MREF fact sheet 3

HRT: the Benefits and Risks explained.

Hormone replacement therapy (HRT), also called menopause hormone therapy (MHT) is an effective treatment for menopause symptoms. Traditional HRT includes oestrogens and progestogens. Testosterone is prescribed off licence for Hyposexual Desire Disorder (HSDD) or low libido.

Benefits associated with HRT

HRT is effective in relieving menopause symptoms including:

• Vasomotor symptoms like hot flushes and night sweats
• Sleep/insomnia related to menopause
• Anxiety and low mood during menopausal transition
• Joint and muscle pains
• Cognitive symptoms
• The genitourinary syndrome of menopause – that is, vaginal dryness, painful sex, and bladder urgency or incontinence.

Symptoms may improve quite quickly for some, within a few days, but for others it could take weeks or even few months. Not everyone experiences benefits from HRT in the same way and for the same symptoms.

The average age of menopause for those born in the UK is 50-51. The oestrogen component is effective in preventing osteoporosis, the thinning of bones that increases the risk of having a fracture. People who have experienced early menopause between the ages of 40-45, or those who have gone through premature ovarian insufficiency (POI) before the age of 40 are advised to take HRT until at least 50-51 to help protect their bones and reduce the risk of heart disease in future .

HRT may also help with preventing sarcopenia, the loss of muscle and muscle strength.

It’s important to exercise regularly to keep your muscles and bones strong.

There are many claims about the benefits of HRT for preventing heart disease and dementia following natural menopause but at the moment it is only recommended for the treatment of menopause symptoms and osteoporosis. It is not recommended as a treatment to prevent other long-term chronic health conditions.

Risks associated with HRT

As with any medication there are risks but they are generally regarded as low and they depend on the type of HRT you take, how long you take it for and your own health profile.

Studies show that there may be a small increased risk of breast cancer if you are taking a combined HRT – that is oestrogen and a progestogen. The risk varies with the type of progestogen. There does not appear to be an increased risk if you are taking oestrogen only HRT but if you have a womb you must have a progestogen component to your HRT as this is vital for protecting the lining of the womb (endometrium), and reducing the risk of endometrial cancer.

Oral oestrogen (tablets) has been associated with an increased risk of blood clots, deep vein thrombosis and stroke but transdermal delivery (patches, gels, implants or sprays) does not carry this risk.

Limited scientific evidence suggests that HRT may be associated with a small increased risk of ovarian cancer – about 1 extra case per 1000 women.

The leaflets inside HRT/MHT products can be quite scary or confusing, and this is why:

HRT has had its share of controversies. It was very popular in the latter half of the 20^th century but the publication of the Women’s Health Initiative trial results in 2002 changed that virtually overnight.

It stated that there was an increased risk of breast cancer and heart disease in HRT users, but it turned out that the women who were studied were much older than those who would normally be starting HRT and they had other co-morbidities. The trial only tested oral conjugated equine oestrogen (CEE) and one form of a synthetic progestogen called medroxyprogesterone. These are not commonly prescribed as HRT now a days.

Despite these limitations, and the incorrect extrapolation of results that the same risk applied to younger women, the popularity of HRT dropped dramatically and leaflets with warnings were added to the boxes. These product information leaflets are still used  today although they do not accurately reflect the actual risks and benefits for most individuals, especially those using the modern, transdermal and body identical HRT versions.

There is believed to be a ‘window of opportunity’ that is within ten years of onset of menopause (your last period) where the benefits outweigh the risks for heart disease. Studies show that there is a beneficial effect of oestrogen on the cardiovascular system with a reduction in coronary diseases and all-cause mortality for those who start using HRT between the age of 50–59 or within 10 years of menopausal onset.

A re-analysis of the WHI study has shown that those taking CEE oestrogen only HRT (women without a uterus) had a reduced risk of breast cancer, while those who were taking combined HRT – the CEE and the synthetic progestogen medroxyprogesterone, had a slightly higher risk of breast cancer but no greater risk of death.

Large observational study data suggest that micronised progesterone and dydrogesterone are two forms of progestogens which are likely to be associated with a lower risk of breast cancer compared to that seen with other progestogens like levonorgestrel, medroxyprogesterone and norethisterone.

The WHI and other studies have shown that HRT has also been shown to reduce the risk of colorectal cancer and there is no greater risk of endometrial cancer from taking HRT as long as the dose and types of hormones in HRT are taken within recommended guidelines.

The impact of lifestyle

Lifestyle and being overweight play a significant role in the chance of developing breast cancer – in some cases they play a much greater role than that of HRT.

Its estimated that 23 women in every 1000 will develop breast cancer over a period of 5 years between the ages of 50-59 (background risk).

If you take the contraceptive pill or combined HRT that figure rises by 4 cases/1000 to 27/1000 women

If you drink more than 2 units of alcohol a day it rises by 5 cases/1000 to 28/1000.

If you smoke there are an extra 3 cases taking it to 26/1000.

If you have a BMI of more than 30 the risk more than doubles with an extra 24 cases/1000 women or 47/1000.

If you take oestrogen only HRT the rise decreases by 4 cases/1000 to 19/1000.

If you exercise 30 min daily for 5 days a week, it drops by 7 cases down to 16/1000.

It is recommended that women who have had a hormone receptive breast cancer do not take systemic HRT and opt for non-hormonal options but vaginal oestrogen is increasingly being considered safe as there is little to no systemic absorption after the initial loading dose. These are discussions to be had with your healthcare provider, balancing out your individual health benefits for quality of life and side effects or risks.

Starting HRT is a shared care individualised decision made between you and your doctor based on your health status and understanding of how the risk factors relate to you.