The most common questions I’m asked are surrounding HRT:
- Should I be taking HRT?
- Is HRT safe?
- What are your views on HRT?
- What are the alternatives to HRT?
This week I want to help you explore the facts around HRT and how to make the right decision for you. Before we get into the detail, I genuinely believe every woman should be able to make their own choice. No guilt, no judgement. What is right for one woman, may not be right for another and as we’ve discussed previously, every woman’s journey through the menopause is different.
Is HRT Safe?
No wonder we are confused about the safety of HRT. For more than 50 years, women had been taking a synthetic hormone to replace oestrogen and ease them through the menopause. But in 2002, a major study announced that HRT increased the risk of cancer. Then, in 2015, another study claimed the dangers had been overstated, and that women should consider HRT again. More recently in 2016, the fears have been raised again, so who is right?
In fact, both sides of the argument could be considered correct. HRT can have a hugely positive impact on the quality of life of a woman suffering severely with menopausal symptoms. There has also been a lot of evidence on the positive impact on bone quality and reducing the risks of osteoporosis. However, especially for women with other risk factors, there is evidence of increased risk of cancer and heart disease. The science is very confusing and often lead by economics.
HRT in the Media
One statistic in particular fuelled much of the backlash against HRT. The WHI study (2002) reported that HRT increased the risk of breast cancer by 26 per cent. That sounds terrifyingly high. But on further inspection this statistic is not quite what it appears to be. Shocking statistics receive more publicity and attention-grabbing headlines sell newspapers.
As an example, we need to understand that there are different ways of presenting risk. For example, if the risk of having a stroke is 2 in 100, and a medication increases it to 3 in 100, then it could be said that the treatment has increased the risk of a stroke by 1 per cent. This method of presenting data is called the ”absolute risk’’. However, it could equally be said that it has increased the risk of a stroke by 50 per cent. While this sounds far more alarming, it is the same data, just presented in a different way. This is called ”relative risk’’ and it is how the WHI study findings were reported. A headline saying “X medication increases your risk of stroke by 1%” is not nearly as attention-grabbing as “X medication increases your risk of stroke by 50%”.
The relative risk doesn’t help us assess the actual risk of someone on HRT developing breast cancer – because it doesn’t tell us how many people would develop it anyway. In the case of breast cancer and HRT, while the relative risk is 26 per cent, the absolute risk is 0.4 per cent. This means that, according to the WHI study, there are four extra cases of breast cancer per 1,000 women taking HRT over a five-year period. While this is still significant, it’s a clear example of how the same data can be expressed in different ways, and how it can affect how important the findings sound. When you take into account that middle-aged women taking HRT were under-represented in the sample, it becomes even more clear why the WHI study has been criticised.
Should I Take HRT?
In truth, like any treatment, HRT has risks and benefits. You need to work with your GP to weigh these up depending on your circumstances, and come to a decision about whether or not HRT is right for you.
There is no right or wrong answer. You need to do what is right for you. We would recommend you look at the food you eat, the way you move and relax your body, how you sleep, your stress levels and the “life laundry” you need to attend to. These are all key components of restoring hormonal health and happiness. If you feel you have tackled these but symptoms aren’t improving, then seek advice from your GP.
It’s also important that we put the risks into perspective against the other risks we take with our lives. Our diet, our habits, our lifestyle have a huge impact on the risks of developing long term conditions.
What types of HRT are available?
For those of your considering HRT, it’s important to understand the different types and combinations of HRT. Understanding the options will help you have a construction conversation with your GP.
There are different types of HRT
- Oestrogen-only HRT, which consists only of oestrogen
- Combined HRT, which consists of oestrogen, plus progestogen
You can take combined HRT in two ways:
- Cyclical (or sequential) combined HRT, where oestrogen is taken every day but progestogen is given in monthly or three-monthly doses
- Continuous combined HRT, where both oestrogen and progestogen are taken together every day
HRT can be taken in several different ways, including as tablets, patches or gels.
Tablets, which are usually taken once a day, are one of the most common ways of taking HRT. Oestrogen-only and combined HRT tablets are available. For some women this may be the simplest way of having treatment. However, it’s important to be aware that some of the risks of HRT, such as blood clots, are higher with tablets than with other forms of HRT (although the overall risk is still small).
Skin patches are also a common way of taking HRT. You stick them to your skin and replace them every few days. Oestrogen-only and combined HRT patches are available. Patches may be a better option than tablets if you think you might find it inconvenient to take a tablet every day. Using patches can also help avoid some side effects of HRT, such as indigestion, and unlike tablets they don’t increase your risk of blood clots.
Oestrogen gel is an increasingly popular form of HRT. It’s applied to the skin once a day and is absorbed by the body. Like skin patches, this can be a convenient way of taking HRT while avoiding an increased risk of blood clots. But if you still have your womb, you’ll need to take some form of progestogen separately too, to reduce your risk of womb cancer.
HRT can be given using small pellet-like implants inserted under your skin (usually in the tummy area) while your skin is numbed with local anaesthetic, although these aren’t widely available and aren’t used very often. The implants release oestrogen gradually over time and can stay in place for several months before needing to be replaced. This may be a convenient option if you don’t want to worry about taking your treatment every day or every few days. But if you still have your womb, you’ll need to take progestogen separately too. If you’re taking a different form of oestrogen and need to take progestogen alongside it, another implant option is the intrauterine system (IUS). An IUS releases a progestogen hormone into the womb. It can remain in place for a few years and also acts as a contraceptive.
Oestrogen is also available in the form of a cream, pessary or ring that is placed inside your vagina. This can help relieve vaginal dryness, but won’t help with other symptoms such as hot flushes. It doesn’t carry the usual risks of HRT and can be used without taking progestogen even if you still have a womb.
Bioidentical hormones are still synthesized in a lab but they are designed to be identical to human hormones & their effects are thought to be more consistent with our biochemistry. These are not available through the NHS and the NHS Choices website doesn’t recommend them as they are not regulated in the same way as HRT. However I know many women who swear by them. I have heard some amazing feedback on the use of bio-identical HRT BUT there is little long term data on their safety.
When should I not take HRT?
The most common reasons where HRT is not recommended includes:
- If you have a history of breast cancer, ovarian cancer or womb cancer
- If you have a history of blood clots
- If you have untreated high blood pressure – you will need to control your blood pressure before you can start HRT
- If you have liver disease
- If you are pregnant – it’s still possible to get pregnant while on HRT, so you should use contraception until two years after your last period if you’re under 50 or for one year after the age of 50
In these circumstances, or with some other long-term health conditions, your GP may recommend alternatives to HRT instead.
Alternatives to HRT
SO if you don’t feel HRT is right for you, you want to try alternatives first or you’re not able to take HRT, what are your options?
There are hundreds of different recommendations for treatment of menopause symptoms from magnets, to herbal remedies, over-the-counter medication and alternative therapies. For many of these if you ask one women they will have had an amazing impact, yet another women might report no such joy. Why is this? As we’ve discussed, every woman’s journey through the menopause is different. Surely this means how we each react to different treatments might also be different. If something is working for you – keep doing it. If something is working for someone else, don’t dismiss it. As with HRT, no right or wrong answer, no judgement.
The biggest thing we can all do is have an honest look at how we are looking after ourselves.
- How well are you sleeping?
- What are your stress levels like?
- How are your fuelling and nourishing your body?
- What exercise are you getting?
- Are you managing your weight?
- How much are you relying on caffeine and alcohol?
- How positive or negative are you about this time of your life?
- What ‘life-laundry’ do you need to take care of?
- Do you put everyone else’s needs ahead of your own?
- Do you do things that feed your soul and bring you joy?
Imagine if you could answer all of the above in a positive way, how do you think you would be feeling?
HRT should not be seen as a scary, evil drug and you shouldn’t feel guilty or judged about taking it. However, if you could manage without by looking after yourself properly, wouldn’t this be a great approach?
Here are a few additional resources that might help you in managing your symptoms and working out if HRT is right for you?