Menopause Care - FAQs
What is HRT?
HRT stands for Hormone Replacement Therapy, medicines given to 'replace' the hormones that are in shorter supply during and after the menopause transition. For most, this will include an Oestrogen and a Progestogen. Most menopause symptoms occur because of a lack of Oestrogen, so replacing this helps to improve or manage the symptoms. If you still have a uterus (womb) you will also need a Progestogen which helps to keep the womb-lining thin and prevent abnormalities which can occur if Oestrogen is given on its own. There are several different ways to give both hormones, including some methods where both hormones are combined into one type of HRT (such as a combined patch). All women taking HRT use Oestrogen throughout the month. If you are still having periods, you will need a Progestogen for at least 12 days in each month (and you will still have a bleed each month). If you are no longer having periods you will need a Progestogen every day (a bleed-free regime).
Can everyone have HRT?
Most women can be offered HRT, but it is important that your care is individualised and takes into account your medical history, family history and any risks to your health. Some women may be advised not to have HRT, or that there are additional risks with HRT compared to the general population. In this situation, non-hormonal alternatives to HRT may be discussed.
What is bio-identical HRT?
There are many HRT products available to manage symptoms of the menopause. Some of the most commonly used products are 'bio-identical' which means they contain hormones that are exactly the same as what your body makes on it's own, so they are sometimes called 'body-identical'. In recent years there have been concerns about HRT being marketed and prescribed privately as 'compounded bio-identical HRT'. These types HRT prescriptions are said to be tailored to you based on the results of blood or saliva tests, but they are not evidence based and are being prescribed by doctors who are not menopause specialists. The British Menopause Society (BMS) has raised concerns about this and does not support this practice. HRT prescribed by your GP or registered menopause specialist is licensed for its use and is evidence based. We will always discuss the options available to you.
Can I have HRT if I am over 60?
If you started HRT before the age of 60, or less than 10 years since the time of your last period, many women can safely have HRT and there is no arbitrary time limit on how long you can have HRT for as long as it remains supervised and safe for you. If you are over 60 and thinking about HRT for the first time, there may be additional considerations about the balance of risks and benefits. Some risks may be increased and in many cases we don't have studies to help us understand the risks after the age of 60.
I have been told HRT will increase my risk of blood clots
The risk of blood clots in the legs or lungs (DVT or PE) is an important consideration for anyone on HRT. Some people have additional risks for developing a blood clot, and we all have an increasing risk as we get older. Blood clots can be very serious or even fatal, and they often require a long period of treatment so it is important to try to reduce this risk wherever possible. Oestrogen given by mouth increases the risk of blood clots due to how it is processed by the body. Oestrogen given through the skin (at normal doses) does not increase or decrease the risk of blood clots, making it a safer option for most people. This includes patches, gel and spray. Even if you have had a blood clot such as a DVT or PE before you may still be able to have HRT if Oestrogen is given through the skin.
I have endometriosis, will HRT have any effect on this?
As endometriosis responds to hormone levels, there is a small risk that endometriosis can come back after the menopause, even if you aren't on HRT. Most women taking HRT with a history of endometriosis do not have a recurrence as the progestogen part of HRT supresses the endometriosis. Rarely, old endometrosis can become cancerous. There have only ever been a few case reports of this and the consensus is that this is likely to be very rare. Of those few case reports that are available they were mostly in women who took oestrogen-only HRT. The advice you are given about HRT will depend on the extent of your previous endometriosis, the treatments you have had and other parts of your medical history. If you have previously had a hysterectomy for endometriosis, you may be advised to have take Oestrogen and a Progestogen particularly if your endometriosis was severe.
I have fibroids, will HRT have any effect on this?
Fibroids are benign tumours that are commonly found in the uterus. For some women they cause discomfort and heavy periods, and their growth is influenced by hormone levels in the body. Usually after the menopause, fibroids shrink in size and eventually disappear, as there are much lower levels of female hormones. In women taking HRT, fibroids stay the same size or even grow bigger which may or may not be noticeable depending on their size. Most women with fibroids can still have HRT, but just like for everyone else it needs to be supervised by a doctor.
I have previously been told I am at higher risk of heart disease, or I have previously had a heart attack
Heart disease is important. Women worry most about dying from breast cancer, but in fact more women die of heart disease overall. This in no way diminishes the importance of breast cancer, but it does highlight how important it is to be aware of heart disease too.
If HRT is started within ten years of the menopause or before the age of 60, HRT can help prevent CVD and reduce the risk of dying from CVD. So, even if you have risk factors for CVD like high blood pressure or high cholesterol, it doesn’t mean that you can’t take HRT. If you start HRT more than ten years after the menopause, HRT may not prevent CVD, but there is no evidence of an increase in CVD, such as heart attacks or strokes. If you have had a heart attack recently, it may be safer to wait until at least a year has passed before starting HRT.
I have a family history of cancer
If you have a family history of cancer and have been thinking about starting HRT for menopause symptoms, you will need to discuss your family history with your GP. They will need to know which family members have had cancer, what type of cancer they had and how old they were when they were diagnosed. It can be helpful to find out the details from your family before you see the GP. In some circumstances it may be necessary to refer you to the menopause clinic or a specialist clinic to talk about your family history in more detail before HRT can be considered.
Blood tests have shown that I have abnormal liver enzymes, can I have HRT?
If you have a diagnosed liver condition, this could increase your risk of blood clots and therefore affect which types of HRT are offered to you. If you have had an abnormal liver enzyme blood test but you are not known to have a condition, your GP may need to arrange other tests or seek advice from a liver specialist prior to offering HRT.
How long should I keep taking contraception after the menopause?
If you are sexually active you will continue to need contraception until you have had 12 months with no periods or you turn 55. You can use contraception alongside HRT, and normally your GP would manage both taking into consideration any other medications or conditions you have in the background. One easy way to combine contraception with HRT is to have a Mirena coil which provides contraception as well as protection for the womb-lining.
What can I do to manage vulvo-vaginal symptoms of the menopause?
Vaginal dryness or discomfort, bladder symptoms and pain or discomfort with sex are all more common during and after the menopause. Ask your pharmacist or GP for advice and don’t be afraid to talk about the health of your vulva and vagina, it’s important! Depending on the problem, your GP will examine you and suggest a plan. This could include products such as vaginal moisturisers or vaginal oestrogen which comes as a cream or a pessary (a tablet that goes into the vagina).
Is a particular type of HRT 'best'?
The type of HRT that is best for you is completely individual and depends on your medical history as well as preferences about how you would prefer to take HRT. There are several different options for this reason and it is common for women to try a couple of different 'types' of HRT in order to find something they feel is well suited to them. You can discuss this with your GP or pharmacist.
How does my lifestyle affect the menopause?
Being overweight or obese and smoking are both risk factors for many medical conditions, and increase your risk of developing a blood clot, developing heart disease or having a stroke. They also both increase the risk of you developing cancer. Smoking and obesity are both associated with a higher chance of mood problems and more or worse hot flushes. Alcohol intake is another important lifestyle factor that can increase your risk of developing medical conditions including cancer.
Women with an active and healthy lifestyle are less likely to experience severe menopause symptoms or may report that they are easier to manage. Smoking cessation and a starting or maintaining an active lifestyle are important steps you can take to improve your menopause transition and invest in your future health.