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There are many different forms of HRT

The Menopause is officially defined as the last day of your last menstrual period, but most people use the term to describe the many months or years during which your body transitions from producing large amounts of reproductive hormone to almost none.

Some women start to feel the beginning of this transition with symptoms such as hot flushes, sweating (especially at night), poor sleep, mood changes and more. Some women are fortunate and don’t experience too much disruption during this time-but for some women, it can be a devastating process. Sleep disruption particularly can be very destructive and will affect all aspects of our wellbeing. Mood is often influenced by female hormone fluctuations and some women will never get a flush but will notice depression, anxiety and /or irritability around the menopause time.

The most efficient way to combat disruptive symptoms brought on by menopausal hormonal fluctuations/ decline is to supplement levels with hormone replacement therapy or HRT. In recent years there has been a lot of anxiety over the use of HRT and how it might affect the development of breast cancer but most of that information was not presented in an accurate way and has caused enormous, unnecessary fear. It might be helpful to know where all this furore came from!

HRT

HRT was prescribed liberally in the western world since the early 1970’s and users derived great benefit from it. In 2002, all of this changed when a study from the U.S. was published with headlines creating concerns about a possible link between using HRT and finding breast cancer. The study was called the Women’s Health Initiative (WHI) and it was commissioned by the U.S. government to look at many different aspects of the health of older women. They were particularly keen to see what factors affected heart disease and cancer.  The ladies in the study were almost all over 55 (most participants were in fact, in their early 60’s) and they were all offered a daily HRT tablet to take - some of them were given real HRT (in the form of horse urine Oestrogens with or without a balancing progestagen hormone) and some were given an identical pill that had no hormones in it at all (a placebo).

In the first 5 years of the study there was no difference in breast cancer detection in the two groups but after those 5 years went by, a slight increase was noticed in the number of breast cancers found in the women on the real HRT vs the women taking the placebo. The extra numbers were small and there was no suggestion that the HRT was creating new cancers. The actual increase in breast cancers being found was quoted as “relative risk of 1.26”. That was the official report; this is about the same extra number of breast cancers we see in women who drink two glasses of wine a day and far lower than the increased risk that being overweight carries. The information derived from that study did not suggest or prove that HRT caused breast cancers to develop, only that there was a slight association in some older women over time. However, that part of the study was halted until more information was gathered which was sensible.

Why All the Concern about HRT & Breast Cancer?

Sadly, things took an unfortunate turn at that stage when some of the authors of the study wrote a paper about HRT and breast cancer without discussing it with most of the other authors.  Moreover, their article in the medical journal was worded in a very alarming tone (they continue to receive much criticism for this even today). The popular papers picked up their story and we were seeing terrifying headlines saying HRT causes breast cancer; without any actual data to support this. It was so sad for Irish patients during those years. Droves of Irish women, as well as millions of women in the US and Europe, stopped their HRT abruptly. Some were fine, but some got their symptoms back with a vengeance but were too terrified to seek help. Even when they did ask for advice, they didn’t know who to believe. No matter how much we tried to reassure patients about the real relationship between HRT and breast cancer there were just as many other doctors who hadn’t read all the information and were still warning patients to avoid it at all costs! This unfortunately still happens today with uninformed GPs and Nurses.

The chart below demonstrates the breast cancer risk for menopausal women compared to other risk sources and puts it all in context.

Source: British Menopause Society

HRT today

Things stayed this way for decades until finally in 2015 a publication from the UK slowly started to reverse the fear mongering of the past 15 years. In Britain there is a government agency known as the National Institute for Health & Care Excellence (NICE). They are charged with making recommendations and formulating guidelines for doctors and nurses in the UK. In November 2015 they published a review of Menopause Care & HRT which reaffirmed what menopause doctors had been saying all along, which is; if your patient is suffering and needs HRT to control troublesome menopause symptoms, she should feel confident to use it and you should support her in her choice. They pointed out that most women who need HRT are young (well under the age of the women in the WHI study) and are probably only going to need it for a few years anyway. This has slowly started a rising confidence in many GP’s about menopause care & HRT prescribing and we have thankfully noticed an increasing number of women willing to talk about their symptoms and seek advice.

How do you know you’re in the menopause?

Menopause symptoms are so varied and there are no blood tests that confirm the diagnosis, so it can be a tricky consultation. In the main, early symptoms include flushes, night sweats and sleep disturbance. Some women are more troubled by emotional and cognitive issues like low mood, poor sex drive, irritability or anxiety, poor memory and/or a cloudiness in their thinking.  As some women move deeper into the transition, issues to do with declining collagen levels arise, so weakness of the pelvic floor with incontinence can worsen. Skin, hair and nail quality declines as collagen levels drop even further. The elasticity of the vaginal wall usually dis-improves as time goes on and that can make things like exercise and having sex less comfortable for some women. It is clearly no picnic and some women suffer much worse than others. The worst of the symptoms usually tail off by the late 50’s but some women continue to have troubles well into their 60’s and beyond.

Where Can I Read Reliable Information on Menopause & HRT?

HRT will combat most if not all symptoms and it is always worth educating yourself before making a decision.  Wonderful information can be found for patients and health workers alike on the NICE website. Additionally, some excellent agencies in the UK offer clear advice and information e.g.  www.womens-health-concern.org and www.menopausematters.co.uk among others. While HRT is worth considering there are also many non- HRT remedies that NICE and other health agencies recommend.

HRT Alternatives

  • Some women who won’t or can’t consider HRT will use over the counter vitamin and mineral supplements to help alleviate symptoms.

  • Some women have tried blood pressure-type medicine to relieve flushes and sweats with good results.

  • Some of the newer anti-depressant medications have been shown to give relief from flushes too, even when used in very low doses. Mood problems can be helped by these drugs too.

  • Vaginal moisturisers and lubricants are available that may help improve the symptoms of vaginal dryness and discomfort that plague some women.