hot flushes. It is too early to say when and if NKB drugs will make it to clinical practice, but this is a truly exciting development for women suffering from severe hot flushes unable to take oestrogen containing drugs like HRT because of breast cancer treatment.
Conclusion
HRT is an unusual medication, since taking it is choice rather than a necessity (like taking a heart medication that is required to keep you alive). In a way, this makes it more difficult to decide on HRT as it comes down to opinion and discussion about a patient’s unique situation. Having an honest discussion about the benefits vs. risks of treatment with an experienced practitioner is critical to ensure that a shared decision and management plan is agreed between doctor and patient.
Further reading and links
Royal College of Obstetricians & Gynaecologists
Faculty of Sexual and Reproductive Healthcare