HRT

What is HRT?

Hormone replacement therapy or HRT is a treatment used to treat menopausal symptoms including preventing osteoporosis (a degradation of the bones associated with menopause). HRT is either a pill, patch or cream containing estrogen or a combination of both estrogen and progesterone. It is offered to women once they have stopped having periods, especially if they experience severe menopausal symptoms such as hot flashes or night sweats.

What happens during menopause?

During menopause, the levels of estrogen and progesterone (both female sex hormones) fall as the ovaries stop releasing eggs each month. This alters the levels of hormones in your body and produces some of the uncomfortable symptoms associated with menopause, such as hot flashes and night sweats.

What is perimenopause?

Perimenopause refers to the period of time leading up to the menopause and can last for a few years. Anyone who starts the perimenopause before 40 is likely to experience early menopause, probably before the age of 45. During perimenopause, periods do not just stop, but instead they become less frequent and can sometimes last for more than 7 days. Erratic spotting or even excessive blood loss can occur during the perimenopause.

When does menopause happen?

The average age of menopause is 51, but it varies based on genetics, race and whether you smoke or not. It is worth keeping in mind that some conditions and treatment can cause early menopause. Autoimmune diseases, removal of the ovaries and some cancer therapies are a few examples of conditions and treatments that can lead to menopause.
 

In the majority of cases, menopause occurs naturally as the ovaries gradually stop hormone production. However various other conditions and treatments can cause menopause at any age after puberty. These include:

• Autoimmune disease
• Chemotherapy
• Radiation & radiotherapy
• Oophorectomy (surgery to remove the ovaries)
• Some breast cancer treatments
• Down’s syndrome
• Addison’s disease

The average age of menopause is 51 but it varies based on heredity, race, and smoking status.

During menopause, the menstrual cycle may become more irregular. Often periods become less frequent until they stop altogether. But menopause also has several other symptoms that are related to the effect of estrogen on different systems of the body. Here we outline common symptoms of menopause and how they relate to these different bodily systems:

Thermoregulation

Estrogen plays a role in regulating body temperature. During menopause, these hormones are out of sync and diminished levels of estrogen can cause the following symptoms.

• Sweating
• Night sweats
• Hot flashes (hot flushes)

The Urogenital System

Estrogen is involved in the formation of collagen, which is an important substance for the lining of the bladder, urethra, vagina and vulva. A decrease in estrogen can lead to the thinning of the mucosal lining of these areas. In addition, this can cause the vagina to lose its elasticity, to become shorter and narrower. The normal secretions of the vagina and the blood supply to the vagina are also reduced. This leads to the following symptoms:

• Vaginal dryness
• Soreness of the vagina
• Painful intercourse
• Urinary frequency and urgency

In addition, as estrogen levels decrease, the production of a substance called glycogen decreases. Glycogen is involved in maintaining the acidity of the vagina. The change in acidity can make the bladder and vagina more vulnerable to bacterial infections. Therefore, this causes an increased risk of the following:

• Urinary tract infections
• Bacterial vaginosis

Bone loss

Bone loss occurs as we age, but it can also be affected by gender, family history, diet, exercise and smoking status. During menopause, the low estrogen levels can accelerate bone loss, especially during the first 5 years of menopause. This can lead to the following conditions:

• Weakened bones (Osteopenia, Osteoporosis) - One in three women develop osteoporosis [4].
• Fractures - Almost half of women will get a fracture after menopause, often in the upper thigh bone (especially in the hip), forearm or spine [4].

Heart

Women are naturally protected against heart disease, however, after menopause women begin to lose this protection and by the age of 65, their risk of having a heart attack is equal to men [5]. This is because after menopause, cholesterol and triglycerides start to increase, deposition of fat changes, clotting factors and other factors that predispose heart disease start to rise. In addition, lower levels of estrogen can lead to overstimulation of the heart causing the following symptoms:

• Racing heart rate
• Heart palpitations

Mood

Hormones, especially estrogen, can have a big effect on mood and mental health. This can lead to the following symptoms:

• Mood changes
• Insomnia
• Depression
• Anxiety

Menopause is diagnosed after one year of having no periods. If the symptoms of menopause are having a negative impact upon your life, you may be suitable for hormone replacement therapy (HRT). To evaluate your suitability, the following tests will be done:

• Urine test
• Blood tests to screen for abnormalities in your levels of fats (lipids) and sugars (glucose) in your blood.
• Blood tests to measure your levels of FSH (follicle-stimulating hormone) - the hormone that tells the ovaries to release an egg. If your doctor is considering giving you an implant, they may also test your estradiol levels.
• Pap smear to check for abnormalities of your cervix inc. cervical cancer
• Ultrasound of the uterus to evaluate the uterus and ovaries
• Mammogram (breast x-ray) to check for breast cancer - this is recommended once every 2-3 years after the age of 50.
• If abnormal bleeding is suspected or if the ultrasound shows that the lining of the uterus is 4mm or thicker, you may also have to have an endometrial sample (biopsy) taken in a hospital.

Treatment Options

If menopausal symptoms are severe enough to have a negative impact on your life, you may be prescribed hormone replacement therapy (HRT) to treat your symptoms. This will not reverse the menopause, you will not regain your fertility. HRT can be started in postmenopausal women if they are at risk of a fracture or osteoporosis (bone weakening) before the age of 60 or within 10 years [4,5].

HRT contains estrogen or both estrogen and progesterone. Depending upon the variety, they may need to be taken daily or cyclically. HRT is available in a wide range of forms including:

• Topical creams
• Pessaries
• Rings for intravaginal use
• Oral pills
• Skin patches
• Skin Gels
• Implants

The International Menopause Society guidelines state that HRT is the most effective treatment for menopause symptoms such as hot flashes. However if you do not wish to take HRT, some anti-depressant medications can be used instead. Examples of suitable antidepressants are: Paroxetine, Venlafaxine, Escitalopram, and Desvenlafaxine [4,5].

Contraindications

HRT is not suitable for patients with the following conditions:

• History of breast cancer
• History of uterine or endometrial cancer
• Severe active liver disease
• Elevated triglycerides
• Blood clots in legs or lungs
• Undiagnosed vaginal bleeding
• Endometriosis
• Fibroids

Side Effects

Common side effects of HRT include:

• Nausea
• Bloating
• Breast tenderness
• Fluid retention
• Mood swings