Menopause and HRT

What is the menopause?

Strictly speaking, the menopause is your last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. In reality, your periods don't just stop. First they tend to become less frequent. It can take several years for a woman to go through the menopause completely. Woman are said to have gone through the menopause (be post-menopausal) when they have not had a period at all for one year.

What causes the menopause?

A natural menopause occurs because as you get older, your ovaries stop producing eggs and make less oestrogen (the main female hormone). The average age of the menopause in the UK is 52. Your menopause is said to be early (sometimes called premature) if it occurs before the age of 45. Early menopause is uncommon.

There are certain things that may cause an early menopause. For example:

• If you have surgery to remove your ovaries for some reason, you are likely to develop menopause symptoms straight away.
• If you have radiotherapy to your pelvis area as a treatment for cancer.
• Some chemotherapy drugs that treat cancer may lead to an early menopause.
• If you have had a hysterectomy (removal of the uterus) before your menopause. Your ovaries will still make oestrogen. However, it is likely that the level of oestrogen will fall at an earlier age than average. As you do not have periods after a hysterectomy, it may not be clear when you are in 'the menopause'. However, you may develop some typical symptoms (see below) when your level of oestrogen falls.
• An early menopause can run in some families.
• In some women who have an early menopause, no cause can be found.

Early (or premature) menopause is not discussed in detail in this leaflet.

What are the possible symptoms and problems of the menopause?

The menopause is a natural event. Every woman will go through it at some point. You may have no problems. However, it is common to develop one or more symptoms which are due to the low level of oestrogen. About 8 out of 10 women will develop menopausal symptoms at some point.

Short-term symptoms

These short-term symptoms only last for a few months for most women. However, for some women they can continue for a few years after their last period:

• Hot flushes occur in about 3 in 4 women. A typical hot flush lasts a few minutes and causes flushing of your face, neck and chest. You may also perspire (sweat) during a hot flush. Some women become giddy, weak, or feel sick during a hot flush. Some women also develop palpitations and feelings of anxiety during a hot flush. The number of hot flushes can vary from every now and then, to fifteen or more a day. Hot flushes tend to start just before the menopause, and typically persist for 2-3 years.
• Sweats commonly occur when in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and night clothes.
• Other symptoms may develop such as headaches, tiredness, being irritable, difficulty sleeping, depression, anxiety, aches and pains, loss of libido (sex drive), and feelings of not coping as well as before. It can be difficult to say whether these symptoms are due to the hormone changes of the menopause. For example, you may not sleep well or become irritable because you have frequent hot flushes, and not directly because of a low oestrogen level. Also, there may be other reasons why these other symptoms develop. For example, depression is common in women in their 'middle years' for various reasons.
• Changes to your periods. The time between periods may shorten in some women around the menopause; in others, periods may become further apart, perhaps many months apart. It is also common for your periods to become a little heavier around the time of the menopause.

Longer term changes and problems

• Skin and hair. You tend to lose some skin protein (collagen) after the menopause. This makes the skin drier, thinner and more likely to itch.
• Genital area. Lack of oestrogen tends to cause the tissues in and around the vagina to become thinner and drier. These changes can take months or years to develop.
  • The vagina may shrink a little, and expand less easily during sex. You may experience some pain when you have sex.
  • Your vulva (the skin next to your vagina) may become thin, dry, and itchy.
  • Some women develop problems with recurrent urine infections.

Osteoporosis after the menopause

As you become older, you gradually lose bone tissue. The bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss, then you have osteoporosis. If you have osteoporosis you have bones that will break more easily than normal, especially if you have an injury such as a fall.

Women lose bone tissue more rapidly than men especially after the menopause when the level of oestrogen falls. Oestrogen helps to protect against bone loss. By the age of 70 some women have lost 30% of their bone material. In the UK, about half of women over the age of 50 will fracture a bone, many as a result of osteoporosis.

However, not all women develop osteoporosis after the menopause. Osteoporosis is more likely to develop if you have, or have had, one or more 'risk factors'. The following situations are risk factors for developing bone loss and osteoporosis. If you:

• Had your menopause before the age of 45.
• Have already had a bone fracture after a minor fall or bump.
• Have a strong family history of osteoporosis.
• Have a body mass index (BMI) of 19 or less. (That is, you are very underweight.) For example, if you have anorexia nervosa. In this situation the level of oestrogen is often low for long periods of time and, combined with a poor diet, can affect the bones.
• Have a time when your periods stop for a year or more before the time of your menopause. This can happen for various reasons.
• Have taken, or are taking, a steroid medicine (such as prednisolone) for three months or more. A side-effect of steroids is to cause bone loss.
• Smoke.
• Lack calcium and/or vitamin D (due to a poor diet and/or little exposure to sunlight).
• Have never taken regular exercise, or have led a sedentary lifestyle (particularly during your teenage years).
• Have, or had, certain medical conditions that can affect the bones. For example, an overactive thyroid gland, Cushing's disease, or anything that causes poor mobility.

Cardiovascular disease after the menopause

Your risk of cardiovascular disease (disease of the heart and blood vessels), including heart disease and stroke, increases after the menopause. Again, this is because the protective effect of oestrogen is lost. Oestrogen is thought to help protect your blood vessels against atheroma (small fatty lumps that develop within the inside lining of blood vessels). Atheroma is involved in the development of heart disease and stroke. After the menopause, your oestrogen levels drop and part of this protective effect is lost.

Do I need any tests to see if I am going through the menopause?

Your doctor can usually diagnose the menopause by your typical symptoms. Hormone blood tests are not usually needed to confirm that you are going through the menopause. However, they may be helpful in some cases. For example, if your doctor suspects that you are going through an early menopause, or if you have had a previous hysterectomy (and so are no longer having periods).

Do I need treatment for the menopause?

Many women do not have symptoms severe enough to require treatment. Only about 1 in 10 women sees a doctor because of her symptoms. Without treatment, the short-term symptoms discussed above last for 2-5 years in most women. In some women they may last longer. Hormone replacement therapy (HRT) is available to ease the symptoms of the menopause. It has benefits and risks, which are discussed below.

There are treatments other than HRT for menopausal symptoms. As a rule, they are not as effective as HRT, but may help relieve some symptoms. (See separate leaflet called 'Menopause - Alternatives to HRT' for details of menopausal symptom treatments other than HRT, which are not mentioned further here.)

What is hormone replacement therapy (HRT)?

All types of HRT contain an oestrogen hormone. If you take HRT it replaces the oestrogen that your ovaries no longer make after the menopause.

HRT is available as tablets, skin-patches, gels, nasal spray or implants (which are put under the skin). There are several brands for each of these types of HRT. All deliver a set dose of oestrogen into the bloodstream.

However, if you just take oestrogen then the lining of the uterus (womb) builds up. This increases the risk of developing cancer of the uterus. Therefore, the oestrogen in HRT is usually combined with a progestogen hormone. The risk of cancer of the uterus is very much reduced by adding in the progestogen. In many HRT products, the oestrogen and progestogen are combined in the same tablet or patch, but they can be taken separately. If you have had a hysterectomy, you do not need a progestogen.

An option to ease symptoms just in the vaginal area is to use a cream, pessary, or vaginal ring that contains oestrogen.

How do I take HRT?

Different women prefer different methods of taking HRT. For example, some women prefer to wear a patch rather than take tablets. You doctor or practice nurse can give you information about the pros and cons of the different types of HRT. In general:

If you start HRT when you are still having periods, or have just finished periods

You will normally be advised to use a 'cyclical combined HRT' preparation. There are two types:

• Monthly cyclical HRT - you take oestrogen every day, but progestogen is added in for 14 days of each 28-day treatment cycle. This causes a regular bleed every 28 days, similar to a light period. (They are not 'true' periods, as HRT does not cause ovulation or restore fertility. The progestogen causes the lining of the uterus to build up which is then shed as a 'withdrawal' bleed every 28 days when the progestogen part is stopped.) Monthly cyclical HRT is normally advised for women who have menopausal symptoms but are still having regular periods.
• Three-monthly cyclical HRT - you take oestrogen every day and then you also take progestogen for 14 days, every 13 weeks. This means that you have a bleed every three months. This is normally advised for women who have menopausal symptoms but are having irregular periods.

You may switch to a continuous combined HRT (see below) if you have been taking cyclical combined HRT for some time but are now over the age of 54. This is because at least 8 in 10 women are thought to be postmenopausal by the age of 54.

If you start HRT a year or more after your periods have stopped

If your periods have stopped for a year or more, you are considered to be postmenopausal. If this is the case, you will normally be advised to take a 'continuous combined HRT preparation'. This means that you take both an oestrogen and a progestogen every day. The dose and type of the oestrogen and progestogen are finely balanced so that they usually do not cause a monthly bleed. However, you may have some irregular bleeding when you start taking this form of HRT. You should see your doctor if this bleeding continues for more than a few months after starting HRT, or if you suddenly develop bleeding after some months with no bleeding.

If you have had a hysterectomy

You will only need to take HRT that contains oestrogen. The progestogen is only added in to other types of HRT so that the lining of the uterus (womb) does not build up and increase your risk of developing cancer of the uterus. So, if your uterus has been totally removed, progestogen is not needed.

Note: if you have had a sub-total hysterectomy (where the main part of your uterus was removed, but your cervix was not) your GP may need to make sure that there is no trace of uterine tissue left before prescribing oestrogen-only HRT. It is not safe to take oestrogen-only HRT if you have any uterine tissue remaining. Therefore, your GP may prescribe cyclical combined HRT for three months or so. If you do not have any bleeding during this time, it is unlikely that there is any uterine tissue left and you can start oestrogen-only HRT.

If you mainly have genital symptoms

You may choose to try some vaginal oestrogen cream to help your symptoms. This alone may be enough to relieve symptoms in some women who would prefer this option or who cannot take other forms of HRT for some reason.

What are the benefits of HRT?

Menopausal symptoms usually ease

This can make a big difference to quality of life in some women.

• HRT tends to stop hot flushes and night sweats within a few weeks.
• HRT will reverse many of the changes around the vagina and vulva usually within 1-3 months. However, it can take up to a year of treatment in some cases.
• There is no good evidence that HRT itself improves your mood or your sleep. However, if you are anxious, irritable, depressed, etc, at the same time as having menopausal symptoms, these symptoms may also ease if symptoms such as hot flushes or a dry vagina are eased. Therefore, there may be a 'knock-on' effect on your general well-being after starting HRT.

If you take HRT long-term (several years or more)

Taking either oestrogen-only or combined HRT may reduce your risk of osteoporosis. You will have a reduced risk of breaking a bone, especially your hip. However, the protective effect against osteoporosis is small. HRT is not usually recommended as a first-line treatment for osteoporosis as the risks (see below) are thought to outweigh the benefits. But, if you are taking HRT for the treatment of, for example, hot flushes and sweats, you will get this small knock-on benefit.

HRT is also thought to produce a small reduction in your risk of developing colorectal (bowel) cancer. However, HRT is not currently recommended just for preventing colorectal cancer. Again, the risks outweigh the benefits. But, if you are taking HRT for the treatment of, for example, hot flushes and sweats, you will get this small knock-on benefit.

What are the risks in taking HRT?

There has been a lot of media attention to the risks of taking HRT. This was after the results of some big studies about HRT were published between 2002 and 2004. These were the Women's Health Initiative Study in the USA and the Million Women Study in the UK. These studies raised concerns over the safety of HRT, particularly over a possible increased risk of breast cancer with HRT and also a possible increased risk of heart disease. However, it is important that the results of the studies are looked at carefully. HRT does increase your risk of developing certain problems but this increase in risk is very small in most cases. The risks of taking HRT are discussed below.

Venous thrombo-embolism

This is a blood clot that can cause a deep vein thrombosis (DVT). In some cases the clot may travel to the lung and cause a pulmonary embolism (PE). Together, DVT and PE are known as venous thrombo-embolism. The risk seems to be higher with combined HRT compared to oestrogen-only HRT and the risk is also higher in the first year that you take HRT. This risk seems to be slightly lower if you use HRT patches rather than HRT tablets taken by mouth.

In women aged 50-59 years, over a five-year period:

• About 5 in 1,000 women who do not use HRT are likely to develop a blood clot.
• In 1,000 women taking oestrogen-only HRT for five years, there will be an extra two women who will develop a blood clot.
• In 1,000 women taking combined HRT for five years, there will be an extra seven women who will develop a blood clot.

In women aged 60-69, over a five-year period:

• About 8 in 1,000 women who do not use HRT are likely to develop a blood clot.
• In 1,000 women taking oestrogen-only HRT for five years, there will be an extra two women who will have a blood clot.
• In 1,000 women taking combined HRT for five years, there will be an extra 10 women who will have a blood clot.

(See separate leaflets called 'Deep Vein Thrombosis' and 'Pulmonary Embolism' for further details.) You should see a doctor urgently if you develop a red, swollen or painful leg, or have shortness of breath and/or sharp pains in your chest.

Breast cancer

You may have a small increased risk of breast cancer if you take HRT. Combined (oestrogen and progesterone) HRT has a higher risk than oestrogen-only HRT. This risk increases the longer you have used HRT. When you have been off HRT for five years, you have the same risk of breast cancer as someone who has not taken HRT.

In women aged 50-59 years:

• About 10 per 1,000 women who do not use HRT are likely to develop breast cancer over a five year period.
• In 1,000 women who are taking oestrogen-only HRT for five years, there will be an extra two women who will develop breast cancer.
• In 1,000 women taking combined HRT for five years, there will be an extra six women who will develop breast cancer.
• About 20 per 1,000 women who do not use HRT are likely to develop breast cancer over a 10-year period.
• In 1,000 women who are taking oestrogen-only HRT for 10 years, there will be an extra six women who will develop breast cancer.
• In 1,000 women taking combined HRT for 10 years, there will be an extra 24 women who will develop breast cancer.

In women aged 60-69 years:

• About 15 per 1,000 women who do not use HRT are likely to develop breast cancer over a 5-year period.
• In 1,000 women who are taking oestrogen-only HRT for 5 years, there will be an extra 3 women who will develop breast cancer.
• In 1,000 women who are taking combined HRT for 5 years, there will be an extra 9 women who will develop breast cancer.
• About 30 per 1,000 women who do not use HRT are likely to develop breast cancer over a 10-year period.
• In 1,000 women who are taking oestrogen-only HRT for 10 years, there will be an extra 9 women who will develop breast cancer.
• In 1,000 women who are taking combined HRT for 10 years, there will be an extra 36 women who will develop breast cancer.

Stroke

There is a small increased risk with both oestrogen-only and combined HRT.

In women aged 50-59 years:

• About 4 in 1,000 women who do not take HRT will have a stroke over a five year period.
• In 1,000 women who take oestrogen-only HRT for five years, there will be an extra one woman per 1,000 who will have a stroke.
• In 1,000 women who take combined HRT for five years, there will be an extra one woman per 1,000 who will have a stroke.

In women aged 60-69 years:

• About 9 in 1,000 women who do not take HRT will have a stroke over a five year period.
• In 1,000 women taking oestrogen-only HRT for five years, there will be an extra three women per 1,000 who will have a stroke.
• In 1,000 women taking combined HRT for five years, there will be an extra three women per 1,000 who will have a stroke.

Coronary heart disease

Coronary heart disease refers to disease of the coronary (heart) arteries. It is the usual cause of angina and heart attacks. So far, studies have shown that oestrogen-only HRT does not seem to increase your risk of coronary heart disease. However, trials have shown that in women who start combined HRT more than 10 years after their menopause, there is a small increased risk of coronary heart disease. There are only a few trials that have looked at younger women who have started HRT at an earlier stage. However, some of these trials have suggested that these women have a lower risk of heart disease with HRT compared to older women and that HRT may even be protective.

Cancer of the uterus (womb)

There is an increased risk of cancer of the uterus due to the oestrogen part of HRT. By taking combined HRT containing oestrogen and progesterone, this risk reduces significantly (see above). This is the reason why progestogen is included in HRT. However, you should always see your doctor if you have any abnormal vaginal bleeding which develops after starting HRT. For example, heavy bleeding, irregular bleeding or bleeding after having sex.

If you have had a total hysterectomy for whatever reason, you should only need to take oestrogen-only HRT.

Cancer of the ovary

There is a slightly increased risk of developing this cancer if you use oestrogen-only HRT or combined HRT. This risk decreases after you stop HRT.

If either combined or oestrogen-only HRT is taken for five years or less, this increased risk is thought to be very small (there will be less than one extra woman who develops ovarian cancer per 1,000 women taking HRT). If HRT is taken for 10 years, there will be between 1-2 extra women who develop ovarian cancer per 1,000 women taking HRT.

Dementia

If you start HRT after the age of 65, it is not thought to protect against dementia. Also, combined HRT may increase the risk of dementia in women over the age of 75 years. HRT is not advised to help prevent dementia.

Other points about risks

So, there is a small but definite increased risk of serious illness when using HRT. But note: your risk of developing the diseases mentioned above depend on a combination of many factors. For example, your family history, and lifestyle factors such as smoking, obesity, diet, etc, which can also affect your risk. You can greatly reduce your risk of developing heart disease and stroke by not smoking, taking regular exercise and eating a healthy diet. These conditions become more common anyway with advancing age. But, if you take HRT, this is now another factor to consider.

Are there some women who shouldn't take HRT?

The risks of taking HRT are thought to outweigh the benefits for some women. For example, HRT may not advised in the following cases:

• If you have a history of endometrial (womb) cancer, ovarian cancer or breast cancer.
• If you have a history of blood clots (a DVT or a PE). If you have a personal or family history of blood clots, your doctor may suggest doing a thrombophilia screen (a blood test to look for any blood clotting problems).
• If you have a history of heart attack, angina or stroke.
• If you have uncontrolled high blood pressure.
• If you are pregnant.
• If you have severe liver disease.
• If you have an undiagnosed breast lump.
• If you are being investigated for abnormal vaginal bleeding.

What about side-effects when taking HRT?

Side-effects are problems that are not serious, but may occur in some women. They tend to go if you stop treatment. Side-effects with HRT are uncommon. Always read the leaflet that comes with the packet which gives a full list of possible side-effects. Side-effects may include the following:

• In the first few weeks some women may develop slight nausea (feeling sick), some breast discomfort or leg cramps. These tend to go within a few months if you continue to use HRT.
• HRT skin patches may cause irritation of the skin.
• Some women have more headaches or migraines when they take HRT.
• Dry eyes (lack of tears) are also thought to be more common in HRT users.

A change to a different brand or type of HRT may help if side-effects occur. Various oestrogens and progestogens are used in the different brands. If you have a side-effect with one brand, it may not occur with a different one. Changing the delivery method of HRT, for example, from a tablet to a patch, may also help if you have side-effects.

So, should I take HRT, and for how long?

The benefits have to be balanced against the risks. Some of the risks associated with HRT increase the longer the time that you take HRT. You have to decide what is right for you, with advice from your doctor or nurse, depending on your circumstances. You tend to notice the benefit from HRT once you have taken it for three months.

As a general rule:

For short-term treatment of menopausal symptoms

If you are troubled with menopausal symptoms, the balance of risks and benefits is probably in favour of taking HRT (provided there are no reasons why you shouldn't take HRT). You may be happy to accept the small risk of taking HRT for 1-3 years to be free of symptoms. You should take the lowest dose which keeps symptoms away. Many women find that after 1-3 years the worst of the flushing-type symptoms have gone and they no longer need HRT to prevent them. In some women, the symptoms can return for a short time after stopping HRT. If the genital symptoms such as vaginal dryness persist after stopping HRT, an option is to use an oestrogen cream or pessary in the vaginal area (see below).

So, if women start HRT around the time of the menopause to help symptoms, the risks are small. However, these risks increase with age. Therefore, it is not usually appropriate for older women to start HRT, as the risks are increased.

For healthy women without symptoms and a menopause at around 50 or over

If you have little in the way of symptoms, HRT is usually not advised as there is little to be gained, and even the small risks of HRT are then unacceptable.

If you mainly have genital symptoms such as a dry vagina

An option which may be advised by your doctor is to use a vaginal oestrogen cream or pessary. This gives the benefits of easing the symptoms, but with less risk than using HRT tablets, patches, etc, as less oestrogen gets into the bloodstream. In some women, this treatment may be needed long-term. Your doctor may suggest that you stop the treatment from time to time to see if you still need it.

What about taking HRT to help prevent osteoporosis?

A few years ago HRT was widely used to prevent osteoporosis. However, recent research has shown that there are potential serious health risks with taking HRT (described above). So, we now know that the balance of risks and benefits for most women is usually not in favour of taking HRT just to prevent osteoporosis.

However, if you have an early menopause, HRT may be advised until you are aged 50. This is to help to prevent osteoporosis (and ease menopausal symptoms if they occur). You have an increased risk of developing osteoporosis if you have an early menopause. Some of the health risks of taking HRT are thought to be smaller until you reach the usual age of menopause (about aged 50).

Stopping hormone replacement therapy

Your doctor will usually follow you up regularly if you are taking HRT. They may suggest a short period off HRT from time to time to see if you still need it. For example, if you have been taking HRT for one to two years and you have no symptoms, your doctor may suggest a trial of stopping your HRT.

Some women do not notice any symptoms if they stop HRT abruptly, while others may experience a recurrence of symptoms such as hot flushes and sweats. These usually go after a few months. Some experts suggest that HRT should be gradually reduced rather than stopped abruptly.

Once your HRT has finished you may need some treatment for vaginal dryness (such as a cream or a lubricant).

You may also need some treatment to prevent osteoporosis such as bisphosphonates, calcium and vitamin D supplements. (See separate leaflet called 'Osteoporosis' for details.)

Some other points about hormone replacement therapy

• HRT does not act as a contraceptive. Therefore, if you are still having periods when you start HRT, or have only recently stopped having periods, you should still use contraception. Your doctor will advise when you no longer need to use contraception. But, as a general rule: contraception should be used to prevent pregnancy for one year after your last period if you are older than 50, or for two years after your last period if you are less than 50.
• If you are taking HRT, you should have regular check-ups with your doctor. This is so that you can regularly discuss the risks and benefits of taking HRT for you, as these may change over time. After some time, your doctor may also suggest stopping your HRT to see if you still need it.
• You should also be 'breast aware' and look out for any changes in your breasts. If you notice any lumps or problems that you are worried about, you should see your doctor. You should also attend your breast cancer screening mammogram when called.

What is tibolone?

Tibolone is a man-made hormone that can be used as an alternative to HRT. It has some oestrogen, progestogen and also some androgen (male hormone) effects. So, you just have to take this one tablet to have these hormone effects.

The following are some points about tibolone:

• It is effective in treating sweats and hot flushes.
• It reduces your risk of osteoporosis.
• It may also improve your libido (sex drive).
• It is associated with a small increased risk of stroke.
• Most studies have shown a small increased risk of having endometrial (womb) cancer diagnosed in women who use tibolone.
• Tibolone may be associated with a small increased risk of breast cancer. Studies have also shown that tibolone increases the risk of breast cancer recurrence in women with a history of breast cancer.

In younger women, the risks of taking tibolone are about the same as taking combined HRT. For women older than 60, the risks associated with taking tibolone start to outweigh the benefits because of the increased risk of stroke.

Further help and information

Menopause Matters

Web: www.menopausematters.co.uk
A website run by health professionals to provide easily accessible, up-to-date, accurate information about the menopause and its treatment.

Women's Health Concern

4-6 Eton Place, Marlow, Bucks SL7 2QA
Tel: 01628 478 473 Web: www.womens-health-concern.org
Women's Health Concern is a leading charity providing help and advice to women on a wide variety of gynaecological, urological and sexual health conditions. An e-mail advice service is available via the website.