THE TRUTH ABOUT HRT AND WHEN TO TAKE IT

Menopause expert Dr Stephanie Goodwin explains the latest thinking on Hormone Replacement Therapy

I have been a GP for many years and about 10 years ago when I started becoming menopausal myself, I realised that I didn’t really know too much about it, which is a bit shameful for female doctor. So I started doing some more training and learning at Guys Hospital.Having completed the Advanced Menopause Certificate I’m now a trainer for the British Menopause Society and really keen to spread the word and get as many doctors up to speed with giving women the right information, so that they can make decisions for themselves about how to manage what can be quite a taxing time of life.

When to start HRT
If you’re getting menopausal symptoms, the main ones being hot flushes and sweats, poor sleep, brain fog, anxiety and muscle pains, and you’re a woman of menopausal age which is generally anybody over the age of 45, then you can use HRT.

The perimenopause is the time leading up to the menopause and you can start getting symptoms five years before you stop having periods. So if you’re perimenopausal and symptomatic, you can start using HRT – you don’t have to wait until you’ve stopped having periods.

Asking for HRT
The thing to do is go in well prepared. Read the NICE guidelines which doctors adhere to. When you speak to your GP, explain what your symptoms are and that you’ve read the NICE guidelines and describe the impact that your symptoms are having on you. Many women are not sleeping, they’re not functioning, they can’t concentrate, they’re having difficulty working and if this is the case for you, say so. For HRT treatment, find out who in the practice is interested in women’s health, it might be a practice nurse rather than one of the doctors. They are the person to speak to as they will have the right information. And if you don’t get anywhere ask to see a different doctor.

Is HRT safe?
Over the years HRT has had very bad press, often based on information that should never have been presented in the way it was. The reason that we have the menopause is to stop reproduction. In the past, life expectancy wouldn’t have been long, but now thankfully, the majority of us are living into our mid 80s. That’s a very long time to go without the hormones that support our whole body from top to toe. Hormone replacement therapy puts back a little bit of what was there before, in very small amounts. And the hormones used in HRT are generally identical to the ones that we make in our own body, so they’re extremely safe, and the benefits of HRT outweigh the risks.

What are the risks?
The majority of women die of heart disease, not breast cancer or ovarian cancer. There are many benefits of taking HRT. HRT reduces your risk of heart disease by up to 50%. You’re seven times more likely to die of heart disease than breast cancer. HRT also reduces the risk of bowel cancer by 30%. It reduces the risk of osteoporosis, which is thinning of the bones – a condition that ultimately can be fatal, causing large numbers of older women to have to go into hospital with a broken hip, not recovering from surgery and dying.

There’s also evidence that HRT reduces the risk of dementia.

The thing that women worry about is, of course, breast cancer risk. But with the newer types of HRT the breast cancer risk is extremely low. One in eight women is going to get breast cancer, that’s just a fact of life. And with each decade, your risk of breast cancer increases. But the extra number of women who get breast cancer who take HRT is very low. For every 1000 women aged between 50 and 59, 23 of those will get breast cancer. If you take HRT, an extra four women will get breast cancer.

If you are overweight or obese, an extra 24 women will get breast cancer. If you drink more than 14 units of alcohol a week, an extra five women will get breast cancer. It’s all about its context, isn’t it? The benefits outweigh the risks.

When to stop taking HRT
There’s no fixed age to stop taking HRT. As many as 60% of women over 60 are still having menopausal symptoms. If you start HRT when you’re 50, and then you’re told that you have to stop it when you’re 55, which is what my GP said to me, then of course, the likelihood is, you’re still going to be in the midst of all of your symptoms. So, take it for as long as you need to. Many women feel so well when they take it that they don’t want to stop. But what you might do when you get older is to switch to using it as a gel or a patch. The reason for that is that if you swallow estrogen it slightly increases the risk of having a clot in your blood, and your risk also increases as you get older. So, it makes sense to switch to an HRT treatment through the skin.

If you’re being pressurised into stopping HRT then speak to someone else in the practice and if you’re having real problems just ask to be referred to a menopause clinic.

As you get older switch to using HRT as a gel or a patch. Swallowing estrogen slightly increases the risk of having a clot in your blood, and your risk also increases as you get older.

HRT can help improve your sex life
What often happens with the menopause, is that you get changes in the vaginal tissues because of estrogen deficiency, and it causes vaginal dryness. So that’s one of the problems and it can be really severe, making intercourse very painful. This can be treated by using vaginal estrogen, in the form of a pessary tablet. There are other non-hormonal treatments, such as vaginal lubricants, which you just use when you have sex. And you can also use vaginal moisturisers which you use every three days. They have a kind of build-up effect.

But lack of libido is also a common problem for menopausal women and there’s lots of reasons for that. It might be that you’re in pain and that pain overrides your libido. If you’re getting night sweats, then you’re not necessarily going to want anybody to come anywhere near you. But also, testosterone deficiency, which is very common in menopausal women, can also have an impact and testosterone treatments are available for this. Of course, work and family and relationships all impact on our sex drive, so whatever the case, talk it through with your GP.

Menopause and dementia
There’s lots of research looking into the oestrogen receptors in the brain. A really common symptom of the menopause is brain fog, which can be distressing if you’re in middle of a presentation and suddenly can’t remember what to say. It can impact on your confidence and then your anxiety levels go up and you end up in this spiral of stress and worry. Dementia is more common in women than in men. There seems to almost certainly be a hormonal link and the more studies that go on looking at that, the more likely it seems that hormone treatment will reduce the risk of dementia.

Starting HRT after the menopause
If you decide after the menopause to take HRT for the health benefits, the window of opportunity is the time during which you’re likely to get the best results in terms of reducing your risk of heart disease, dementia osteoporosis, etc. Ideally, you would want to start HRT within six years of your last period, but you can do it within 10 years. If you start taking HRT beyond that, you do actually increase the risk of having some sort of blood clot or coronary event.

When not to take HRT
Many women are mistakenly told they can’t take HRT. For example, women with high blood pressure. HRT is in fact very good for the cardiovascular system so it’s suitable for women with high blood pressure or even for diabetics. It’s really going to be women who either currently have breast cancer which has oestrogen receptors on it, or women with a history of oestrogen receptor positive breast cancer. So those women would be advised not to take HRT. However, we see women who have had breast cancer, and whose menopausal symptoms are so bad that they actually have said “I need to take my hormonal treatment again because I can’t live like this”. And actually, when you look at the evidence, if you do give those women HRT they’re probably not going to get a recurrence of their breast cancer.

Alternatives to HRT
We can use a drug called Clonidine, which is an alpha blocker, and it makes the peripheral blood vessels close down a bit so it reduces sweating. We use another drug called Gabapentin, which acts on the nervous system and that can be very helpful. Acupuncture can be very helpful, as can antidepressants. Cognitive Behavioural Therapy can be very helpful as can watching your diet, carefully regulating your blood sugar levels, not drinking too much alcohol because alcohol can really make symptoms worse, and limiting caffeine. So just a generally healthy lifestyle, with plenty of exercise and so on. And actually, there are new drugs coming out soon that we will be able to use for women who have oestrogen receptor positive breast cancer, because the drugs that they’re given for their breast cancer can bring on very severe menopausal symptoms. I can’t wait for this drug to come out in the next year or two because these women suffer terribly.

Why some women are prescribed testosterone
Testosterone is prescribed for women who are experiencing low sexual desire. But actually when you talk to women, it also just makes you feel better. It gives you energy, drive and a sort of joie de vivre that for many women disappears during the menopause. You either take small amount of the man’s version, which some GPS will prescribe. But many NHS GPS refuse to prescribe it, because they haven’t done the training and they’re not happy to do so. But the British Menopause Society has written guidelines for doctors and for patients about prescribing and using testosterone in women. There’s also an Australian testosterone called AndroFeme, which is specifically for women, but that’s only available from a private doctor. So you wouldn’t get that from your GP. If you’re suffering from really low libido and your GP isn’t able to help you and you’ve looked at the British Menopause Society guidelines, ask to be referred to a specialist clinic. With testosterone it takes up to 3 months for the benefit to kick in and there can be side effects, but if used as prescribed it can really help.

Words: Dr Stephanie Goodwin. For more information go to www.drstephaniegoodwin.co.uk

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