By Imogen Robinson
Hormone replacement therapy, or HRT, first became available in 1940 and proved for many years to be a complete life saver for millions of women. It controlled, or stopped entirely, their symptoms of menopause, effectively alleviating hot flushes, vaginal dryness, osteoporosis, joint pain, and memory loss, among other things.
However, the therapy got a bad rep in 2002 and 2003 when the results of two studies were published. One, by the Women’s Health Initiative (WHI), found HRT put women at increased risk of breast cancer, along with coronary heart disease, stroke, and pulmonary embolism. The other, the Million Women Study at Oxford University, which was funded in part by Cancer Research UK, also found increased risk of breast cancer, as well as increased risk of ovarian cancer.
While subsequent studies have cast doubt over those findings, back then UK regulatory authorities were immediately given new guidelines as to how and when they were able to prescribe HRT. Doctors were told they should only prescribe the lowest effective dose for symptoms and should not use the therapy as a first-in-line treatment for osteoporosis. The resulting confusion that ensued among both doctors and menopausal women meant that many doctors stopped prescribing HRT altogether, and the number of women taking HRT dropped.
More recent research has shown that many fears were unfounded. While numerous studies have shown that HRT can indeed raise your risk of breast cancer, critics of the WHI study said that it was unrepresentative of women who would normally be considered suitable for HRT. This is because, they said, many of the women in the study were over 60, many were overweight, and many had been taking HRT for some years prior to the beginning of the study.
With more studies being done and women gradually gaining confidence in HRT again, many women are finding that the benefits far outweigh the risks. Currently, there are more than 50 types of HRT available, including tablets, skin patches, oestrogen gel, implants, creams, pessaries, and rings. Different types, or combinations, work for different women. For example, women who have had a hysterectomy don’t need combined HRT and will instead take solely oestrogen, while others will normally take some combination of oestrogen and progestogen.
For many women, it has literally transformed their lives, suggesting that if you are aware of risks and do as much as you can to mitigate them in other areas of your life, going on HRT can be hugely beneficial. Jane Dowling, 49, entered menopause three years ago due to stress. She started taking HRT in mid-December 2016, and says it has changed her life. When she first went to her GP she was advised not to use HRT due to the increased risk of breast cancer. Instead, she was told just to eat oestrogen-rich food. But a lot of the symptoms she was having were so debilitating that she couldn’t physically do her job as a personal trainer anymore.
“My job involves working with so many different women,” she said. “And I noticed that women who had gone down the private route for HRT seemed to be having a lot better outcome than going down the NHS route.” This is because there are wider treatment options available, she says, and seeing a specialist gives the two of you more time to figure out exactly what the perfect dose of hormones is for you. While most private doctors in London were out of her means financially, she came across Dr. Louise Newson, based in the West Midlands who was affordable, and she recommends going private to those that are able to, although of course this is not a possibility for many.
“Louise told me all the different options I could have,” says Jane. “She gave me patches for oestrogen, and tablets to take for progesterone, she did tests and gave me gel. She’s very knowledgeable and up-to-date in the latest research.” Having taken all the risks and benefits into account before starting, now Jane says she feels like she has been given “a new lease of life”. “My joint pain is gone, I’m sleeping better, I’ve got more energy,” she says. “I’m feeling really positive, I’ve got no flushes, no night sweats. Now I’m a complete advocate of HRT and I think it’s brilliant.”
As someone who has an extremely physical job, osteoporosis was also a massive worry for Jane, and one of the biggest benefits of HRT for her is that it decreases the risk of that. “I work with women in their 70s,” adds Jane, “and osteoporosis is a silent killer and one I’ve been wary of my whole life. I’m in early menopause, I went into it three years ago due to stress, and that specifically increases your risk of osteoporosis.”
Jane thinks that women should be given more information and more help in deciding what the best thing is for them to do. “The thing is,” she says, “is that when you Google research about HRT, a lot of the stuff that comes up is the huge amount of negativity that is out there, which is what my specialist is trying to fight against. There isn’t enough information out there for women going through menopause and you do feel very isolated because it’s just not talked about.”
Felicity, a 45-year-old biochemist, underwent a hysterectomy when she was 41, as an ultimate solution for fibroids, ovarian cysts and heavy, painful periods. She had a series of post-op complications that went on for two years, during which time she took no HRT at all. She eventually started HRT aged 44, and hasn’t looked back since. She uses the Estraderm MX patch, which is transdermal estradiol (oestrogen).
Before she started HRT, she says although she felt the information she was given was sufficient in some areas, in other ways it was lacking. “It’s hard to quantify, but I would say the information I was given was just about adequate with regard to the need for oestrogen,” she says. “The picture is totally different for testosterone, however, which has never been mentioned. This may well have to do with the fact that currently in the UK, testosterone is not licensed for women.”
In terms of the impact HRT has had on her health, Felicity says that it was extremely effective in tackling a huge amount of symptoms, including nausea, palpitations, dizziness, joint aches, vaginal dryness, gum issues and dry, itchy skin. “Getting these issues under control has had a significant positive impact on my quality of life. I had minimal vasomotor symptoms before HRT, and since taking HRT I’ve not had any problems with these at all,” she says. Vasomotor symptoms is the medical term for hot flushes or night sweats.
With regards to her mental health, she noticed that HRT made big improvements there too. Now she finds her mood is improved, and while she is still susceptible to episodes of low mood, she finds these are less debilitating and she is able to bounce back much more quickly than she used to — in a matter of days rather than months. Before HRT, she says she had started to lose her “sense of self” — and says her life is definitely brighter on it, although still suffers from low-key anxiety which she tackles with CBT, meditation, and exercise.
Despite the benefits, there were a couple of factors that originally put her off starting the treatment. “Firstly, I had a long-suspected diagnosis of endometriosis finally confirmed during my hysterectomy,” she says. “At the back of my mind, I was initially concerned that oestrogen therapy might potentially result in a partial recurrence of the disease.” While this was very much her own private opinion, it was still enough to stop her taking oestrogen for two years. After this though, she decided she was prepared to run the risk of a recurrence. “That was a simple quality of life decision,” she says. “And in the end let’s face it — nothing in life is risk free.”
In terms of other worries regarding HRT, for Felicity the advantages of protecting her bone, urogenital and cardiovascular health outweighed “any potentially very minimal increased risk of other problems”. “I paid very little attention, if any, to the original outcome of the 2002 WHI clinical trial of HRT during my own decision making process,” she says. “Maintaining a healthy weight, eating a healthy, balanced diet, and taking regular exercise are also an important part of it. I try to look after my body and stack the cards as much in my favour as I can.”
The bottom line for her is that her experience of using HRT has been good, for both her physical and mental health. She suspects she may still need to optimise her dose of oestrogen and perhaps try and add in some testosterone. “It’s very much still a case of ‘work in progress’ for me,” she says, “But I’m slowly getting there.”
While for Jane and Felicity, HRT has had an extremely positive effect on their quality of life, of course it isn’t a solution for everyone. Plenty of women still choose to avoid HRT, deeming that the risks for them outweigh the benefits, while others may give it a go and discover they actually prefer tackling the symptoms of menopause without it.
Yvonne, a 55-year-old dental surgeon, was advised to start taking HRT by her GP, due to her menopause symptoms. She didn’t have much other advice given to her about HRT, nor much advice from her doctor. “I think she was just following protocol,” says Yvonne. “I took it for two days but stopped because of the side effects I was experiencing. I wish I had never taken it – I didn’t sleep for two days and suffered heart palpitations and anxiety.” While the side effects of HRT were the primary reason for her decision to come off HRT almost immediately, she also looked up the risks and decided that, on balance, she was better off without.
Instead, Yvonne decided her menopause could be treated more efficiently and safely simply by changing her lifestyle, and for her following a healthy diet is particularly important. “I have cut out sugar almost completely,” she says, “as well as all trans fats and as many preservatives as I can. I eat a lot of vegetables, fruit, seeds, and healthy fats, especially omega 3.” For vaginal dryness she uses organic vitamin E oil and paw paw cream topically, and she walks up to 15km a week. The result? “All my menopause symptoms have resolved and I feel like I’m back in my 30s,” she says.
In short then, what works for some women may not work for everyone. While many find that the benefits of HRT massively outweighed any side effects or risks, for others, such as Yvonne, a lifestyle approach was considerably more effective. However you decide to combat your menopause symptoms, your doctor should be able to give you detailed advice about HRT and other remedies to help you make the choice that works best for you.