HRT - YOUR QUESTIONS ANSWERED

What is the Menopause?

The menopause occurs when a woman's periods stop altogether. Before this happens many women experience irregular periods and menopausal symptoms. This time, leading up to the periods stopping, are sometimes called the climacteric or 'the change of life'.

Why does it happen?

The menopause occurs when a woman's ovaries switch off and produce far less female hormones. There are two types of female hormones called progesterone and oestrogen. In the time leading up to the menopause the hormone levels fluctuate. It is the fluctuation in the oestrogen levels which cause symptoms such as hot flushes and other body changes to occur.

What are the symptoms?

The menopause affects women in different ways. We can simply divide the symptoms into short term and long term.

Short term symptoms

Hot flushes

Some women experience no symptoms at all as they go through the menopause. However, three out of four women experience sudden unpleasant sensations of burning heat spreading across their face, neck and chest. This is called a hot flush. It can last from a few minutes up to an hour. Some women get one or two flushes a week, others get ten or fifteen a day.

Untreated, hot flushes can carry on for two years or more.

Night sweats

These are usually associated with hot flushes and tend to occur at night in bed. Some women find that their sleep is badly disturbed by having to get out of bed many times or even to change their night clothes.

Skin

During the menopause a type of protein called collagen is lost from the skin. This makes the skin thinner, drier and more likely to itch or bruise easily. Sometimes underarm and pubic hair thins, but occasionally facial hair increases. The loss of collagen can also affect other parts of the body, for example, the breasts lose their shape and firmness.

Vaginal & urinary problems

The lining of the vagina becomes thinner, less flexible and drier. This can lead to painful sexual intercourse and consequently problems with sexual relationships. The vagina is also less resistant to infections. Similarly, the tissues that support the bladder and urethra become thinner. This can lead to symptoms such as a sudden urge to pass water (urgency) or lack of control of water on coughing or sneezing (stress incontinence).

Psychological

Up to a half of all women experience some sort of psychological complaint during the menopause. This usually takes the form of upset emotions, forgetfulness, loss of concentration and insomnia. Some women find their mood becomes depressed. Many of these symptoms may wrongly be put down to the menopause, it often helps to talk them through with your family, friends or your doctor.

Changes in menstrual periods

During the climacteric the menstrual cycle may shorten. Sometimes one or two periods are missed every so often. As the menopause gets nearer, the cycles may grow longer and a period might not be seen for many months. The periods themselves usually stay much the same although bleeding may get lighter.

Many women find that when they miss a period their symptoms, eg. hot flushes, get worse.

Remember, whilst you are having periods, no matter how infrequently, it is still possible to become pregnant - make sure you discuss this with your doctor.

Long term effects

Osteoporosis

Osteoporosis is the medical term for weak and brittle bones. Before the menopause oestrogens help keep the bones healthy and strong. After the menopause much less oestrogen is found and the bones lose bone mass, which, as a woman grows older, results in osteoporosis. Bones with osteoporosis are much more likely to break (fracture) especially with an injury such as a fall. Osteoporosis commonly affects bones in the wrist, hip and spine. Left untreated almost one half of all women will have experienced a fracture at one of these sites by the time they are 70 years of age. Fractures in the spine can lead to a loss of height or a curve in the spine commonly known as 'dowagers hump' Fractures in the hip are very serious and one in four elderly women die as a result of the fracture.

Heart disease and stroke

Heart disease and stroke are the commonest causes of deaths in women who have gone through their menopause. After the age of 65 around three out of every five women who die do so because of heart disease and stroke. This is far more common than deaths from cancer and other diseases.

Why does this happen?

Before the menopause, oestrogen produced by the ovaries protects a woman from heart disease and strokes compared to men. It does this largely because it keeps the blood fats (such as cholesterol) at healthy levels. After the menopause, oestrogen levels fall and therefore protection is lost. Heart disease and stroke are probably the most important consequences of the menopause.

When will the menopause begin?

The average age of the menopause in the U.K. is around 51 years. This is only an average however and some women experience the menopause much earlier and some much later than this. The climacteric or change of life leading up to the menopause usually lasts for two or three years and starts around the age of 46-48 years. However in some women the climacteric can last much longer. Women who have their ovaries removed at a younger age by surgery will experience the menopause straight away and often find that the short term and long term effects are more severe.

Hormone replacement therapy

What treatments are available?
By now you may be concerned about the problems that the menopause can cause. Fortunately there are a number of ways of dealing with the problems. The most effective way is with Hormone Replacement Therapy (HRT).

How does HRT work?

HRT replaces the oestrogen hormones that your ovaries no longer produce for themselves.

There are various ways of giving HRT. The most common ways are tablets taken by mouth every day or 'patches' that stick to the skin and continuously release hormones into the body.

Patches are changed every three or four days. Another way is to place hormone pellets (implants) under the skin. These last for several months and then need replacing. If vaginal dryness is the main problem then your doctor may recommend you use a HRT cream or pessaries to place inside the vagina. The hormones used in HRT are naturally occurring hormones unlike those used in the contraceptive pill.

How effective is HRT?

Any of the symptoms caused by the menopause are helped in some way by taking HRT. Hot flushes always respond to HRT and usually disappear within a few weeks of starting treatment. HRT also helps dryness of the vagina. If insomnia and moodiness are caused by the menopause then many women find that HRT helps these too. More importantly, HRT can dramatically reduce the development of osteoporosis and the likelihood of fractures. We have already discussed how important are heart disease and stroke. The good news is that HRT, by replacing the lost oestrogen can cut the risk of these by up to one half in women who have gone through their menopause.

What HRT won't do for you

Taking HRT does not slow down ageing. If you are unhappy or depressed for a reason other than the menopause then HRT will not help you.

Can all women take HRT?

There are very few reasons why a woman cannot take HRT. Some reasons include severe liver disease, cancer of the womb or breast and abnormal bleeding from the vagina of unknown cause. If you think you may not be able to take HRT, discuss it with your doctor. You may find it is alright for you after all. Remember HRT is not the same as the contraceptive pill. If you were told not to take the pill when you were younger this does not always mean that you cannot take HRT. Ask your doctor's advice on what is best for you.

Am I too old to take HRT?

It is best to start HRT soon after or just before your periods stop altogether. Starting at this time will help the symptoms of the menopause but also gives the best effect on osteoporosis and heart disease.

How long should I use HRT?

For the short term symptoms such as hot flushes, treatment for one to two years is often advised. For osteoporosis and heart disease most doctors agree that at least five years' treatment is best. Discuss with your doctor what is best for you. If your doctor agrees and there are no reasons to stop your HRT then the longer treatment is better for you.

What are the side effects?

Like all medicines HRT can cause side effects. Most of these are minor and often disappear if you continue treatment. About one in ten women develop leg cramps, tender breasts and slight nausea when they start treatment. HRT patches can occasionally cause skin irritation. More serious side effects are quite rare, however you should be aware of them.

Changes in Weight

You may find that you retain fluid at the start of your HRT treatment. This can cause a slight increase in weight. Do not worry as this usually disappears over time. Research has shown that HRT does not cause a permanent increase in weight. It does however make women feel better in themselves which may mean that they eat more. Remember to keep your weight steady and avoid over-eating.

High blood pressure

High blood pressure is unlikely to develop in women who have not had this problem before.

There is some evidence that HRT patches cause less problems with high blood pressure than other types of HRT.

Thrombosis, heart attack and stroke

At one time doctors thought that HRT may cause more problems with thrombosis, heart attack and stroke in the same way that older oral contraceptives did. Nowadays doctors have much less concern. As we have already discussed, recent research has shown that HRT actually reduces the risk of heart attack and stroke in those women who use it for long enough.

Women who still have their womb and who take oestrogen HRT atone have a higher risk of developing irregular bleeding or cancer of the womb. For this reason, if you have not had a hysterectomy, your doctor will give you a type of the other female hormone called progesterone to take with your oestrogen HRT. This will cause you to have a regular monthly 'withdrawal bleed' which is usually lighter than a normal period. Much discussion has occurred about any link between HRT and women developing breast cancer. Most doctors agree that HRT does not increase the risk of breast cancer if used for five to ten years.

There is no evidence that HRT increases the risk of cancer of the cervix.

Your doctor and you

What should I do now?

If you think that you should try HRT go and discuss it with your doctor. Your doctor will be happy to talk it over with you and recommend whether HRT is suitable or not. If you do decide to try it, give the HRT a few months and see how you feel.

What if I have problems with my HRT?

You should see your doctor straight away if any of the following happen:

• Any unusual bleeding or discharge from the vagina.
• Any lumps in your breasts.
• Any bleeding from the vagina after sexual intercourse.

In any event it is a good idea to see your doctor for a check up at regular intervals.

Other questions

Will HRT stop me getting pregnant?

HRT is not a contraceptive. Although the chances of getting pregnant are much reduced as a woman gets older, a small chance still exists until her periods stop altogether. If you start HRT before this then ask your doctor for advice on contraception.

What will happen when I stop the HRT?

If you stop your HRT suddenly whilst you are still going through the menopause then your symptoms may return. After the menopause you can stop the HRT whenever you want. You may find that the problem of vaginal dryness comes back over time. If this happens ask your doctor's advice as vaginal HRT cream may be useful. There is no evidence that tablets or patches are addictive, although it can sometimes be difficult to tail off the pellet implant in some women.

What else can I do to keep healthy?

Of course, HRT is only one part of keeping you healthy as you grow older. You should always take plenty of exercise to keep you heart and blood circulation healthy. This also helps to maintain strong bones. Remember, if you are unused to physical exercise ask your doctor's advice on how much exercise you should do to start with.

If you smoke then try to give up or at least cut down as far as you can. Do not drink too much alcohol as this can effect the strength of your bones, amongst other problems. Try to eat a good varied diet without too much fat. Choose foods that contain plenty of vitamins and minerals, especially calcium to help keep your bones healthy. As you grow older you need twice as much calcium as you did when you were young. Foods such as dairy products (but watch the fat contents), green vegetables and small bony fish are rich in calcium.

Make sure that you regularly have a check up by your doctor. Keep your appointments for cervical smears and breast screening. Learn how to examine your own breasts for lumps - your doctor can show you how.

Where else can I go for advice?

Usually your doctor or practice nurse are the best people to ask if you need advice about your health, the menopause or HRT. Many doctors now hold special 'well women clinics which you can attend.

Remember, the menopause is not something 'that women must put up with.'