Menopause and HRT Information
PLEASE NOTE THAT ALL MEDICAL INFORMATION GIVEN ON THIS WEBSITE IS AS ACCURATE AND COMPREHENSIVE AS POSSIBLE BUT IT IS ONLY GENERAL ADVICE AND SHOULD NOT BE USED AS A SUBSTITUTE FOR CONSULTING YOUR OWN DOCTOR FOR INDIVIDUAL ADVICE.
This has occurred when you have not had a natural period for one year (if you are not on medication that stops your periods). The average age for this in the UK is 51 but any time between 45 and 55 is considered normal. You are then described as postmenopausal.
This is the time when you develop menopausal symptoms but are still having periods although they may be more frequent, less frequent, lighter or heavier. This phase can last up to 10 years and ends once you are 12 months past your last period.
This is a vaginal bleed when your last period was at least one year ago and you are not on HRT. THIS NEEDS URGENT ASSESSMENT WHICH SHOULD BE ARRANGED VIA YOUR GP.
Your ovaries are removed during a surgical operation (bilateral oophorectomy). This causes a rapid onset of menopausal symptoms due to the sudden loss of oestrogen (and testosterone).
Can be caused by chemotherapy, radiotherapy and some other drugs.
The menopause occurs before the age of 45.
Premature ovarian insufficiency (POI)
The menopause occurs before the age of 40 (about 1 in 100 women). If you have been diagnosed with an early menopause or POI it is very important to take HRT until at least your early 50s unless there is a specific contraindication. Many women in this age group have been put off taking HRT by media scares but they do need to replace the natural hormones they have lost to protect their heart and bones for the future. Young women with a surgical menopause need to start HRT as soon as possible after their operation. They often benefit the most from testosterone replacement as well.
We have oestrogen receptors in cells all over our bodies, including our bones, brains, heart, joints, skin, bladder and vagina. There are many possible symptoms related to the menopause, some more commonly talked about than others. Symptoms vary a great deal between women and can change with time. Some women never have the well known hot flushes or night sweats. Vaginal symptoms can come on first or not develop until much later. Symptoms can be very brief or last for decades, the average is about 7 years. A few lucky women ‘sail through’ the menopause with no problems but are still left with the effects of a long-term lack of oestrogen.
Physical symptoms can include irregular periods, hot flushes, night sweats, difficulty sleeping, worsening migraines and other headaches, palpitations, lack of energy, feeling faint or dizzy, aching muscles, painful joints, vaginal dryness or burning, painful sex, urinary frequency, pain and incontinence, recurrent urinary tract infections, loss of libido, breast pain, dry eyes, dry ears, dry or burning mouth, indigestion, altered sense of smell, tinnitus, restless legs, weight gain around the abdomen, increased allergies, thinning and drier hair, brittle nails, increased facial hair, spots and dry, itchy skin.
Psychological symptoms can include brain fog, loss of confidence, anxiety, low mood, depression, mood swings, irritability, crying easily, poor concentration, lack of motivation, poor memory, loss of joy and low self esteem. Many women are given antidepressants at this stage of life when they really need HRT.
When you consider that many of us are also coping with at least one of the stresses of looking after a partner, children, elderly relatives or work issues it is amazing that we manage to keep going at all!
This symptom checker (click to download or open) may be useful to print off and fill in if you are having a GP consultation. If attending my clinic, we will go through these symptoms during the consultation.
Types of HRT
Oestrogen only HRT
This is prescribed if you have had your uterus (womb) removed. If you still have your cervix (a subtotal hysterectomy) or have had severe endometriosis you may still need combined HRT, at least initially.
Sequential combined HRT
Involves taking oestrogen every day and a progestogen is taken for 12 to 14 days out of every 28 days. This usually gives you a monthly bleed.
Continuous combined HRT
Involves taking oestrogen and a progestogen every day. This is designed to stop any bleeding but it may take several months to achieve this.
Can be delivered by a tablet, patch, gel or spray.
Can be delivered via tablets, patches (only if in combination with oestrogen) or via the intrauterine system (Mirena).
Can be delivered via cream or gel. Implants are not generally recommended. There is no licensed form of testosterone for women in the UK at present so we either use very small doses of the licensed male preparations or Androfeme cream which is licensed for women in Australia and imported to the UK via special licence. Androfeme is only available privately but some GPs in some areas are able to prescribe the products designed for men on the NHS.
Compounded bioidentical versus regulated body identical HRT
I encourage the use of body identical hormones (also known as regulated bioidentical hormones) which have the same molecular structure as the hormones we produce and are derived from a chemical extracted from a tropical root vegetable (the yam). Ongoing prescriptions can be via the NHS or from the clinic.
I do not prescribe the compounded bioidentical hormones that some private clinics offer at vast expense together with unnecessary monitoring via blood, urine or saliva tests eg the DUTCH test. These can include hormone combinations that are not necessary and some of the types and doses of progestogen offered may not fully protect the lining of the uterus. These hormones are not regulated or licensed and are not recommended by the British Menopause Society.
Testosterone can be an important hormone for women as well as men. We produce it both in our ovaries and via our adrenal glands and production can slowly decline from our 30s onwards. However, many older women still have reasonable levels or don’t have symptoms from a low level so not every woman on HRT needs to add it. Levels reduce more dramatically for women who have their ovaries removed or if their ovaries stop functioning at a young age so these women tend to benefit the most from the addition of testosterone.
I can prescribe testosterone if indicated, mainly to help with low libido as indicated by NICE guidelines. There are many different factors that affect our libido but low testosterone can be one of them. Some women find it can also improve sleep, motivation, mood, concentration, cognition, energy levels and muscle strength but we don’t have the medical evidence for these effects yet.
It is very important to get established on the right dose of transdermal oestrogen for you before considering adding in testosterone. If you are on oral oestrogen, you will need to be changed to transdermal oestrogen first.
If you are on suitable HRT and want to try adding in testosterone, the BMS guidelines now suggest blood tests first. You can ask your GP for testosterone and sex hormone binding globulin levels. Oestradiol levels can also be considered if you are on the maximum recommended dose of HRT but still getting lots of symptoms. Please have the results available for your consultation. You will need further blood tests to monitor your levels once you have started the testosterone, these will be explained at your appointment.
Many GPs are not able to prescribe this on the NHS and if this is the case you will need to be seen privately for ongoing monitoring and private prescriptions.
Local (vaginal) oestrogen (not classified as HRT)
As we lose oestrogen we develop thinning of the tissues of the vagina, vulva and bladder. This is not something that settles after the menopause but steadily gets worse, often leading to vaginal burning and itching, painful sex, urinary frequency and recurrent urinary tract infections. It can easily be prevented by the regular, long-term use of vaginal oestrogen which is very safe and effective. It has no risk of causing breast cancer. I can discuss the different ways of applying this as well as advising on vaginal moisturisers and lubricants.
Vaginal oestrogen can be used with HRT or on it’s own as a long-term treatment. Most women on HRT find their vaginal symptoms are greatly improved but at least 25% find they need to add in long-term vaginal oestrogen. If you are having bad symptoms when you are first seen you can start both HRT and vaginal oestrogen at the same time and can then consider a trial off vaginal oestrogen once the HRT has started to work.
Benefits of HRT
HRT can be very effective at improving the symptoms of the menopause which can be debilitating and lead to women giving up work, relationships breaking down, mental health issues and even suicide. Many women find they are back to feeling like their normal selves again once they are on the right HRT for them.
The long term health benefits are not well publicised but every woman needs to know about them so they can make an informed decision about whether or not to take HRT.
Before the menopause women have a much lower incidence of cardiovascular disease (heart attacks and blood vessel disease) than men but after the menopause we soon catch up with them. If started within 10 years of your last period or below the age of 60 and continued long-term, HRT can significantly reduce your future risk of cardiovascular disease.
We all start losing bone density from our late 30s and this accelerates during and after the menopause. Certain medications, diseases and lifestyle factors, such as smoking and heavy drinking, can put you at higher risk and it can also run in families. Osteoporosis has no symptoms until you start getting fractures after only minor trauma and it can lead to the classic stooping posture of some elderly people due to fractures in the spine. Fractured hips after falling are a common cause for hospital admission in the elderly, often leading to loss of independence. Lifestyle factors such as weight-bearing exercise and a good diet are important in helping with bone health.
HRT can also significantly reduce the risk of developing osteoporosis. It is an effective first line treatment if you are diagnosed with osteopenia or osteoporosis under the age of 60. If you are diagnosed with premature ovarian insufficiency or an early menopause it is very important to take HRT at least until the age of 51 to reduce your risk of developing osteoporosis.Those who are unable to take HRT e.g. breast cancer patients who have had their ovaries removed or switched off, will be offered other medical options to protect their bone health.
When to stop HRT
Although symptoms of the menopause such as hot flushes and night sweats do eventually go, your body is still left without oestrogen for the rest of your life unless you are taking HRT. The NICE guidelines say that women can take HRT for as long as the benefits outweigh the risks. For the majority of women this means they can continue it into old age, as long as they are having transdermal oestrogen and an annual review to assess their individual benefit to risk ratio. The dose of oestrogen can be gradually reduced as we get older as a low dose can still protect bone health into old age. If you decide to stop HRT we recommend doing this gradually.
Risks of HRT
There are so many myths about HRT that are still being perpetuated and many doctors are still very cautious about prescribing it despite the proven benefits. Typical misconceptions are that it makes you put on weight, that you can’t have it if you get migraines or blood clots or have a family history of breast cancer, that it just delays your menopause and that you should only be on it for the shortest possible time. You do not have to have stopped your periods before you start HRT. See my HRT MYTHS section below for more details.
The biggest worry for most women is the risk of breast cancer but this has been overstated in the past. It also does not apply to women needing HRT for POI or early menopause and the small risk doesn’t start until they reach their early 50s.
A research paper from the Journal of the American Medical Association (JAMA) published on July 28th 2020 confirms that women who have taken oestrogen only HRT (because they have had a hysterectomy) for more than 20 years have little or no increased risk of either developing or dying from breast cancer compared to women who had never had HRT. Taking oestrogen and a synthetic progestogen did increase the risk slightly as we already knew but there is no increased risk of death from breast cancer. Those on the body identical micronised progesterone (Utrogestan) rather than the synthetic form have an even lower risk of breast cancer. This small risk has to be considered in context with the improvement in quality of life by reducing symptoms and the long-term benefits of HRT on heart and bone health. Please see the Understanding Risks of Breast Cancer chart from Women’s Health Concern on the resources page. This looks at the modifiable lifestyle risk factors. It doesn’t include the main risks of being female, getting older and genetic risk (only about 5-10% of breast cancers). As with any cancer diagnosis, sometimes you can do everything possible to improve your lifestyle but still be unlucky.
There is a small increased risk of blood clots and ischaemic strokes with the oral forms of oestrogen but not with the patch, gel and spray forms of oestrogen, absorbed through the skin. The body identical progesterone capsules are the safest form of progestogen for those at risk of blood clots.
Unfortunately most of the patient information leaflets that are provided in HRT packaging give out of date information and list risks that do not relate to the newer transdermal HRT preparations and the most recent research analysis.
The bottom line of current evidence is that all cause mortality is reduced for women on HRT compared to women not on HRT. This is so important but is never highlighted in the media!
There are so many myths about HRT, many of them stemming from the misleading results of the Women’s Health Initiative study of 2002 which have since been re-evaluated. Here are some of the common myths.
Many women get symptoms of low oestrogen in their 40s (occasionally younger) when their periods are still fairly regular or just beginning to change. You CAN start HRT at this stage if you need it
Not true. Current guidance is that women can continue HRT for as long as the benefits outweigh the risks. For most women this means for the rest of their lives because of the proven reduction in cardiovascular disease (heart attacks and most strokes) and osteoporosis (thinning of bones leading to fractures) if started on HRT at the right time and taken long term. It is important to have oestrogen through the skin rather than via tablets as you get older to avoid the risk of blood clots.
Not true. HRT helps with symptoms while you are going through the menopause but doesn’t change when your symptoms would naturally stop. Average time to have symptoms is 7 years but very variable. No need to stop HRT as you get older anyway-see Myth 2.
Not true. If you are 45 or over the diagnosis can be made on your symptoms alone. If you are under 45 it is useful to have the hormonal blood tests but normal levels do not mean that you can’t have a trial of HRT. Our hormones fluctuate all the time so the test is only showing our hormone levels on that one day.
No, no, no! This is the myth that probably upsets me the most. Many women get psychological symptoms around the time of the menopause - low mood, mood swings, irritability, anxiety and panic attacks, low self-esteem, reduced confidence, lack of motivation and loss of joy. These symptoms can all be due to reducing or fluctuating levels of oestrogen and are improved by HRT. Antidepressants can be very helpful in certain illnesses but there is no evidence that they help in this situation.
Not true. Migraines are often caused by or made worse by fluctuations in hormone levels. Transdermal oestrogen via a patch, gel or spray is safe and can reduce the frequency of migraines by providing a steady level in the body.
Not true. High blood pressure needs to be reduced by improving lifestyle and often by taking medication. However oestrogen through the skin doesn’t affect blood pressure and if women get relief from their menopausal symptoms with HRT they will feel less stressed and may find it easier to tackle the lifestyle issues such as taking more exercise, improving diet, losing weight, reducing alcohol and stopping
Not true. Transdermal oestrogen is safe for women with a high BMI. It is much easier to address lifestyle issues contributing to weight gain if we are not struggling with menopause symptoms as well. Menopause causes metabolic changes that mean we start putting on weight around our middle. Most of us at this stage will put on weight every year without lifestyle changes, sad but true
Not true for most women. 1 in 7 women will get breast cancer at some point in their lives. Risk factors include being female, growing older, drinking 2 or more units of alcohol a day, BMI of 30 or over and smoking. Exercise reduces risk. For many it is just bad luck. Oestrogen only HRT (if you have had a hysterectomy) is associated with little or no change in risk. Combined HRT can be associated with a small increase in risk. However this has to be considered in context with the reduction in cardiovascular disease, endometrial and bowel cancer and dementia. All cause mortality is reduced in women on HRT. Only a small number of breast cancers are caused by inherited genetic mutations but if you are worried about your family history your doctor can check the NICE guidelines to see if you need referral to a family history clinic to assess your risk eg if your sister or mother are diagnosed with breast cancer under the age of 40. There are examples of who should be referred on the NICE website and lots more information on breast cancer and HRT on womens-health-concern.org
Not true with the right HRT. Oral HRT does increase the risk of venous thrombosis so should be avoided if your BMI is 30 or over, once you are over 60, if you or close relatives have had a venous thrombosis in the past or if you have a known inherited blood clotting disorder. However transdermal HRT (patches, gel or spray)has been shown to be safe in these cases. Oral micronised progesterone (Utrogestan) is our only bodyidentical progesterone option and also does not increase the risk over your background risk. If your doctor is unsure they can ask your haematologist for advice.
Not necessarily true! The most beneficial time to start HRT is within ‘the window of opportunity’ which is under the age of 60 or within 10 years of your last period. This significantly reduces your risk of future cardiovascular disease (heart and blood vessel problems) but this benefit may be lost if you start at a later age. However, whatever age you start HRT it will still benefit your bone health as well as helping with all the other symptoms which can go on for many years. Lots of women have been told to stop their HRT in the past but they may be able to restart after a gap if they are still getting symptoms. It is very important to begin with a much lower oestrogen dose than the standard one and build up very slowly if needed when starting or restarting after this window. Each patient needs an individual assessment of their health and risk factors. Oestrogen should be given through the skin after the age of 60.
Not true. 5% of women have the onset of the menopause before the age of 45, 1% before the age of 40 and 0.1% before the age of 30. If under the age of 40 it is called premature ovarian insufficiency, POI for short. As well as menopausal symptoms these women are at increased risk of cardiovascular disease, osteoporosis and cognitive impairment. However 12-14% do not experience any symptoms so may not seek medical advice. It is really important that all women with POI are given HRT(or in some cases the combined contraceptive pill initially) until the age of 52.
Oh no. There are over 40 symptoms of the perimenopause and menopause. As well as these 2 well-known symptoms (that not every woman gets) possible physical symptoms include headaches, worsening migraines, palpitations, feeling faint or dizzy, difficulty sleeping, low energy, aching muscles, painful joints, sore breasts, weight gain around the middle, vaginal dryness and soreness, loss of libido, urinary symptoms and recurrent infections, dry mouth, sore mouth, metallic taste, thinning hair, dry and itchy skin, increased facial hair and spots, dry eyes, ears or nails, a sensation like insects crawling over your skin, restless legs, tingling extremities, tinnitus, change in body odour and an increase in allergies. Psychological symptoms include anxiety, panic attacks, low mood, depression, mood swings, irritability, more emotional, loss of joy, poor concentration, brain fog, poor memory, loss of confidence, low self-esteem and lack of motivation.
Not true. Why suffer the symptoms and long term health implications of the menopause if you are able to take HRT? Only a small proportion of women have a medical contraindication. Your reducing oestrogen can be replaced with bodyidentical oestrogen, derived from yams to be the same molecular structure. Our bodies were designed to work with oestrogen. When we used to die soon after the menopause it didn’t matter that our arteries were furring up and our bones were thinning. Nowadays we are living longer and these conditions can seriously affect our quality of life as we age.
Not true. Guidelines are that if your periods stop under the age of 50 you need to continue contraception for at least another two years,. If you are over 50 when your periods stop you need to continue contraception for at least one year. If you are on a type of contraception that alters or stops your bleeding you may not know when your menopause has happened. In some cases your GP can arrange an FSH blood test to help with this. This photo shows the Mirena/IUS which can act as reliable contraception and also the progestogen part of HRT so is a great option for many women. Others prefer to use the progestogen only pill (minipill) or condoms. All women can stop contraception once they are 55.
menopausehealth So wrong. Most women will get symptoms of vaginal dryness at some stage. For some it is the first symptom of the approaching menopause, others may not notice any changes until they are much older. As well as dryness, women can experience soreness, itching and urinary symptoms, including recurrent urinary infections. It can become too uncomfortable to have sex, ride a bicycle or even wear jeans. Sadly this problem only gets worse without long-term treatment. Local vaginal oestrogen is a very safe and effective option. It is not absorbed into the circulation but just acts locally. It can be supplied via vaginal cream, gel, pessaries or a ring. The ring (pictured) is flexible and easily inserted into the vagina and changed every 3 months. About 75% of women who go on HRT find their vaginal symptoms settle but 25% need to continue vaginal oestrogen as well. If you are suffering I recommend reading Me and My Menopausal Vagina by Jane Lewis for lots more useful information and you can follow her via @my_menopausal_vagina contraception once they are 55.
Not a good idea when the information is wrong! All HRT package leaflets list all the possible risks of the old type of oral HRT. Almost all of these risks do not apply to oestrogen through the skin and none of them apply to vaginal oestrogen. However women understandably get put off starting their treatment if their doctors have not explained this. Campaigners such as @lizearlewellbeing and @themenocharity founded by Dr Louise Newson are trying to tackle this issue but meanwhile women are missing out on safe and effective treatment for their symptoms.
Not true. Testosterone is an important hormone for women too, helping with libido, energy levels, mood and concentration. It is produced in the ovaries and the adrenal glands and levels gradually reduce with age. Young women who have their ovaries removed surgically may suffer from a dramatic drop in levels. NICE guidelines say that testosterone can be considered for those that need it, once established on a suitable dose of oestrogen (plus a progestogen if required). However most GPs are not yet confident in prescribing it and some are not allowed to prescribe on the NHS due to local restrictions. We do not currently have a licensed preparation for women in the UK so small doses of the preparations for men can be used on the NHS off-licence. There is also an Australian product designed for women called Androfeme 1 which can only be prescribed privately. This is my last myth (for now) and I wish you all a very happy World Menopause Day 2020! Please feel free to share my myths series. So many women are being deprived of HRT when they could really benefit from it. Every women needs to be able to make her own decision about whether or not to take HRT based on the evidence, not the myths.