Hormone Therapy

Commonly referred to as Hormone Replacement Therapy (HRT)

The term HT refers to use of oestrogen, progesterone and occasionally testosterone for women who have symptoms of a deficiency.

Whilst there are many types of HT and reasons for prescribing it, this information sheet is focused on HT in relation to menopause.

The dramatic fall in the levels of the female hormones, particularly oestrogen and progesterone, can account for changes before and during the menopausal years. Some women will also be affected by a drop in testosterone levels.

HT is medication prescribed to women whose menopausal changes, such as hot flushes, incontinence, insomnia, loss of libido and mood swings, are interfering with their quality of life.

Supplementing hormones naturally produced by women increases their well being and helps prevent diseases, such as osteoporosis.

The decision to start HT is an individual one. It is important that all women seek as much information from their doctors and other sources as they need to enable them to make an informed choice about their treatment.

Forms of HT

HT can be prescribed as tablets, patches, skin gels, implants, nasal sprays or vaginal preparations, such as creams, pessaries or tablets. Not every form of HT may be suitable for all women, so it’s important to discuss the options available with your doctor.

Most forms of HT used in Australia are a combination of two hormones, progesterone and oestrogen, but it has been suggested that sometimes only one hormone is needed. See your doctor for more information.

Oral (tablets, capsules etc)
Tablets are generally taken orally on a daily basis.

Patches
Patches containing oestrogen and progesterone are applied to the skin and changed once or twice a week.

Implant
Generally oestrogen only, the implant is inserted under local anesthetic and lasts for between 4-6 months.

Gels
Skin gels are rubbed into the skin daily.

Vaginal creams and pessaries
Creams and pessaries are generally used twice weekly.

Intranasal spray
Used once or twice daily.

Non-hormonal treatments such as the medication Livial, and some types of antidepressant treatments, can reduce hot flushes and other symptoms.

Short or long term HT?

Short term HT is when HT is taken for between 1 and 5 years. Many women require short term use only.

Long term HT refers to HT used for over 5 years. There may be increased health risks when using HT long term, with the main risk being breast cancer.

Who can take HT?

HT is suitable for most women, but there may be health risks for some.

You should not take it if you have:

a history of breast, endometrial (lining of the uterus) or ovarian cancer
vaginal bleeding, the cause of which has not been diagnosed
hepatitis, any other active liver disease or if you have severely impaired liver function
current or recent blood clots (eg deep vein thrombosis)

Special discussion with your doctor is needed if you have:

diabetes
hypertension (high blood pressure)
a history of heart disease or thrombosis (blood clots)
any form of liver disease
migraines
a history of endometriosis
had a hysterectomy

Possible risks and benefits

For some women, the benefits they get from HT will outweigh the possible risks, while for others the opposite may be the case. Women should discuss the risks and benefits of taking HT with a doctor.

Advantages/benefits

Reduction in hot flushes and vaginal dryness. Without treatment, these problems may persist for 2-15 years after menopause
Reduction in the risk of osteoporosis and fractures
Reduction in the risk of bowel cancer
Reduced genital and urinary infections and incontinence
Short term memory and clarity of thinking may be improved.

Disadvantages/risks

In women who still have their uterus HT may cause small, artificial periods induced by the hormone progesterone. Progesterone is needed to protect against endometrial cancer
During early treatment a woman may also experience nausea, slight weight gain or breast tenderness. Adjustment of the dose will usually alleviate these problems
There may be a small increase in the incidence of gallstones and the size of uterine fibroids may increase on HT
Small increase in the risk of heart disease, stroke and thrombosis (blood clots) in older women on HT. New evidence suggests that older women on HT may be more prone to Alzheimer’s disease (a type of dementia).

Health issues and HT

There have been many trials on the effects of HT, and the research continues. Some of the health issues that have been of concern are discussed below.

Cancer

Breast Cancer
The incidence of breast cancer increases with age in all women. Taking HT has been associated with an increased risk of breast cancer and an increased mortality rate. Doctors are cautious of using HT on women who have had breast cancer in the past.

Bowel (Colorectal) Cancer
Some research has shown a reduction of bowel cancer in participants receiving long term HT. A diet high in fibre, fruit and vegetables can also provide some protection against bowel cancer.

Endometrial (lining of the uterus) Cancer
Taking oestrogen alone can increase a woman’s risk of endometrial cancer, so a combination of HT (oestrogen and progesterone) is used to reduce this risk. For women who have had a hysterectomy there is no risk of endometrial cancer.

Osteoporosis
Osteoporosis is a decrease in the density of the bone below what is considered normal, leading to weaker bones that are more prone to breaking.

It is usual for a slow, steady rate of bone loss to occur from about the mid 30’s onwards. Due to menopause, bone density decreases more rapidly. HT has been shown to significantly slow down this process.

A calcium-rich diet and regular weight-bearing exercise are also important factors in maintaining strong bones. Some women may need calcium supplements in addition to the calcium in their food.

Cardiovascular disease (heart/blood clots)
A history of heart disease and deep vein thrombosis must be discussed when considering taking HT.

Sexuality and sex

Feelings about sex can sometimes change around the time of menopause, including having a lower libido. These changes can be due to many factors. For most women, short term use of HT or use of vaginal oestrogen creams and pessaries can be effective in relieving physical changes such as vaginal dryness. Vaginal creams and pessaries are not associated with the risks of other forms of hormone treatment.

While fertility is diminishing at this time, becoming pregnant is still a possibility, so contraception is an important consideration.

Alternatives to HT

Some women, for various reasons, may prefer not to take HT. Other options that can be beneficial include improving your lifestyle habits, and natural therapies.

A number of women find changes in diet and exercise can help to relieve some of their menopausal problems. Having a healthy, balanced diet and exercising regularly will also improve feelings of general well being, and may prevent serious conditions developing.

Some women have found natural therapies to be of benefit in managing menopausal changes. If you are considering using natural therapies for the treatment of menopause, it is important to see a trained natural therapist. Make sure you tell your doctor if you are taking any other medications, natural or otherwise, as some products can react with one another.