It can be like magic for women who feel their life is wrecked. Most women go through the menopause between the ages of 45 and 55, although for some it happens prematurely and others are thrown into it by cancer treatment to stop the body producing oestrogen, as the hormone feeds breast and ovarian cancers. The first oestrogen pill was introduced in , and HRT became available to women in the UK in , without the sort of trials that would be done today to look at the side-effects.
The rationale was clear: the pills replaced the oestrogen women were losing. Without any evidence, the suggestion was planted that HRT would restore both vigour and beauty. The science came later and caused much dismay. Both found an increased rate of breast and ovarian cancer.
Thousands of women stopped taking HRT. Thousands more were anxious about starting it. The pendulum has recently swung back the other way, with guidance from Nice, the National Institute for Health and Clinical Excellence, in November Millions of women should no longer have to suffer in silence, it said. An estimated 1. HRT worked, Nice said, and should be considered.
And now the WHI study has published its long-term findings showing women do not die from taking it. Hamoda is also on the medical advisory council of the British Menopause Society which has lobbied for HRT and disputed the risk findings in the past. Hamoda says the breast cancer risk is not high.
The WHI study puts it at one more case in 1, It is similar to the [breast cancer] risk of drinking a glass of wine a night. A more recent study, from the Institute of Cancer Research in London, found last year that among the , women taking part to look at the causes of breast cancer, those on HRT had a 2. The risk is higher for woman taking the combined oestrogen and progesterone pill and lower for oestrogen only — but women need progesterone to protect against womb cancer unless they have had a hysterectomy.
Gynaecologists like Hamoda understand the need. The average duration of symptoms is seven years but one in three go beyond that. Author Jeanette Winterson described two years of mental breakdown. But conventional doctors say there is no difference. Women are given oestrogen in the form of estradiol on the NHS, which Hamoda says is bioidentical — identical — to that made in the female body. The progesterone that most women get is synthetic, but bioidentical micronised progesterone, made from plants, is also available on the NHS.
Venous thromboses are blood clots that form inside veins. Women under 50 years of age, and women aged 50 to 60, face an increased risk of venous thrombosis if they take oral HRT. The increase in risk seems to be highest in the first year or two of therapy and in women who already have a high risk of blood clots.
This especially applies to women who have a genetic predisposition to developing thrombosis, who would normally not be advised to use HRT. Limited research to date suggests the increased risk of clots is mainly related to combined oestrogen and progestogen in oral tablet form, and also depends on the type of progestogen used.
Some studies suggest a lower risk with non-oral therapy patches, implants or gels or tibolone. The endometrium is the lining of the uterus. Use of oestrogen-only HRT increases the risk of endometrial cancer, but this risk is not seen with combined continuous oestrogen and progestogen treatment.
There is no risk if a woman has had her uterus removed hysterectomy. The increased risk of ovarian cancer is very small and estimated to be one extra case per 10, HRT users per year. A recent review linked HRT to two types of tumours: serous and endometrioid cancers. Cholecystitis is a disease in which gallstones in the gallbladder block ducts, causing infection and inflammation. On average, there is a slightly higher risk that a woman will develop cholecystitis when using oral HRT, but patch treatment is associated with a lower risk.
Treatment for cholecystitis includes surgery to remove the gallbladder. Weight gain at the menopause is related to age and lifestyle factors. An increase in body fat, especially around the abdomen, can occur during menopause because of hormonal changes, although exactly why this happens is not clear.
Normal age-related decrease in muscle tissue, and a decrease in exercise levels, can also contribute to weight gain. Most studies do not show a link between weight gain and HRT use. If a woman is prone to weight gain during her middle years, she will put on weight whether or not she uses HRT. Some women may experience symptoms at the start of treatment, including bloating, fluid retention and breast fullness, which may be misinterpreted as weight gain.
These symptoms usually disappear once the therapy doses are changed to suit the individual. HRT is not a form of contraception. The treatment does not contain high enough levels of hormones to suppress ovulation, so pregnancy is still possible in women in the perimenopause the time of hormonal instability leading up to menopause.
Periods can be erratic in perimenopause, and egg production will be less frequent, but can still occur until menopause. For women younger than 50, contraception is recommended for at least two years after the final period. For women aged 50 and above, contraception is recommended for at least one year after their final period. It is currently believed that, overall, the risks of long-term more than five years use of HRT outweigh the benefits.
HRT should not be recommended for disease prevention, except for women under 60 years of age with substantially increased risk of bone fractures, or in the setting of premature menopause. Women with liver disease, migraine headaches, epilepsy, diabetes, gall bladder disease, fibroids, endometriosis or hypertension high blood pressure need special consideration before being prescribed HRT.
In these situations HRT is often given through the skin transdermally. Despite the risks of long-term use, in women with severe and persistent menopausal symptoms, HRT may be the only effective therapy. Women with premature or early menopause are prescribed HRT long-term because of their increased risks of earlier onset of heart disease, osteoporosis, and some neurological conditions compared to women undergoing menopause around the age of 50 years. Seek specialist advice from a menopause clinic or menopause specialist.
Regular check-ups are recommended. Many medical organizations and societies agree in recommending against the use of custom-compounded hormone therapy for menopause management, particularly given concerns regarding content, purity, and safety labeling of compounded hormone therapy formulations. There is a lack of safety data supporting the use of hormone therapy in women who have had breast cancer. Non-hormonal therapies should be the first approach in managing menopausal symptoms in breast cancer survivors.
The Bottom Line: Hormone therapy is an acceptable option for the relatively young up to age 59 or within 10 years of menopause and healthy women who are bothered by moderate to severe menopausal symptoms. Individualization is key in the decision to use hormone therapy. Consideration should be given to the woman's quality of life priorities as well as her personal risk factors such as age, time since menopause, and her risk of blood clots, heart disease, stroke, and breast cancer.
Medical organizations devoted to the care of menopausal women agree that there is no question that hormone therapy has an important role in managing symptoms for healthy women during the menopause transition and in early menopause. Ongoing research will continue to provide more information as we move forward.
Going Mad in Perimenopause?
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