Menopause is the final period and occurs because a woman stops ovulating, her 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 marks the start.
Many women, although not all, experience uncomfortable symptoms during and after menopause, including hot flushes, night sweats, sleep disturbance and vaginal dryness. These symptoms and physical changes can be managed in various ways, including lifestyle changes like healthier eating and increased exercise, and by hormone replacement therapy (HRT).
Hormone replacement therapy (HRT)
HRT, also known as hormone therapy (HT) or menopause hormone therapy (MHT), is medication containing hormones that a woman’s body stops producing after menopause. HRT is used to treat menopausal symptoms.
While HRT reduces the likelihood of some debilitating diseases such as osteoporosis, colorectal (bowel) cancer and heart disease, it may increase the chances of developing a blood clot (when given in tablet form) or breast cancer (when some types are used long-term).
For women who experience menopause before the age of 45 (early or premature menopause), HRT is strongly recommended until the average age of menopause onset (around 51 years), unless there is a particular reason for a woman not to take it.
Menopause symptoms and HRT
Menopause symptoms that may be relieved by HRT include:
- hot flushes and night sweats
- vaginal dryness
- thinning of vaginal walls
- vaginal and bladder infections
- mild urinary incontinence
- aches and pains
- insomnia and sleep disturbance
- cognitive changes, such as memory loss
- reduced sex drive
- mood disturbance
- abnormal sensations, such as ‘prickling’ or ‘crawling’ under the skin
- hair loss or abnormal hair growth
- dry and itching eyes
- tooth loss and gingivitis (gum problems).
Other therapies, including vaginal oestrogen products, antidepressants or other medication, may be used depending on the symptoms and risk factors. Seek advice from your doctor.
Added benefits of HRT
HRT reduces the risk of various chronic conditions that can affect postmenopausal women, including:
- Diabetes – taking HRT around the time of menopause reduces women’s risk of developing diabetes.
- Osteoporosis – is weakening of bones such that they break more easily. HRT prevents further bone density loss, preserving bone integrity and reducing the risk of fractures, but it is not usually recommended as the first choice of treatment, except in younger postmenopausal women (under the age of 60).
- Bowel cancer – HRT slightly reduces the risk of colorectal cancer (bowel cancer).
Side effects of HRT
HRT needs to be prescribed for each woman individually. Some women experience side effects during the early stages of treatment, which may include:
- breakthrough bleeding
- breast tenderness
HRT-related health risks
While HRT reduces the risk of some debilitating diseases, it may increase the risk of others. These small risks must be balanced against the benefits of HRT for the individual woman. Talk to your doctor about any concerns you may have.
Breast cancer and HRT
Women over 50 years of age who use combined oestrogen and progestogen (progesterone) replacement for less than five years have little or no increased risk of breast cancer. Women who use combined HRT for more than five years have a slightly increased risk. Women on oestrogen alone 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 breast cancer if she uses HRT. The risk with combined oestrogen and progestogen is greater than with oestrogen alone or with newer HRT agents such as tibolone (sold as Livial) and may also depend on the type of progestogen used.
Cardiovascular disease and HRT
Women over 60 have a small increased risk of developing both heart disease and stroke on combined oral (tablet) HRT. Although the increase in risk is small, 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 further if taken in tablet form, but not if using a skin patch. Similarly, tibolone increases the risk of stroke in women in their 60s and older.
Women who commence HRT around the typical time of menopause have lower risks of cardiovascular disease than women aged 60 or more, and may have no increase in risk if treated with low doses by mouth or through the skin. It is not recommended to commence HRT in women over 60.
Venous thrombosis and HRT
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. Some studies suggest a lower risk with non-oral therapy (patches, implants or gels).
Endometrial cancer and HRT
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).
Ovarian cancer and HRT
A recent review of women with ovarian cancer has linked HRT use to an increased risk of two types of ovarian tumours; serous and endometrioid tumours. However, the increased risk was very small, and was estimated to be one extra case per 10,000 HRT users per year.
Cholecystitis and HRT
Cholecystitis is a disease where 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 (tablet form) oestrogen or oestrogen and progestogen for five years, but patch treatment is associated with a lower risk. Treatment for cholecystitis includes surgery to remove gallstones or the gallbladder.
HRT does not cause weight gain
Weight gain at the menopause is more likely to be related to gaining 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 resulting decrease in energy 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 do so 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 changed to suit each woman.
Contraception and HRT
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 who are ovulating occasionally in perimenopause. It is generally advised that menopausal women should continue to use contraception until their natural periods have ceased for at least one year if they are aged over 50, or after two years without periods if they are younger than 50.
Long-term use of HRT
It is currently believed that, overall, the risks of long-term (more than five years) HRT use 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.
No alternative therapy has yet been clinically proven to reduce a menopausal woman’s risk of osteoporosis. Some of the more popular alternative therapies include soy products, phytoestrogens and herbal medicines.
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, which may be given through the skin (transdermal) in many cases.
Despite the risks of long-term use, in women with severe and persistent menopausal symptoms, HRT may be the only effective therapy. Women with early or premature menopause may be prescribed HRT long-term, as their risks for heart disease and osteoporosis are higher than a woman who undergoes menopause around the age of 50 years. Seek specialist advice from a menopause clinic or menopause specialist. Regular check-ups are recommended.
HRT for breast cancer survivors
It is advisable for women with a prior history of breast cancer to avoid HRT unless other treatments are ineffective and their quality of life is made intolerable by menopausal symptoms. It should only be done in consultation with your breast surgeon or oncologist.
Evidence has not conclusively shown that HRT will increase the risk of breast cancer recurring in a woman with a prior history of the disease. However, oestrogen and progestogens (forms of progesterone) may stimulate some types of cells in the breast and increase the risk of breast cancer in women without a history of breast cancer.
Phytoestrogens and prior history of breast cancer
It is not recommended that women at high risk of breast cancer or breast cancer survivors take highly processed soy supplements, but eating moderate amounts of whole soy foods appears to be healthy.
Where to get help
- Your doctor
- Jean Hailes for Women's Health
- Australasian Menopause Society Tel. (03) 9428 8738
Things to remember
- Menopausal symptoms can be managed with support, education, lifestyle changes and HRT.
- In the early postmenopausal years, HRT is an effective therapy for menopausal symptoms. In most women with moderate to severe symptoms, the benefits outweigh the small increases in risk.
- The long-term use of HRT has some benefits, but it also has some risks.
- The current role of HRT is for menopausal symptom relief, at the lowest dose and for the shortest duration required for the control of menopausal symptoms.
- The decision to use HRT, and for how long it should be used, must be based on individual assessment and needs.