Hormone Replacement Therapy (HRT) for Menopause: Is It the Right Choice for Me?

As its name suggests, hormone replacement therapy (HRT) replaces the hormones that decline during the perimenopausal and menopausal periods. But what is menopause, and how does it impact women’s health? What is the significance of hormone replacement therapy (HRT), and is it even necessary? In this article, we delve into the world of menopause and HRT, giving you the knowledge to help you make the right decision. 

What is menopause?

Menopause is a natural biological process that marks the end of a woman's reproductive years. It typically occurs in middle age, usually in a woman's late 40s to early 50s, although this varies between individuals. One is deemed to have reached menopause if there is cessation of menstruation (periods) for one year, and women typically undergo a perimenopausal transition prior to that. This whole process may also be associated with a range of physical and hormonal changes in a woman's body.

The main hallmark of menopause is a decline in the production of certain hormones, particularly estrogen and progesterone, by the ovaries. This hormonal shift can lead to a variety of physical and emotional symptoms.

What are the symptoms of perimenopause/menopause?

Common perimenopausal/ menopausal symptoms include: 

• Irregular periods: Intervals between menstrual cycles may become shorter or longer, with varying degrees of flow.
• Hot flashes: Sudden and intense feelings of warmth that may occur randomly, often accompanied by sweating.
• Night sweats: Hot flashes that occur during the night, which can disrupt one’s sleep quality.
• Vaginal dryness: Thinning and dryness of the vaginal tissues, which can lead to discomfort during intercourse.
• Mood swings: Changes in mood, including irritability, anxiety, and depression.
• Sleep disturbances: Difficulty falling asleep and staying asleep.
• Changes in sexual desire: Some women may experience a decrease in libido.
• Changes in skin and hair: These can include thinning hair, dry skin, and changes in skin texture.
• Weight gain: Due to a decrease in metabolic rate, many women may find it more challenging to maintain their weight.
• Changes in bone density: A decrease in estrogen levels typically leads to a loss of bone density over time, increasing the risk of osteoporosis.

If you are experiencing any of the symptoms stated above, you are not alone, as this is a physiological process that every woman needs to go through eventually. Make an appointment with your gynaecologist to understand what you are going through and learn how to navigate the next chapter of your life, especially if you find that your quality of life is being adversely affected.  

What is Hormone Replacement Therapy (HRT)?

Hormone replacement therapy is used to alleviate the symptoms of menopause by effectively replacing the hormones (oestrogen and progesterone), which levels decline during the perimenopausal/menopause period. 

There are different types of hormone therapy, these are:

• Systemic hormonal therapy: systemic HRT consists of either oestrogen-only or oestrogen and progesterone therapy and is used to help alleviate perimenopausal/menopausal symptoms such as hot flashes, mood swings, night sweats, etc. Oestrogen-only therapy is typically recommended for women who have had their uterus removed (hysterectomy), whilst oestrogen and progesterone therapy is used for women who still have their uterus intact. The function of progesterone is to protect the uterus, as oestrogen-only therapy in women with an intact uterus can increase the risk of endometrial (uterine) cancer. Systemic HRT comes in many forms, including oral pills, transdermal patches, topical creams/gels, vaginal rings etc. The choice of administration should be individualised, considering one’s preferences and clinical situation. 
• Local hormonal therapy: local Hormone Replacement Therapy (HRT) primarily involves the use of hormonal medications (namely, oestrogen) to address specific symptoms that are related to the vaginal and urogenital area. Unlike systemic HRT, which delivers hormones throughout the body, local HRT has a more localised effect on a targeted area and aims to alleviate vaginal atrophy, dryness, burning sensation/discomfort, and painful intercourse as well as to help with urinary symptoms (e.g. urinary frequency, urgency, incontinence, recurrent urinary tract infections that can occur during the perimenopausal/menopausal period). Local HRT is usually administered topically and comes in the form of either a vaginal cream or vaginal tablets, or both, which help to restore the health, elasticity and moisture of the urogenital region. As it is usually low dose with a localised effect, it is generally considered to have lower risks compared to systemic HRT; however, it does not typically help in alleviating other perimenopausal/menopausal symptoms such as hot flashes, mood swings, etc. 

What are the benefits of hormone replacement therapy (HRT)?

• Alleviating menopausal symptoms: HRT can effectively alleviate menopausal symptoms, which can sometimes be debilitating and improve one’s quality of life and interpersonal relationships. It can also help prevent osteoporosis and may have a beneficial effect on heart health when started relatively early in menopause.
• Improving bone health: HRT can help delay the onset/development of reduced bone density, which eventually may lead to osteoporosis; however, HRT is not typically started as the primary indication for osteoporosis prevention in perimenopausal/menopausal women.  
• Potential cardiovascular benefits: The relationship between HRT and cardiovascular benefits is complex and has been the subject of extensive research. The effects of HRT on cardiovascular health can vary depending on several factors, including the type of HRT, the timing of initiation, and the individual's health profile. A woman's individual health profile and risk factors play a significant role in how HRT may affect her cardiovascular health. It is hence essential to assess an individual's cardiovascular risk factors, such as blood pressure, cholesterol levels, smoking history, and family history, before considering HRT, and the decision to use HRT made on a case-by-case basis; HRT is not typically started for the primary indication for cardiovascular health in perimenopausal/menopausal women. It is important to note that lifestyle changes such as a healthy diet, regular exercise, and smoking cessation are just as (if not more) effective in promoting cardiovascular health without the need for HRT.

What are the risks and side effects of hormone replacement therapy (HRT)?

As much as hormone replacement therapy (HRT) can offer benefits, there can be potential risks/side effects involved, which also depends on the type of HRT, duration of use, individual’s health profile and other considerations. 

• Cardiovascular Risks: HRT can increase the risk of blood clots in the legs (deep vein thrombosis), which can migrate to the lungs (pulmonary embolism).
• Breast Cancer Risk: Systemic HRT (estrogen and progesterone) is associated with a slightly increased risk of breast cancer, especially with long-term use.
• Endometrial Cancer Risk: Women who have a uterus and take oestrogen without progesterone (or progestin) are at an increased risk of developing endometrial cancer.
• Ovarian Cancer Risk: Some studies have suggested a possible increased risk of ovarian cancer with long-term HRT use, although the evidence is not conclusive.
• Stroke: HRT, especially when initiated in older postmenopausal women, has been associated with an increased risk of stroke.
• Vaginal Bleeding: Irregular or unexpected vaginal bleeding can occur with HRT, especially in women who still have their uterus - this should be flagged up to your gynaecologist promptly to see if further evaluation is required.

The decision to use HRT should be individualised, taking into account a woman's medical history, age, risk factors, and the severity of her menopausal symptoms. It's essential to have a thorough discussion with your gynaecologists to weigh the potential benefits and risks. The optimal duration of HRT also varies from person to person. Regular follow-up with your gynaecologist is crucial to monitor the effects of HRT and adjust the treatment plan as needed.

Who is hormone replacement therapy (HRT) suitable for?

Hormone replacement therapy is not for everyone. There are also several contraindications to consider before even considering this treatment. This is why a thorough consultation with a specialist is essential if you plan on going on hormone replacement therapy.

• Factors to consider
  • Age and menopausal stage: HRT is best suited for women who are perimenopausal and/or newly menopausal, with the aim of the lowest effective dose for the shortest duration; starting HRT for older women who are many years past menopause and/or continuing on HRT for many years beyond the age of menopause entail increased levels of risk. 
  • Medical history: HRT is generally not advisable for women with hormone-dependent cancer, e.g. breast cancer, endometrial cancer, ovarian cancer, etc. It is also not suitable for women with a medical history of clotting disorders. 
  • Uncontrolled cardiovascular risk factors: e.g. poorly controlled hypertension, can increase the risk of adverse events, such as stroke. 
  • Severe liver disease: As the liver metabolises HRT, individuals with severe liver disease may need to avoid using HRT.
  • Undiagnosed vaginal bleeding: Unexplained vaginal bleeding should be investigated and diagnosed before considering HRT. It can be a sign of underlying medical conditions that may need treatment.

What are the alternatives to hormone replacement therapy (HRT)?

There are several alternatives to Hormone Replacement Therapy (HRT) for managing the symptoms of perimenopause and menopause. The choice of alternatives depends on an individual's specific symptoms, preferences, and medical history. Here are some common alternatives to HRT:

• Lifestyle Modifications:
  • Diet: A balanced diet rich in fruits, vegetables, whole grains, and lean proteins can help manage menopausal symptoms and promote overall health.
  • Exercise: Regular physical activity can help reduce hot flashes, improve mood, and maintain bone health.
  • Stress Reduction: Techniques like mindfulness, yoga, meditation, and deep breathing exercises can help manage stress and reduce mood swings.
  • Smoking Cessation: Quitting smoking can improve overall health and reduce the risk of heart disease and lung problems.
  • Dietary Supplements: Some women find relief from menopausal symptoms by taking certain dietary supplements, such as:
  • Calcium and Vitamin D: These supplements can help maintain bone health.
  • Black Cohosh: This herbal supplement may alleviate hot flashes and other menopausal symptoms in some women.
  • Soy Isoflavones: Found in soy products, these compounds may have a mild oestrogen-like effect and help with menopausal symptoms.
    
• Prescription Medications: Non-hormonal prescription medications can be used to manage specific symptoms. For example:
  • Selective Serotonin Reuptake Inhibitors (SSRIs): These can help reduce hot flashes and improve mood.
• Vaginal Moisturisers and Lubricants: For vaginal dryness and discomfort, over-the-counter or prescription non-hormonal vaginal moisturisers and lubricants can provide relief during sexual activity.
• Behavioural Therapies: Cognitive-behavioral therapy and other forms of counselling can help women manage emotional and psychological symptoms associated with menopause.
• Acupuncture: Some women have reported relief from hot flashes and other symptoms through acupuncture treatments.
• Herbal Remedies: Herbs like red clover, evening primrose oil, and dong quai have been used by some women to alleviate menopausal symptoms. However, scientific evidence supporting their effectiveness is limited, and their safety varies.

What long-term considerations should I consider before going on hormone replacement therapy (HRT)?

Before considering HRT, there are several important factors and considerations. 

• Individual Health Profile: Your gynaecologist will assess your individual health history, including any medical conditions, medications, and family history. This evaluation is crucial in determining whether HRT is a safe and suitable option for you.
• Symptoms and Needs: Consider the severity of your menopausal symptoms and how they affect your quality of life. HRT is typically recommended for individuals with moderate to severe symptoms, but the decision should be tailored to your specific needs.
• HRT Type and Formulation: Discuss with your healthcare provider the type of HRT (systemic or local) and the specific formulation that may be most appropriate for you. The choice can depend on whether you have a uterus, your risk factors, and the nature of your symptoms.
• Duration of Use: Decide how long you wish to try HRT – it is typically for the shortest effective duration for symptom management. Your healthcare provider can help you establish a treatment plan with clear goals.
• Regular Monitoring: If you choose HRT, expect regular follow-up appointments with your gynaecologist. Monitoring is essential to assess the benefits and risks of HRT over time and make necessary adjustments.
• Potential Risks: Be aware of the potential risks associated with HRT, such as an increased risk of blood clots, heart disease, breast cancer, and stroke. Your gynaecologist will help you assess these risks based on your health profile.
• Alternatives: Consider alternative approaches to managing menopausal symptoms, such as lifestyle modifications, non-hormonal medications, and complementary therapies. Discuss these options with your healthcare provider to determine the most suitable treatment plan for you.
• Side Effects and Tolerability: Pay attention to any side effects or discomfort related to HRT. Share these concerns with your healthcare provider to ensure the best treatment experience.
• Discontinuation: Discuss the process and potential effects of discontinuing HRT if and when it becomes necessary or desirable.

Conclusion

The decision to use HRT should be based on an individualised assessment of benefits and risks in consultation with a healthcare provider. HRT is not a one-size-fits-all solution. It should be tailored to an individual's specific needs, considering their medical history, health profile, and menopausal symptoms – i.e. its use should be informed, individualised, and closely monitored. Ultimately, the decision to use HRT is a personal one that should be made in collaboration with your gynaecologist to optimise health and well-being during and after menopause.