REPROSAIT 4 U

Many women, although not all, experience uncomfortable symptoms during and after menopause, including hot flushes, night sweats and vaginal dryness. These symptoms, and the associated physical changes, can be managed in various ways including education and lifestyle changes like diet and exercise.

Hormone replacement therapy (HRT) is also available if required. This is also known as hormone therapy (HT). While HRT reduces the risk of some debilitating diseases, it also increases the risk of others.

Menopause occurs when a woman stops ovulating, the ovaries no longer produce oestrogen (one of the female sex hormones) and her monthly period (menstruation) ceases. It is a natural event that marks the end of the reproductive years, just as the first menstrual period during puberty marked the start.

Menopause symptoms can be reduced by HRT

The following menopause-related symptoms may be reduced by HRT:

1. Hot flushes
2. Night sweats
3. Vaginal dryness
4. Thinning of vaginal walls
5. Vaginal and bladder infections
6. Mild urinary incontinence
7. Insomnia
8. Cognitive changes, such as memory loss
9. Reduced sex drive
10. Mood disturbance
11. Abnormal sensations, such as ‘prickling’ or ‘crawling’ under the skin
12. Palpitations
13. Hair loss or abnormal growth
14. Dry and itching eyes
15. Tooth loss
16. Gingivitis (gum problems).

Side effects of HRT

HRT needs to be individually tailored. Some women experience side effects during the early stages of treatment, which may include:

1. Breakthrough bleeding
2. Breast tenderness
3. Bloating – around one in 10,000 women aged 50 experience bloating and this increases with age
4. Blood clots – the risk increases with age. Younger women on oral HRT face a one in 5,000 to one in 10,000 risk of blood clots. Older women, aged 50 to 60 years, face a one in 500 to one in 1,000 risk of blood clots when on oral HRT.

HRT does not cause weight gain

An increase in body fat, especially around the abdomen, can occur during menopause because of our own hormonal changes, although exactly why this happens is not clear. The age-related decrease in muscle tissue and the slowing down of the metabolism can also contribute to weight gain.

Various studies prove that weight gain is not linked to HRT. If a woman is prone to weight gain during her middle years, she will do so regardless of whether or not she uses HRT. Some women may experience symptoms at the start of treatment, including bloating and breast fullness, which may be misinterpreted as weight gain. These symptoms usually disappear once the therapy doses are modified to suit the individual.

Contraception is still needed

HRT is not a form of contraception. The treatment does not contain sufficient hormones to suppress ovulation, so pregnancy is still possible in women who are ovulating occasionally in the perimenopause. It is generally advised that menopausal women should continue to use contraception until their natural periods have ceased for at least one year.

Long-term use of HRT to prevent disease

HRT reduces the risk of various chronic conditions that can affect postmenopausal woman, including:

• Osteoporosis – thinning of the bones to the point where they break easily. HRT prevents further bone loss, which preserves bone integrity and reduces the risk of fractures, but is not recommended as a first-line treatment.
• Bowel cancer – the risk of colorectal cancers is slightly reduced with HRT.

HRT- related health risks

While HRT reduces the risk of some debilitating diseases, it also increases the risk of others. These small risks must be balanced against the benefits for the individual. Three areas of concern are:

• Breast cancer – current research suggests that women over 50 years of age, who use oestrogen and progestogen replacement for less than five years, have little or no increased risk of breast cancer. Women who use HRT with progestogen for more than five years appear to have a slightly increased risk. Women on oestrogen alone appear to have no increased risk up to 15 years of usage. There is no evidence to suggest that a woman with a family history of breast cancer will have an added increased risk of developing the disease if she uses HRT. The risk with combined oestrogen and progestogen is greater than with oestrogen alone or with newer HRT agents, including Tibolone, but research in this area is ongoing.
• Cardiovascular disease – current research suggests that women over 60 have a small increased risk of developing both heart disease and strokes on combined oral HRT. Although this risk is small (7 heart attacks and 8 strokes per 10,000 treatment years – that is, 1,000 women treated for 10 years), it needs to be considered when starting HRT, as the risk occurs early in treatment and persists with time. Oestrogen used on its own increases the risk of stroke (12 per 1,000 women per year). Women who commence HRT around the time of menopause may not have the same increased risk as women aged 60 or more. The risk with other forms of hormone therapy such as Tibolone is unknown. The results of ongoing research are awaited with interest.
• Thrombosis – these are blood clots that form inside veins. Some women on HRT are more likely to get thrombosis than women who are not on HRT. This risk seems to be highest in the first one to two years of therapy and in women who have a high risk of blood clots anyway. This especially applies to women who have a genetic predisposition to developing thrombosis. More research is needed to clarify if oestrogen applied through the skin as patches, implants or gels has the same effect. Limited research to date would suggest the increased risk of clots is mainly related to oestrogen and progestogen in tablet form.
• Endometrial cancer – this is cancer of the lining of the uterus. Long-term use (for 10 years or more) of oestrogen alone increases the risk of this cancer, but this risk is neutralised with the addition of progestogen to the treatment.

Long-term use is not recommended

It is currently believed that, overall, the risks of long-term HRT use outweigh the benefits. HRT should not be recommended for disease prevention. However, the jury is still out on the use of oestrogen alone, other HRT preparations (including Tibolone) and other forms of HRT (including patches). We await the results of further trials before recommendations in these areas can be made.
However, in women with long-term severe symptoms, HRT may be the only effective therapy. Seek specialist advice from a menopause clinic or specialist physician. Regular check-ups are recommended.

HRT and prior history of breast cancer

To date, there is conflicting specific evidence that HRT will increase the risk of breast cancer recurring in a woman with a prior history of the disease. However, oestrogen and progestins may stimulate some types of cells in the breast and increase the risk of breast cancer in women without a history of breast cancer. It is advisable for woman with a prior history of breast cancer to avoid HRT.

Phytoestrogens and prior history of breast cancer

There is no evidence that phytoestrogens increase the risk of breast cancer recurring but, under certain circumstances, some breast cells may be stimulated. Other forms of management for menopausal symptoms may be advised, such as oestrogen vaginal creams or low doses of antidepressants, which may reduce hot flushes. Be advised by your doctor.

Alternative therapies

Alternative therapies for the management of menopausal symptoms remain controversial. Many of these therapies have not been subjected to clinical trials, so their effectiveness is based on the experiences reported by some women. To date, no alternative therapy has been clinically proven to reduce a menopausal woman’s risk of osteoporosis, and preliminary studies would suggest there is no benefit for the bones. Some of the more popular alternative therapies include:

1. Soy products
2. Phytoestrogens
3. Herbal medicines.