For years doctors were super cautious about prescribing HRT but there’s been a rethink says Patsy Westcott
Plagued by menopausal miseries? For the past decade official advice has gone like this: ?Take HRT but in the lowest dose for the shortest time to avoid increasing your risk of breast cancer and heart disease.? For healthy women with debilitating symptoms we can now say with confidence that HRT is effective and safe,? says Mr Tim Hillard, consultant gynaecologist at Poole Hospital NHS Foundation Trust and former chairman of the British Menopause Society.
The current NHS line is that, taken for up to five years, HRT?s benefits outweigh its risks. But, says Mr Hillard, ?This time limit is fairly arbitrary. For many women favourable effects outweigh any downside for much longer.? Here?s what you need to know?
Is it effective?
Yes, it's the most effective solution for hot flushes and night sweats - medically referred to as menopausal vasomotor symptoms. It also helps prevent osteoporosis and may protect against heart disease if started close to menopause.
Is It Safe?
There are risks and benefits. Research from the Institute of Cancer Research in London has shown that taking the combined HRT therapy (with oestrogen and progesterone) can increase the risk of developing breast cancer. The study also revealed that HTR using only oestrogen showed no overall increase in breast cancer risk.
If however, you start taking HRT at 60+it can increase your risk of heart problems as chances are the process of atherosclerosis has already begun. HRT can trigger an inflammatory reaction that can destabilise paques, which can lead to rupture and clotting. If you do start HRT after your 60th birthday, the doctor should prescribe the lowest dose. Vaginal Oestrogen pessaries, gels and creams are fine at any time after the menopause because they act locally rather than being absorbed into your bloodstream.
What About Bioidentical Hormones?
These are hormones synthesised from plant chemicals found in yam and soya, with the same molecular structure as those produced in your body. By this token, oestradiol, the most common form of oestrogen used in conventional HRT, is bioidentical. Although touted as a more natural or gentle alternative, like conventional HRT, bioidentical hormones are still synthesised in a lab. There is no evidence they are better tolerated or absorbed than conventional HRT. And they still carry the same risks.
Newer US research on younger women (average age 52), who started low dose HRT less than three years from their last period, not only found no effect on heart disease risk markers but also found that, in patch form, it increased ?good? HDL cholesterol
Other recent research has suggested that HRT may halve the incidence of heart disease if begun within 10 years of menopause - without any apparent increase in cancer
So what about breast cancer?
The jury is still out but current thinking is:
? More than five years use - HRT slightly increases risk
? Oestrogen alone HRT (if you?ve had a hysterectomy) carries minimal risk
? Combined HRT (oestrogen with progesterone) carries a slightly higher risk
? HRT is one of many factors that increase breast cancer risk postmenopausally but has less effect than being overweight or regular alcohol consumption
What do doctors now agree are the health benefits?
There is strong evidence that HRT offers relief from hot flushes, night sweats, vaginal dryness, painful sex and ?irritable bladder? and that it lowers your risk of osteoporosis and fracture ? it helps slow bone loss and preserves bone density.
There is good evidence that it lowers the risk of heart disease ? oestrogen increases elasticity of blood vessels so they dilate (widen) and let more blood through - when started early on in your menopause. It lowers the risk of colon cancer (oral combined HRT) and improves glucose levels.
There is some evidence that it improves your mood and improves ?foggy brain? and, according to some studies, when started early, lowers the risk of dementia and Alzheimer's.
How long do benefits last? Symptoms such as hot flushes benefit only when you are taking it but these will usually stop within two or three years. Bone and heart benefits are longer lasting but to reap them you need to take HRT for longer.
Discuss the pros and cons with your doctor if you have:
Severe menopausal symptoms
A risk of osteoporosis
Had a premature menopause or premature ovarian failure? HRT is essential to maintain normal oestrogen levels until the age of your natural menopause. If your GP isn't well informed ask to be referred to a gynaecologist.
When shouldn?t you take it? If you have a history of breast or endometrial cancer (cancer of the womb lining), heart disease or recurrent thrombosis (blood clots).
What happens when you stop taking HRT?
Sudden loss of oestrogen can cause rebound flushes so it's best to taper it off gradually over three to six months to avoid this. If you're taking HRT for another reason such as bone health discuss alternative strategies with your doctor. These may include other medications, weight bearing exercise and a calcium-rich diet.
Can you start taking HRT for the first time years after menopause?It depends on your overall health and the severity of symptoms. Because oestrogen widens (dilates) blood vessels if these are already damaged, HRT may increase your risk of a blood clot. If you're healthy you may be able to tolerate it but in a low dose. If you have a heart disease risk for example you're overweight, have high cholesterol, high blood pressure or diabetes, however, it's no go.
In what form should you take it?Ideally as an oestrogen skin patch or cream plus Mirena (an intrauterine device containing progesterone). Taken this way oestrogen is absorbed straight into your system without first going through the liver so is more efficiently absorbed and less likely to affect blood clotting.
...For example soya products and supplements such as Red clover or black cohosh
NO Says Dr Sarah Gray, a GP specializing in women's Health.
They don't work well enough to recommend. Phytoestrogens are plant-derived compounds that have an oestrogen-like activity. They are however weak oestrogens and when evaluated we find there is no robust evidence to show that they have a significant effect. I would go as far as saying that herbs such as red clover or black cohosh are more of a 'foreign? substance in your system, than traditional HRT products, which more closely replicate the natural hormones in your body. It's far better to cut down on caffeine and alcohol, increase your fruit and veg intake and do more exercise. This will help more with symptoms than herbs and supplements.'
YES says Maryon Stewart, Health nutritionist and menopause expert.
?Lots of studies have found natural sources of oestrogen, phytoestrogens found in soya, red clover supplements and black cohosh to be very effective in reducing hot flushes. Cutting down on caffeine drinks (coffee and coke) and alcohol can also help. Fibre can help to balance your hormones and moods so eat more bran oats and beans. It's also worth taking a multi-vitamin supplement formulated for the menopause.?
Maryon is author of The Natural Menopause Plan (Amazon £10.39) Maryonstewart.com
Do menopause home tests work?
The tests, on sale in chemists, claim to show whether your symptoms are due to the onset of menopause by measuring the levels of follicle stimulating hormone (FSH) in a urine sample using a dipstick a bit like a pregnancy test. There are two tests to do a week apart. However Dr Sarah Gray says: ?The tests may tell you that your ovaries are not responding at that moment in time but not how far through the process of transition you are or whether they may respond again in the future. Menopause diagnosis is based on your pattern of bleeding and symptoms.?
Kits include Promensil Menopause testing kit, £17.99
Unsure about HRT or confused about complementary therapies? A recent report fromm the respected North American Menopause Society (NAMS) reviewed all the evidence for non-hormonal therapies and their effect on hot flushes and night sweats.
Only Cognitive Behavioural Therapy (CBT), including advice on relaxation and sleep hygiene (things like winding down before bed, going to bed at the same time), clinical hypnosis or hypnotherapy and some low-dose antidepressants, and other precibed non-hormonal drugs (which require specialist advice, see the chart opposite) get the NAMS seal of approval. Consultant gynaecologist Professor Janice Rymer of King's College London, comments, "We don't know the mechanism by which these work because we don't really know what causes flushes. Howeve, what they seem to have in common is that they all act on the nervous system." This fits with current thinking that, although the dip in oestrogen at menopause is somehow responsible, an over-reactive autonomic nervous system that controls things like breathing, heart rate, sweating and the fight-and-flight reflex, may be the immediate underlying cause.
Could Be Worth A Try
A cautious thumbs up goes to isaflavones, plant chemicals found in soya beans, soya milk and tofu, and isoflavone supplements such as red clover. The only snag is that they don't work for everyone. Your gut bacteria have to be able to convert isoflavones into an active chemical called equol. If you're not an equol produce, you may still be plagued by flushes, no matter how much soya milk you quaff or how many supplements you take. Weight loss and mindfulness-based stress reduction could also help, says NAMS, although the evidence isn't cast iron.
What Doesn't Work
Perhaps suprising to the many who swear by them, NAMS concludes that yoga and acupuncture do nothing to quell flushes. Avoiding trigger factors like hot rooms, alcohol and caffeinated drinks don't reduce the number of flushes either. Even aerobic exercise gets a thumbs down, although of corset has myriad other benefits at midlife.
Unlikely to work
Herbal remedies such as Black Cohosh, thought to work by blocking oestrogen receptors, and the Chinese herb Dong Quai , which has question marks over safety, were also rejected by NAMS. Chriopractic and nutritional supplements such as linseeds (flax), which contains oestrogen-like chemicals, evening primrose oil, omega 3s, vitamins, minerals and pollen, are also dismissed on grounds of inadequate evidence.