Menopause and Hormone Replacement Therapy

Hormone replacement therapy (HRT) does exactly what its name suggests – it replaces the hormones that a woman’s body ceases to produce after the menopause.

Eternal youth

HRT has been touted as an ‘elixir of life’, a magic potion that can reverse the effects of ageing, keeping a woman young forever. HRT is not the answer to eternal youth, but it can make many women feel younger. Successful treatment of exhausting hot flushes and sleepless nights restores energy. In turn, feeling better means it is easier to take regular exercise and follow a healthy diet, both of which have their own benefits.

Critics are sceptical that the menopause requires any medical intervention and see it as a natural event that should run its own course. This is fuelled by the fact that not every woman becomes severely oestrogen-deficient after ‘the change’. Although the ovaries are the main source of oestrogen, the adrenal glands produce small amounts and oestrogen is also formed in fat. These extra-ovarian sources are insufficient to restore fertility but may be adequate to prevent the development of severe menopausal symptoms.

Fear of cancer, particularly breast cancer, is another cause for concern but studies suggest that the risks are minimal if HRT is taken for less than 10 years. Even then, the evidence for increased risk is controversial.

Many women accept these risks once they realise the benefits of HRT, although some find it hard to cope with a return of monthly ‘periods’ and the regular pill taking that many regimens require.

Progesterone protection

Although oestrogen replacement effectively relieves the symptoms of the menopause, it is not without its problems. Doctors noticed a sudden increase in cancer of the lining of the womb, the endometrium, that was clearly linked to treatment. The oestrogen was stimulating growth of the endometrium resulting in the formation of potentially cancerous cells. In a percentage of women, true cancer developed but in a form that, in most cases, responded to treatment. Fortunately, a simple means of prevention was found -a 12-day course of synthetic progesterone (called progestogens) taken each month ‘opposes’ the oestrogens creating an artificial bleed similar to a ‘period’, which expels any cancerous cells. Women who have had a hysterectomy are not at risk of endometrial cancer and can safely take ‘unopposed’ oestrogens.

Refuting myths

Many of the fears associated with HRT are due to its effects being confused with those of the oral contraceptive pill. In fact, they are entirely different.

The oral contraceptive pill contains high doses of synthetic oestrogens which are up to eight times more potent than the natural oestrogens used for HRT. These high doses are necessary to prevent the ovaries releasing an egg each   month, producing a contraceptive effect. A disadvantage of synthetic oestrogens is that they make blood more sticky, increasing the risk of clots and thromboses in veins and arteries, which can lead to heart attacks and strokes. In contrast, natural oestrogens have minimal effects on blood clotting, and the dose used for HRT is equivalent to the amount produced in the body during the normal menstrual cycle. Natural oestrogens reduce the risk of clots in arteries, so heart attacks and strokes are less likely to occur. The risk of a clot in the veins (venous thrombosis) in a woman taking HRT is the same risk as she would have during her re­productive years, although this is greater than for a postmenopausal woman who is not using HRT.

Because of these important differ­ences, women who were unable to take the ‘pill’ can safely take HRT.

Unfortunately many myths surround the use of HRT and misinformation abounds, even within the medical profession. Research shows that women obtain most of their information from non-experts, especially the media, so it is not surprising that there is so much confusion about HRT.