Menopause is a natural process that all women will experience in their lifetime. It is a time of transition and can be accompanied by a variety of symptoms that can be uncomfortable and very difficult to manage and may significantly impact a woman’s quality of life. Hormone Replacement Therapy (HRT) has long been used to manage the symptoms of menopause, but there are some fears of the risks associated with its use. In this blog post, we will examine the relative risks of HRT and discuss the alternatives available, and hopefully enable you to make an informed decision about the best treatment option for you.
Understanding the menopause
Menopause is a natural process that all women will experience at some point in their life, some women will be more affected than others. This has no bearing as to what is happening, it is simply a reflection on a woman’s sensitivity to her endogenous hormones. Menopause is the time when a woman’s ovaries stop producing eggs and her body no longer produces the hormones oestrogen and progesterone. This transition typically occurs between the ages of 45 and 55, but it can occur earlier or later depending on a woman’s individual circumstances. Menopause is typically defined as the absence of menstrual periods for 12 consecutive months; it can occur naturally, or it can be induced by medical or surgical treatments. The transition period, when the hormone levels begin to drop is known as the peri-menopause and this is often the time when women start to have non-specific symptoms and start feeling less like their normal self. During the perimenopausal period, blood tests will often be inconclusive so it is usually a clinical diagnosis (the diagnosis is given from the woman’s history of symptoms and likelihood of being in the perimenopausal period) rather than a diagnosis given from blood test results.
Menopausal symptoms
Common symptoms of menopause are hot flashes, night sweats, mood swings, brain fog and vaginal dryness, but there are many other symptoms which can be attributed to the reduced production of oestrogen in the perimenopausal and menopausal period. These symptoms cann be significant and ccan seriously affec a woman’s quality of life. These symptoms can be managed in a variety of ways including HRT, natural remedies and lifestyle changes, such as avoiding triggers, exercising regularly, and getting enough sleep.
What is HRT?
Hormone replacement therapy (HRT) is a form of medical treatment that is used to replace hormones that are lost during menopause. HRT typically involves the use of synthetic hormones, such as oestrogen and progesterone, which are taken orally or applied topically. HRT is often prescribed to help alleviate menopausal symptoms and reduce the risk of certain diseases, such as osteoporosis. There are many forms of HRT available including creams, gels, implants, sprays, patches, tablets and coils. Many people are now talking about bioidentical HRT (BHRT), but what is this? Well, put simply, BHRT is a precise duplicate of human hormones rather than synthetic or equine (yes, that is horse!!) alternatives. There are currently 2 forms of BHRT – compound (c) and regulated (r). The difference between these is that cBHRT is produced by specialist pharmacies which do not follow MHRA regulatory pathways and rBHRT is produced in a conventional way in MHRA regulated pharmacies. Neither is wrong, it is just that one is regulated and the other does not follow the same guidelines.
It is generally considered that transdermal (creams, patches etc – it is applied to the skin rather than swallowed) HRT is safest for use in terms of reduction of the risk of adverse events such as cardiovascular problems (strokes, heart attacks etc), venous thromboembolic events (blood clots – DVTs etc) and transdermal HRT also has been shown to have a lower risk of breast cancer development.
Breast Cancer risks with HRT
There is a lot of misinformation around the risks of breast cancer with taking HRT. In the late 1990s, several studies were published showing a causal link between taking HRT and going on to develop breast cancer and whilst it has been proven that yes, HRT (particularly the oestrogenic component) can increase the risk of breast cancer, the risk is nothing like what was reported in these studies. So what are the risks? Well, it is generally accepted that the overall risk is that 1 in 8 women throughout their lifetime will develop breast cancer. These are usually oestrogen receptor positive cancers and so from this we can begin to understand the basis of the increased risk of breast cancers with taking HRT – the more exposure to oestrogen will mean that cells which are present and likely to become cancerous have more of a chance to do so with the extended exposure to oestrogen.
When determining whether the risk is right for you though, bear in mind that you are balancing the risk of potentially developing breast cancer in your lifetime against the quality of life you will have without the menopausal symptoms and also the protective benefits that HRT imparts on cardiovascular health and mortality, and skeletal strength (essentially the reduction in risk of heart attacks, strokes and osteoporosis). If we look a little further at this; the risks of developing breast cancer in women with no background risks and aged 50-70 years is about 2 per thousand per year and in women younger thann 50 years, the risk is 1 per thousand per year. That is less than 1% risk. If we assume that taking HRT will double this risk, it remains less than a 1% risk.
Women with a family history of breast cancer remain a candidate for HRT as the background risk is still low – genetics are not the only influence at play! If a woman has more than 1 first degree relative (mother, aunt, sibling) with breast cancer, they should be considered for genetic testing (speak to your GP, they should know what to do!) to rule out BRCA 1 or BRCA 2 genetic mutation – this will significantly increase a woman’s overall risk of developing breast or ovarian cancer. Definitive treatment of BRCA gene mutation is bilateral mastectomy and oophorectomy (removal of both breasts and ovaries to remove the risk of these cancers). After this, add back HRT can safely be offered to help improve symptoms and therefore improve quality of life.
But what if you have had breast cancer in the past? Can you still use HRT?
Well, to determine the answer to this, we must return to the whole risk/benefit thing again. Yes the risk will be increased a little but if a woman has just had breast cancer, they will be closely followed up and will also be very self aware for a long time. And is it worth living with symptoms that affect pretty much every part of the day to possibly reduce the risk of developing this cancer again? Also, there are the protective benefits that the HRT imparts on the cardiovascular system and skeleton. It is very much a risk/benefit decision but ensure all aspects of the decision are considered. I would suggest talking it through with the breast surgeon to help get a good idea of how much bigger the risks would be in each case. After all, if a woman has just lived through treatment for cancer, surely her quality of life is the most important aspect right now? As a side note, HRT can be used in women who are receiving treatment for their breast cancer – Tamoxifen is fine – but it is not recommended to be used with Aromatase Inhibitors (Letrazole and Anastrozole) as it interferes with its mode of action; either switching to Tamoxifen or alternative therapies would be prudent.
There are no limits on duration of use of HRT as long as there are no adverse side effects – it can be taken lifelong; afterall, you wouldn’t ask a diabetic to stop taking the hormone (insulin) that is keeping them going would you? If a woman is stable and comfortable on her HRT, then the benefits of using her HRT outweigh the risks of menopausal symptoms. It is thought that initiating HRT before the age of 60 years has a more favourable risk/benefit profile to the woman taking it as it prevents the detrimental effects of reduced oestrogen on the cardiovascular system. HRT started before the age of 60 or within 10 years of menopause is associated with reduced incidence of dementia, osteoporosis, coronary heart disease and cardiovascular mortality.
To put the risks of breast cancer into perspective: obesity and drinking more than 2 units of alcohol per day increase your overall risk far more than a family history of breast cancer will! So lifestyle changes and modifying these risk factors will help in the reduction of overall risk.
But what if you don’t want to or cannot use HRT? What are your options?
Alternatives to HRT for those unable to use it or who wish to manage their symptoms without medication, depending on symptoms. I have put together some options for alternative medicinal management for symptoms. There are many more options but this is my list of the top few products available:
Shutterstock photo
Vitamin B6 (Pyridoxine) – regulates hormonal activity and supports the immune system. It is responsible for managing symptoms caused by reduced serotonin such as low mood, poor energy levels and fatigue.
Soy isoflavones – plant based chemicals which mimic oestrogens. Found in soy bean products, they bind to oestrogen receptors in the body, therefore reducing the frequency and severity of hot flushes, supporting cognitive function and balancing hormones. Magnesium – plays a role in female hormonal balance. It is good for sleep and helps control energy metabolism (it reduces tiredness and fatigue).
Valarian root – has been shown to reduce hot flushes, improve sleep and calm the body via its mild muscle relaxant effects.
Rosemary – reported to aid memory, improve cognition and benefit mood – brain fog problems anyone?
Liquorice – can be used to boost energy levels, balance hormonal fluctuations and soothe aching joints via its effects on the adrenal glands. Care must be taken by those with a heart condition or arrhythmia.
Black Cohosh – traditionally used as an alternative to HRT but for a short time was not recommended as it was thought to have an increased risk of breast cancer development. It has been shown more recently that it acts on the pituitary gland, modifying hormone regulation via neurotransmitter activity. It is used to reduce hot flushes and improve sleep, energy levels and brain fog. It should be avoided in anyone with a liver condition.
Sage – has also been used traditionally to help manage hot flushes and improve metabolism and brain fog. It is not clear how it works but it is thought to have an anti-inflammatory effect which helps improve menopausal symptoms.
Red Clover – is another traditional treatment which has been used for some time. It contains isoflavones (plant oestrogens) to help with hot flushes, reduce skin changes associated with ageing and skin conditions associated with hormonal changes (acne, rosacea, skin sensitivity etc). It also acts as an anti-inflammatory and helps with blood vessel support.
Maca Root – is used to help with libido, helps improve concentration and increase energy levels. It contains plant sterols which helps to balance out hormone fluctuations.
Conclusion:
Hormone replacement therapy can be a useful treatment for management of menopausal symptoms, cardiovascular health, skeletal strength and improve overall quality of life, but it is not entirely without risks. It is important to discuss the potential risks and benefits of HRT with your doctor before making a decision about whether it is the right choice for you but remember you are weighing up the quality of life you have with the small increase in risks. There are very few people who cannot truly take HRT with the right follow up and support.
There are also alternatives to HRT that can help reduce menopause symptoms, such as lifestyle changes and natural remedies. I hope this blog has been of use to you in helping you make your own, informed decision.
Keywords: Hormone Replacement Therapy, HRT, Menopause, Breast Cancer, Risks, Benefits, Natural HRT.
References:
The BMS website: www.thebms.org.uk/education
Natural Medicine, Anne Henderson
The Definitive Guide to The Perimenopause and Menopause, Dr Louise Newson
The Million Women Study
The Risks and Benefits Of HRT Before and After a Breast Cancer Diagnosis – a consensus study, The British Menopause Society
NICE guidelines on HRT and Menopause Management
