Doctor Ailsa talks about the menopause

HRT has been around since the 1960s. Estrogen only HRT was prescribed for both women with and without a uterus. In the 1970’s, progesterone’s were added to HRT in women who had not had hysterectomies to protect women from womb lining (endometrial) growth thereby greatly reducing their risk of uterine cancer.

This combo is still needed and women should be reminded by their GP of the need for both oestrogen AND progesterone HRT  if they still have a uterus.

The positive effects of HRT on bone strength, heart disease, brain fog, skin and reduction in all cause of deaths (including both cancer and non cancer deaths) in women became very obvious.

However, over the last 20 yrs confusion has arisen from conflicting trial results interpretation and press scaremongering, amongst the public but also within the medical profession. So that the true benefits of HRT have been hidden, thereby denying a large number of women relief from their menopausal symptoms.

In this Blog I will attempt to summarise the reasons behind the rise, fall and rise again of HRT prescribing in the UK and USA . In the last two years the demand for HRT has far outstripped the supply with a world wide shortage. This is due, in part, to high profile individuals sharing their menopausal experiences, but also in the re education of GPs and other health care professionals, using reputable research renewing their confidence in prescribing HRT.

Bad press and misinformation regarding high profile HRT trials

In 2002, the results of the large WHI USA study were leaked before the study was finished.  Although the early results clearly showed HRT had a positive effect on bone strength, heart disease prevention and all cause mortality, it suggested that HRT might increase the risk of breast cancer.
The study was leaked to the Press, before full scientific review, resulting in 1000s of women stopping their HRT overnight. 1000s of newly menopausal women at the time, were refused HRT for menopausal symptoms.

20 years further on we now know the true risk of breast cancer due to HRT. We no longer prescribe the old fashioned HRT used by women recruited in those trials.

There is NO increased risk of death from breast cancer in women started on HRT within 10 years of their menopause if taken for 5 years or less.
The risk of breast cancer from obesity and high alcohol consumption are far higher than that of HRT especially if micronised progestogens are used.

Do I need HRT?

Every woman has a different perimenopausal experience. Some women have no hot flushes or night sweats at all. However, they should be aware of the hidden benefits of HRT on their bones, their cardiovascular system and their brain, skin and cancer risk. HRT even reduces the risk of developing diabetes.

Each individual has their own risk based on their genes, their family history, past medical history, their smoking and alcohol intake, their weight, blood pressure and bone status, to name a few.

The risks and benefits of starting HRT needs to be a discussion with a trusted health care professional with an interest in the menopause.
A shared decision making process is the best way forward, but this takes time. NHS GPs often do not have the luxury of enough time to answer the many questions that arise in this discussion. Certainly not all in one appointment!!

Once started, time is needed for the clinician to assess response, adjust dose or type of HRT and regularly monitor the patient’s risk factors as these change over time too.

Older synthetic progestogens VS newer body identical micronised progestogens

Studies show that the newer micronised body identical progestogens cause NO increased risk of breast cancer in the first 5 years of HRT use if started within 10 years of the menopause.

There is no increase risk of breast cancer in women taking oestrogen only HRT.

After 5 years of use of combined HRT using micronised progestogen, there is a slight increase in breast cancer risk but once this is discontinued, their risk goes back to their original baseline risk.

Women on the older HRT with synthetic progestogens take longer to reduce their risk once they stop it.

This evidence suggests we should be prescribing combined HRT using micronised progestogen.

Women who wish to continue their old HRT with synthetic progestogen should be warned of the slight increase risks associated.

HRT tablets VS HRT patches/gel?

There is no increase risk of clots if HRT is used in gel/patch form. Women who have had a clot/DVT should not be prescribed oral(tablet) HRT

Progestogen component of HRT?

I’ve pointed out the benefits of the newer types of progestogen (which can be taken in tablet form or inserted into the vagina).

but there is also the Mirena coil. It contains progestogen that can be used as part of HRT.

Its protection of the womb lining lasts 5 years. It also provides contraception, still needed until age 55.

Sequential(cyclical) vs continuous combined every day HRT?

The average age of the menopause in the UK is 52.

Daily HRT prescribed for perimenopausal symptoms before age 52  can cause irregular bleeding. We therefore often start with cyclical HRT, only using progestogen on days 15-26 of the cycle to allow for a monthly bleed UNLESS your periods had already stopped at least a year earlier. This reduces the risk of irregular spotting.

Dr-Ailsa-Maguire
Dr Ailsa Maguire
MBBS MRCP MRCGP DRCOG DipGUM PGCE

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