I love the term 'Hormone Optimisation Therapy' (HOT) when talking about HRT.
Raging fury, worsening PMS, hip pain, backpain, joint pains, ligament issues, brain fog, unable to think of words, increasing anxiety, difficulty sleeping, night sweats, hot flushes, changes in cycle (longer/ shorter or heavier). Lack of energy and fatigue. Lack of motivation. Lack of stamina. Worsening headaches and migraines. You don’t have to have hot flushes to indicate you are menopausal.
Menopause is a retrospective diagnosis unless surgically induced. It is defined as not having had a period for a year. HRT and testosterone should be offered to women after a surgery that induces menopause.
The perimenopause is the time before this where oestrogen levels start to decline. Many people are surprised to learn that oestrogen levels start declining from the age of 35 and in the build-up to the menopause the oestrogen we produce is variable. It is like a monthly rollercoaster where some months you produce a lot of oestrogen and other months you don’t. So, you get menopausal symptoms well before the menopause. The average age of menopause is 51. Perimenopause relates to the beginning of the reduction in hormones; you can start HRT when you still have regular periods. So start thinking about symptoms and HRT from age 40 onwards. If you had post-natal depression, or bad PMS previously it gives you an indication of how hormones play a role in your mood.
The lack of oestrogen increases the risk of other diseases such as heart disease, osteoporosis, arthritis and diabetes. Giving back/ topping up hormones reduces the risks of these diseases.
What is HRT?
It is oestrogen and, if you still have a uterus, it is given with progesterone. With a surgical induced menopause you will need oestrogen. If you have a uterus, we need to give progesterone with the oestrogen to counteract the thickening of the lining of your womb that would occur with oestrogen. This mimics your menstrual cycle hormones. The most prescribed oestrogen and progesterone are 'body identical' and derived from yam plants. Ideally oestrogen is given in a patch or a gel and the micronised progesterone is taken at night which often helps sleep. For many women there is no reason not to do a 3-month trial of HRT. Once you start it you don’t have to stay on it; it’s a very personal choice. Contraception needs to be assessed. The progesterone only pill does not give you oestrogen but there are ways of using it with HRT.
It will come as no surprise that we all respond differently to hormones and treatment needs to be tailored and regularly reviewed. Sometimes women start HRT and feel better and then plateau. Incrementally increasing oestrogen to reach optimal oestrogen and symptom control is important. The dosage can be anything from 2-8 pumps of oestrogen gel a day or 25 mcg – to 2 x 100 mcg doses. The specific dosage needs to be tailored from person to person.
Testosterone is a female hormone. In the peri menopause women produce three times as much testosterone as oestrogen. The lack of testosterone contributes to brain fog, energy, concentration, cognitive function, muscle strength, drive, motivation, and libido. When HRT is at a settled dose, it is worth looking at incorporating testosterone. It is can be the icing on the cake.
There are some people who may have contraindications to HRT. It does not mean a categorical no to HRT, but they may need to see a menopause specialist and a wider team.
Over the age of 45 you do not need a hormone blood test to start HRT. You may need a blood test to rule out any other underlying causes of symptoms such as thyroid issues or anaemia.
Under the age of 45 you can be offered a FSH blood test however a normal (FSH blood result) does not mean you are not perimenopausal. It is important to treat symptoms and not the test results. If you are not getting the results we expected from HRT it is possible to test your hormone levels to check absorption further down the line.
100 years ago, women would die naturally about five years after the average menopause age. Now they will probably live for 30 years in a hormone deficiency unless treated. The oestrogen component reduces the risk of vascular dementia, reduces the risk of bowel cancer, reduces risk of ovarian cancer, reduces the risk of type 2 diabetes, and reduces the risk of osteoporosis.
Everyone has individual risks that need assessing. Most people are concerned about breast cancer.
There is no increased risk of breast cancer if you start HRT under the age of 50 as you are replacing your normal hormones. The risk of breast cancer comes from the choice of progesterone. Women who have had a hysterectomy and therefore only need oestrogen do not have an increased risk of breast cancer. Micronised progesterone – Utrogestan has the lowest breast cancer risk. Being overweight or drinking more than 3 glasses of wine a day increases the risk of breast cancer more than HRT.
You can assess your own breast cancer risk here https://bcrisktool.cancer.gov
If a woman has a history of blood clots, liver disease or migraine, there is a small risk of clotting if taking the tablet form of oestrogen, but taking it through the skin as a patch, gel or spray does not have these risks so is safe for these women.
Your doctor or nurse will discuss the risks with you. Aside from HRT, there are many factors which can affect your risk of breast cancer, cardiovascular disease, stroke and DVT.
There can become side effects while your body adjusts but it is important to review these regularly and trouble shoot with your doctor or nurse. So many issues can be managed by changing dosage and the way the HRT is delivered. It can take some time to get to the optimal dosage but with the right support and expertise it can be so beneficial.
Points to note
There are more benefits to your health if you start HRT early; don’t wait for your symptoms to get worse.
The menopause means living with a longterm hormone deficiency that, if left untreated, will increase your risk of osteoporosis and heart disease in the future.
There is no maximum length of time for which you can take HRT – you can take it forever if it works for you.
HRT does not ‘delay’ your menopause if you have menopausal symptoms after stopping HRT, this means you would still be having symptoms even if you had never taken HRT.
The benefits of HRT have to be balanced against any risks. You have to decide what is right for you depending on your individual circumstances and in discussion with your healthcare professional.
How long to take HRT for?
Menopause is a long-term hormone deficiency. There is no reason to stop HRT unless clinically indicated or personal preference
HRT in older women - a small amount of oestrogen replacement can often alleviate your symptoms effectively and provide you with the bone and heart protection you need. If you still have your womb (uterus) you will also need to take a progestogen, such as micronised progesterone, to protect the lining of your womb.
There is very little evidence regarding starting HRT for older women because this research has not been undertaken. However, most women who are otherwise fit and well do still gain benefits from taking HRT even if it has been more than 10 years since their menopause.
1. Optimise oestrogen in your 40's either with HRT or a combined oral contraceptive.
2. Perimenopause is the time to act
3. There is no upper age limit on HRT
Follow this blog for more information on vaginal health, vaginal dryness, libido, testosterone, contraception, mental health and the menopause, starting HRT later in life or long after the menopause .
Lexie Minter - Prescribing nurse with a Menopause interest.
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