Hormone treatment for the menopause is now much more complex than simply giving oestrogens for hot flushes, sweats and vaginal dryness. There are now many new developments to deal with specific problems, to improve acceptability and continuation therapy in individual patients.
NB There are two ways of spelling 'oestrogen', or 'estrogen' depending on whether you are American or British. The inclusion of the 'o' at the beginning of the word is the British form of spelling. As this is a British website and for the sake of continuity we will use this form of spelling for oestrogen.
The menopause occurs because the ovaries are no-longer able to produce hormones, oestrogen being the most important of these hormones. As a result, the periods stop and the loss of oestrogen leads to a variety of symptoms which have long term health consequences. The health implications for the loss of oestrogen can be serious as they can include an increased risk of heart disease, osteoporosis and dementia. It therefore usually makes good sense to replace any deficiency in this hormone.
The average age of the menopause is 51. However the ovaries may continue producing reduced quantities of oestrogen in the years leading up to the menopause and when regular periods may still be experienced. However, periods often become irregular at this time. This is sometimes referred to us the peri-menopause or menopause transition.
Sometimes the symptoms are most troublesome in the peri-menopause. In these cases, menopause due to oestrogen deficiency may not be recognised, there is a risk that the diagnosis can be missed especially if the woman feels she is too young for menopause to happen or because of continued periods.
The symptoms experienced vary from woman to woman; the main symptoms are listed below.
Osteoporosis - The bone density declines in both men and women but in women there is a marked increase in the rate of loss of bone density leading following the menopause leading to osteoporosis or brittle bones. This can result in fractures particularly of the hip bone and vertebrae (spine) which can lead to curvature of the spine, sometimes referred to as dowagers hump, loss of height and back pain.
The risk of heart disease increases in women after the menopause because oestrogen is thought to have a protective effect. Women who have a premature menopause are particularly at risk of heart disease.
Oestrogen replacement can help alleviate the symptoms of the menopause improve quality of life, and reduce the risk of developing, osteoporosis, heart disease and possible dementia.
There are many types of HRT and careful assessment of an individual woman's needs and medical back round will determine the most appropriate type for her. There is no one form of HRT that is suitable for all.
Oestrogen be given orally as tablets but we favour transdermal route using oestrogen gels, patches or implants because this is safer because it avoids the excess risk of thrombosis that occurs with oral oestrogen.
Women taking oestrogen also need to take a second hormone, progestogens for 7-14 days every month to ensure regular monthly bleeds and prevent overthickening of the endometrium or lining of the womb and thereby reduce the risk of endometrial cancer of the womb.
Oestrogen alone will usually alleviate the symptoms of the menopause but sometimes symptoms such as tiredness low moods and loss of libido may persist. In such cases the addition of testosterone can be very helpful.
HRT is safe but a number of recently published studies that have been flawed have received much attention in the media and has lead to many women discontinuing HRT. Some of these studies have suggested that HRT can increase the risk of breast cancer and Heart disease but these studies were on women who started HRT for the first time when they were over 60 years of age and up to twenty years after the menopause. More recent studies in women who were in their fifties and within a few years of the menopause indicate that these risks do not apply and there may be reduction in the risk of breast cancer and heart disease especially in women who have had a hysterectomy and only take oestrogen and not oestrogen plus progestogen. This is very important because most women who start HRT do so before the menopause or soon after as this is when the symptoms are most troublesome. It is very unusual for a woman to start HRT for the first time after the age of 60. Some times women do need to start HRT when they are in their 60s and in this cases a lower dose is required.
The symptoms of the menopause can be very troublesome and last for many years. HRT is effective in controlling these symptoms improving quality of life as well as preventing the long-term effects of the menopause. HRT is safe and the benefits far outweigh any risks. However the type of HRT needed should be tailored to the individual woman.