WHAT IS HRT?

What is HRT?

HRT stands for hormone replacement therapy and it is a treatment that is used to relieve symptoms of the menopause.The oestrogen in HRT replaces the declining natural oestrogen levels that occur as you approach the menopause.

Like all medications, there are benefits and risks associated with taking HRT. It is important to discuss this matter with your doctor when you are deciding on your treatment options and if HRT is right for you.

WHAT TO DO IF YOU THINK YOU NEED TREATMENT FOR MENOPAUSAL SYMPTOMS?

You should discuss your symptoms and your treatment options with your GP.

WHAT HAPPENS IF I AM PRESCRIBED HRT?

There are different types of HRT available and your GP can discuss these with you and help you to choose an option best suited for you.

It is common to start with a low dose of HRT which can then be increased, if needed. The effects of treatment may not be felt straight away, sometimes it can take a few weeks, and you may experience some side effects at first.

Usually a 3 month trial of treatment will be advised to see if it helps. If it doesn’t there are options your doctor may propose such as changing the dose or trying a different type of HRT, every woman’s experience of the menopause can be different and so can their treatment.

WHO CAN TAKE HRT?

Most women can take HRT. However it is important to remember that HRT is not be suitable for everyone.

If any of the following apply you should speak to your doctor and you should not take HRT:

• if you have or have ever had breast cancer, or if you are suspected of having it.
• if you have cancer which is sensitive to oestrogens, such as cancer of the womb lining (endometrium), or if you are suspected of having it.
• if you have any unexplained vaginal bleeding.
• if you have excessive thickening of the womb lining (endometrial hyperplasia) that is not being treated.
• if you have or have ever had a blood clot in a vein (thrombosis), such as in the legs (deep venous thrombosis) or the lungs (pulmonary embolism).
• if you have a blood clotting disorder (such as protein C, protein S, or antithrombin deficiency).
• if you have or recently have had a disease caused by blood clots in the arteries, such as a heart attack, stroke or angina.
• if you have or have ever had a liver disease and your liver function tests have not returned to normal.
• if you have a rare blood problem called “porphyria” which is passed down in families (inherited).
• if you are pregnant – it is still possible to get pregnant while taking HRT, so you should use contraception. It is important that you discuss your contraceptive options and choices with your doctor.

In these circumstances, alternatives to HRT may be recommended instead.

WHAT TYPES OF HRT ARE AVAILABLE?

When considering HRT you should discuss all options with your doctor, including possible alternatives to HRT.

HRT comes in many different forms: Tablets, gels and patches with different types of strengths of hormones. Finding the right treatment choice for you may take some time.

HRT replaces the hormones in a woman's body that are no longer produced because of the menopause.

The two main hormones used in HRT are oestrogen and progestogen.

Treatment with HRT can be taking both of these together (combined HRT), or only taking oestrogen (oestrogen-only HRT).

Most women take combined HRT because taking oestrogen on its own can increase your risk of developing cancer of the womb (endometrial cancer). Taking progestogen alongside oestrogen minimises this risk.

HOW IS HRT TAKEN?

HRT may be taken in a number of different ways; speak to your doctor to decide on the best option for you, for example:

• Tablets and capsules
• Patches
• Gels and sprays
• Intrauterine systems
• Vaginal oestrogen

WHAT TREATMENT ROUTINES ARE AVAILABLE?

Your treatment options for HRT depends on if you are in the early stages of the menopause or if you have had menopausal symptoms for some time.

For women who need to take progestogen, treatment may be either cyclical (or sequential) HRT or continuous combined HRT.

Cyclical (or sequential) HRT
With cyclical HRT you will still have regular periods or bleeds.

There are two types of cyclical HRT:

• Monthly HRT – oestrogen is taken every day, and you take progestogen as well for the last 14 days of your menstrual cycle. You will have monthly periods on this type of HRT.
• Three monthly HRT – oestrogen is taken every day, and you take progestogen alongside it for around 14 days every 3 months. In this case you would have a period every 3 months.

These types of HRT maintain regular periods which means you will know when they naturally stop.

Continuous combined HRT
This type of HRT is specifically for women who are postmenopausal which is generally defined as not having had a period for a year. With continuous combined HRT you are taking oestrogen and progestogen every day without a break and you will not have periods on this type of HRT.

Oestrogen-only HRT
For women who are suitable for oestrogen-only HRT (those that have had a hysterectomy), this is normally taken daily without a break.

HOW IS HRT TREATMENT STOPPED?

There is no defined time on how long you can take HRT, but you should discuss with your doctor about their recommendations on how long you should continue treatment for.

Most women would expect to stop taking it once their menopausal symptoms have stopped, which is usually after a few years.

Women who take HRT for more than 1 year have an increased risk of some types of cancers, it is important to consider this when starting treatment (see Risks of HRT).

When you decide to stop taking HRT, you can do it either suddenly or gradually. Some women find that gradually decreasing their HRT dose reduces the chance of their symptoms returning in the short term.

If after stopping HRT you have symptoms that return and continue for months, or if they are severe or impacting on your daily life, you should contact your doctor. You may need some treatment for these symptoms or you may need to start HRT again.

WHAT ARE THE SIDE EFFECTS OF HRT?

As with all medicines, HRT can cause side effects. However, these may pass within a few months of starting treatment.¹

Common side effects include:¹

• Breast tenderness
• Headaches and dizziness
• Feeling sick and stomach upsets
• Indigestion
• Abdominal (tummy) pain
• Vaginal bleeding or spotting
• Weight increase or decrease, swelling caused by fluid retention
• Depression, nervousness, lack of energy
• Hot flushes, increased sweating
  More information is available in the package leaflets that are provided with each medicine.

WHAT ARE THE ALTERNATIVES TO HRT?

There are some alternative ways of trying to control the symptoms you experience in the menopause if you are unable or unwilling to take HRT.

Alternatives to HRT include:

• Cognitive behavioural therapy (CBT) – therapy that examines the things you think and the things you do through talking and can help with feelings such as low mood and anxiety
• Healthy diet and exercise - maintaining a healthy weight and staying fit and strong can improve some menopausal symptoms
• Non-hormonal medicines that will help with some of the symptoms of the menopause

BENEFITS OF HRT

Most menopausal symptoms can be improved with the use of HRT, these include:

• Hot flushes
• Mood swings
• Night sweats
• Vaginal dryness
• Reduced sex drive

Without HRT treatment many of these symptoms will fade after a few years, but for many women these symptoms can have a significant effect on their life and how they feel. For these women HRT is often the only way to alleviate these symptoms and get through the menopause.

RISKS OF HRT

When deciding if hormone replacement therapy (HRT) is the right option for you, it is important to
understand and consider the risks and discuss these with your doctor.

HRT AND CANCER

• Taking oestrogen-only HRT will increase the risk of excessive thickening of the lining of the womb (endometrial hyperplasia) and cancer of the womb lining (endometrial cancer). The progestogen in HRT protects you from this extra risk.
• Breast cancer
  Evidence shows that taking combined oestrogen-progestogen or oestrogen-only hormone replacement therapy (HRT) increases the risk of breast cancer. The extra risk depends on how long you use HRT. The additional risk becomes clear within 3 years of use. After stopping HRT the extra risk will decrease with time, but the risk may persist for 10 years or more if you have used HRT for more than 5 years. The UK Medicines and Healthcare Products Regulatory Agency advice on HRT Risks and Benefits can be found here 

Comparison:

It is important to regularly check your breasts. See your doctor if you notice any changes such as:

• dimpling of the skin.
• changes in the nipple.
• any lumps you can see or feel.

Additionally, you are advised to join the breast screen programme when contacted. For mammogram screening, it is important that you inform the nurse/healthcare professional who is actually taking the x-ray that you use HRT, as this medication may increase the density of your breasts which may affect the outcome of the mammogram. Where the density of the breast is increased, mammography may not detect all lumps.

Ovarian cancer
Ovarian cancer is rare, much rarer than breast cancer. The use of oestrogen-only or combined oestrogen-progestagen HRT has been associated with a slightly increased risk of ovarian cancer.

The risk of ovarian cancer varies with age. For example;

In women aged ≤59 years who are not taking HRT, about 2 women in 1000 will be diagnosed with ovarian cancer over a 5-year period

For women who have been taking HRT over 5 years there will be ˂1 extra case per 1000 women

EFFECT OF HRT ON HEART AND CIRCULATION

Blood clots in (thrombosis)
The risk of blood clots in the veins or lungs (pulmonary embolism) is about 1.3 to 3 times higher in HRT users than in non-users, especially during the first year of taking it.

Blood clots can be serious, and if one travels to the lungs, it can cause chest pain, breathlessness, fainting or even death.

You are more likely to get a blood clot in your veins as you get older and if any of the following applies to you. Inform your doctor if any of these situations applies to you:

• you are unable to walk for a long time because of major surgery, injury or illness
• you are seriously overweight (BMI > 30 kg/m²)
• you have any blood clotting problem that needs long-term treatment with a medicine used to prevent blood clots
• if any of your close relatives has ever had a blood clot in the leg, lung or another organ
• you have systemic lupus erythematosus (SLE)
• you have cancer
• pregnancy/postpartum period

Comparison:

Looking at women ≤69 years who are not taking HRT, on average, over a 5-year period, 5 in 1,000 would be expected to get a blood clot in a vein

For women ≤69 years who have been taking oestrogen-progestogen HRT for over a 5-year period there will be 12 cases in 1,000 users (i.e. an extra 7 cases per 1000)

Heart disease (heart attack)
There is no evidence that HRT will prevent a heart attack.
Women over the age of 60 years who use oestrogen-progestogen HRT are slightly more likely to develop heart disease than those not taking any HRT.

Stroke
The risk of getting a stroke is about 1.5 times higher in HRT users than in non-users. The number of extra cases of stroke due to use of HRT will increase with age.

Comparison:

Looking at women ≤69-years who are not taking HRT, 4 in 1,000 would be expected to have a stroke over a 5-year period

For women ≤69-years who have been taking HRT, there will be 5 cases in 1,000 users over 5-years (i.e. an extra 1 case per 1,000)

Other conditions
HRT will not prevent memory loss. There is some evidence of a higher risk of memory loss in women who start using HRT after the age of 65. Speak to your doctor for advice.

If you are taking thyroid hormone replacement therapy (e.g. thyroxine), your doctor may monitor your thyroid function more often when you start treatment.
If you have or have had cholasma (yellowish-brown pigmentation patches on the skin, particularly of the face); if so, minimize your exposure to the sun or ultraviolet radiation whilst using HRT.