What is hormone replacement therapy?

Hormone replacement therapy, HRT, are medications prescribed mainly to women who have reached menopause. These medications contain hormones that the female body does not produce any more after menopause and is used to treat the symptoms of menopause such as hot flashes and vaginal discomfort. HRT also reduces bone loss and decreases fracture risk in postmenopausal women.

Along with the benefits of HRT, it has some risks. The risks vary with the different types of hormone replacement therapies, the dose of HRT and the timeframe of HRT use. HRT should be tailored to each individual to ensure the best results are achieved and regular appointments with the doctor are needed to re-evaluate the therapy.

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What is menopause?

Women go through a stage in life when their period stops. This is called menopause and is a normal part of aging. In the year prior to and during menopause, the level of female hormones in the body fluctuates. These manifest as symptoms like hot flashes, night sweats, painful sex, and vaginal dryness. For some, the symptoms are quite mild and resolve on their own. For others with more prevalent symptoms, HRT can be taken to relieve the symptoms and protect against osteoporosis. 

Types of therapy

Estrogen:

For women who have had a hysterectomy (surgical removal of the uterus) or bilateral oophorectomy (surgical removal of the uterus and ovaries), low dose estrogen is usually suggested by doctors. Estrogen is available in different forms such as a daily pill, patch, vaginal ring, gel or spray. The pill and patch are more popular than the rest. 

• Pill - the most common treatment form. There are many brands offering an estrogen pill. Most should be taken once a day before food, however, some have a more complex dosing schedule. 
• Patch - the patch is worn on the skin of the abdomen. The length of use of each patch varies depending on the dose. Some are changed every few days while others can be worn for a week. 
• Topical - These come in the forms of creams, gels, and sprays. These forms are absorbed through the skin directly into the bloodstream.
• Vaginal - The vaginal forms comes as a cream, vaginal ring or vaginal estrogen tablet. This treatment form is primarily for the women experiencing increased vaginal dryness, itchiness and burning during intercourse. Most rings should be replaced every 3 months. The tablets are generally used daily for the first 2 weeks then it reduces to twice a week for the remaining weeks. Creams have different schedules, either being used daily or several times a week. 

Combined (Estrogen/Progesterone/ Progestin therapy):

This is referred to as combination therapy as it includes both estrogen and progestin (synthetic progesterone). This combined form is for women who have not had their uterus removed. Taking a combination of both estrogen and progesterone helps lowers the risk of endometrial cancer. 

• Oral progestin - taken as a pill. 
• Intrauterine - Not approved for use in the USA.

There has been a shift towards treating menopause using natural progesterone rather than synthetic progestins as natural progesterone has no negative effects on the lipid levels in the body and is a good HRT choice for women suffering from high cholesterol levels.  

Side effects of HRT?

As with any medication, HRT has side effects. If experiencing any of these, it would be beneficial to book an appointment with your doctor and discuss any further alternatives. 

• Bloating
• Swelling or tenderness of the breast
• Headaches
• Mood changes 
• Nausea
• Vaginal Bleeding

Who can take HRT?

Systemic estrogen is the most potent treatment of menopausal symptoms regardless of the health risks it poses. For some, the benefits of HRT may outweigh the risk. These individuals are:

• Experiencing moderate to severe menopausal symptoms 
• Have experienced bone mass loss and have not benefited or tolerated other treatments for bone loss
• Stopped having periods before the age of 40 (premature menopause)
• Lost normal ovary function before the age of 40 (premature ovarian insufficiency)

For women who have gone through early menopause, especially those who have had their ovaries removed and do not take HRT until 45 are at a higher risk of:

• Osteoporosis 
• Heart Disease
• Parkinson’s-like symptoms 
• Anxiety or depression 
• Early death 

The factors that play a significant role in the risks correlate to HRT depends on your age, type of menopause and time lapsed since experiencing menopause. 
For premature post-menopausal women, the benefits of the HRT is higher than the risks.

Who should not take HRT?

Women with certain conditions should stay away from HRT. Women who have had these should not take HRT:

• Breast cancer
• Ovarian Cancer
• Endometrial cancer
• Blot clots in the legs or lungs
• Stroke 
• Liver disease 
• Unexplained vaginal bleeding 

What can I do if I am not suited for HRT?

Menopausal symptoms such as hot flashes can be managed with healthy lifestyle changes. Keeping cool, reducing caffeine and alcohol intake and practicing relaxation techniques can help regulate the symptoms. Vaginal moisturizers and lubricants are alternatives to combat vaginal itching and dryness. 

Bottom line?

HRT has its pros and cons. The best way to find out if HRT is for you is to speak to your doctor. They will help provide the information and advice needed for you to make an informed decision about HRT. 
 

References

1. Cold, F, E Health, H Disease, L Disease, P Management, & S Conditions et al., "Menopause and Hormone Replacement Therapy.". in WebMD, , 2020, <https://www.webmd.com/menopause/guide/menopause-hormone-therapy#1> [accessed 18 March 2020].
2. Hormone therapy: Is it right for you?". in , , 2020, <https://www.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/art-20046372> [accessed 18 March 2020].
    

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