Menopause: should I take HRT?

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1 Patient information from the BMJ Group Menopause: should I take HRT? The menopause is when your periods stop for good. It isn't an illness. It's a normal part of every woman's life. But sometimes it causes symptoms that can be distressing. You can get symptoms of the menopause for several years. Treatments for the symptoms of the menopause include hormone replacement therapy (HRT). This can work well, but it increases your chances of some serious health problems. So you need to think carefully about whether or not to take it. What happens in the menopause? As you approach the menopause, your body makes less of two hormones, called oestrogen and progesterone. Among other things, these hormones control when you have a period.you may notice your periods becoming less regular. They might be heavier, or lighter, and last for more or fewer days than usual. Many women have hot flushes when they go through the menopause.you suddenly feel hot, and may go red in the face. It's also common to find your vagina feels dry and uncomfortable, which may make sex painful. Both of these symptoms are caused by changes in your hormone levels. You may also have trouble sleeping, feel depressed, put on weight, and have less interest in sex. These things might be caused by changes to your hormones, or by changes to your life around the time of the menopause. Not everyone needs treatment. Some people find the symptoms don't bother them much. But other women find the symptoms more distressing. If you are worried by your symptoms you might want to talk to your doctor about treatments. What is HRT? HRT stands for hormone replacement therapy. It's a type of medicine that contains the hormone oestrogen. The aim is to replace some of the oestrogen that your body stops making when you reach the menopause.the drop in oestrogen at the menopause causes symptoms such as hot flushes and vaginal dryness. Most women take a combination of oestrogen and another hormone called a progestogen. Taking oestrogen on its own increases your chance of getting cancer of the womb lining (endometrial cancer). Adding a progestogen to oestrogen reduces your chance of getting this kind of cancer.this type of treatment is called combined HRT. Some common brands are Evorel Conti, Nuvelle, Premique, and Prempak-C. If you've had an operation to remove your womb (a hysterectomy), you can take oestrogen without a progestogen, because there's no chance of getting endometrial cancer. Some common brand names of oestrogen-only HRT are Premarin, Estraderm, and Evorel. page 1 of 5

2 You can take HRT in a way that copies your natural cycle and gives you a period. This is called cyclical HRT. It's often prescribed for women who are having menopausal symptoms but are still having periods. Or you can take HRT every day without a break and have no period. This is called continuous HRT. It's more suitable for women who haven't had periods for a year. HRT comes as lots of different products. You can take it as a skin patch, a tablet, a gel, an implant, or a vaginal cream or ring. Some types work best for certain symptoms. Talk to your doctor to decide which product is likely to suit you best. How can it help? If you take HRT tablets you will get fewer hot flushes after about three weeks. Other forms of HRT, such as a patch or gel, should also reduce your hot flushes. But we don't know how the different HRT products compare for this symptom. Women with the worst symptoms get the most benefit. All doses of HRT will reduce hot flushes. Higher doses may work better, but they may also be more likely to cause side effects (see below). HRT can relieve vaginal dryness, as a cream, a patch or a tablet. If you find that having sex is painful, HRT can help.you only need a low dose of HRT to relieve vaginal dryness and pain when having sex. HRT can stop you getting infections in your urinary tract (the parts of your body that carry urine out of your bladder). Oestrogen creams and tablets that you put in your vagina (pessaries) work better at reducing urinary infections than oestrogen tablets. Taking HRT is likely to make you feel less 'down'. But we don't know if HRT helps women who are severely depressed. HRT may also help you sleep a bit better. Some studies show that you're likely to have a greater feeling of wellbeing if you take HRT. But not all the research agrees. One large study found that taking HRT for a year didn't seem to improve women's general health, their relationships with family and friends, their energy levels or their sexual satisfaction. HRT reduces your chance of getting thin bones (osteoporosis). Osteoporosis makes you more likely to break a bone. But doctors don't prescribe HRT for this purpose, because of the risks (see below). Other drugs can be prescribed for osteoporosis. Can it be harmful? There are several serious risks associated with taking HRT. For most women the increased risks are very small, but you will need to talk to your doctor to weigh up the risks and benefits for you as an individual. Doctors are advised that women should take the lowest dose that controls their symptoms, for the shortest time possible. These are the main risks. The evidence about them comes mainly from studies looking at combined HRT (oestrogen with a progestogen). There is less evidence about the risks of taking oestrogen HRT alone. page 2 of 5

3 With some (but not all) creams and tablets you put in your vagina, doctors think the risks of side effects are lower because very little hormone gets into your bloodstream. Talk to your doctor about this. Taking combined HRT slightly increases your chances of getting breast cancer. For every 1,000 women who take HRT for five years, it causes an extra three or four cases of breast cancer. The risk is a little higher for women who take HRT over the age of 60. The risk goes up slowly in the first five years you use HRT, then more quickly if you continue using it after that. But five years after stopping HRT, your chance of getting breast cancer is back to the same as if you had not taken HRT. Women taking HRT are more likely to get blood clots than women who don't take it, but the increased risk is very small for most women. Having clots in your blood can be dangerous, because they could block an important blood vessel. If a blood clot blocks the blood flow to your lungs, it can kill you. In one big study, over five years, less than 1 in 100 women taking HRT got a blood clot in their lungs. But this was about twice the number of women who weren't taking HRT. If you've had blood clots before, you should let your doctor know and talk about whether HRT is suitable for you. Women who take combined HRT or HRT with oestrogen alone are slightly more likely than other women to have a stroke. The risk is higher for women over 60. If 2 in 100 women not taking HRT have a stroke, then 3 in 100 women taking HRT will have a stroke. Women who are over 60 and take HRT more than 10 years after the menopause have an increased risk of heart disease. But the risk is small to begin with. Over five years, nearly 2 in 100 women taking HRT were at risk of heart disease, compared with 1.5 in 100 women not taking HRT. Some research suggests HRT may also slightly increase your chance of ovarian cancer, although the risk seems to disappear when you stop using HRT. Other side effects There's a chance that taking HRT for a year or more could increase your risk of gallbladder disease (gallstones) or urinary incontinence. You may also get less-serious side effects with HRT. Sometimes they go away when you have been on HRT for a while. Sometimes a change of product helps. These side effects include unexpected bleeding, tender breasts, headaches, and mood swings. There's no evidence of weight gain with HRT. Researchers have found that, although women may put on some weight when they first start to take HRT, after a while their weight is the same as it was before treatment. page 3 of 5

4 What are the alternatives? Tibolone (brand name Livial) is another type of hormone treatment, but it doesn't contain oestrogen or progesterone. It doesn't affect the lining of your womb. This means that, if you start taking it at least one year after your periods have stopped, you shouldn't get any monthly periods. If you take tibolone, you're likely to have half as many hot flushes, less vaginal dryness, improved sexual satisfaction, and more sexual arousal. Researchers have found that sex drive increases much more in women taking tibolone than in women taking combined HRT. Tibolone may slightly increase your chance of breast cancer, but less than if you take combined HRT. The most common side effect is spotting or bleeding from the vagina. About 1 in 10 women get this. Some researchers have also found that if you take tibolone your levels of 'good' cholesterol (HDL cholesterol) falls by about one-third. There's not enough research to show whether this drop in HDL cholesterol is harmful, or whether women who take tibolone are more likely to have a heart attack or a stroke. Phyto-oestrogens are chemicals that are found in some plants. They act like a weak form of oestrogen. 'Phyto' means 'from plants'. Soya products such as tofu and miso are rich in phyto-oestrogens, as are beans, lentils, certain fruits, and celery. You can also get over-the-counter supplements such as red clover pills from some pharmacies and health food shops. The research into phyto-oestrogens isn't as good as that for HRT. Most of the research suggests that they don't help reduce hot flushes. Phyto-oestrogens probably don't help with the sexual problems or bladder infections linked with the menopause. Because phyto-oestrogens act like oestrogen in the body, it's possible that they could increase the chance of breast cancer and cancer of the lining of the womb (endometrial cancer). But there's not enough good research to say whether this happens or not. If you decide to take phyto-oestrogens, it's a good idea to discuss this with your doctor, especially if you are taking other medicines as well. Black cohosh is a herbal treatment. You can buy products made from black cohosh from health food shops. Most good-quality research suggests that black cohosh doesn't make much difference to hot flushes. Some people taking black cohosh get stomach pain. You might also feel dizzy and nauseated, and get headaches when you take it. Black cohosh may cause liver problems. If you get any of the symptoms below, you should stop taking black cohosh and see your doctor as soon as you can. Feeling tired Losing your appetite Yellowing of the skin and eyes page 4 of 5

5 Menopause: should I take HRT? Severe pain in the top part of your stomach and vomiting Dark urine You should always tell your doctor if you're taking herbal treatments. That's because they can sometimes react with treatments your doctor may prescribe. Some other treatments have also been tried for HRT, but the evidence doesn't show whether they work or not. They include clonidine (a medicine used for high blood pressure), antidepressants, and the male hormone testosterone. More research is needed about all these treatments. Some women try acupuncture for menopausal symptoms. But research suggests that probably doesn't help. How do I decide? Guidelines say that your doctor should make sure you understand the risks of HRT before you start taking it. These are some of the things you might want to consider and discuss with your doctor: How much do your menopause symptoms bother you? Can HRT help with the symptoms that bother you most? Which type of HRT is likely to work best for these symptoms? What are the alternatives to HRT for these symptoms? Do some ways of taking HRT have fewer side effects than others? What are the health risks with taking HRT? Are you at high risk or low risk of getting health problems from HRT? How long will you need to take HRT? What side effects might you get with HRT? This information is aimed at a UK patient audience. This information however does not replace medical advice. If you have a medical problem please see your doctor. Please see our full Conditions of Use for this content. These leaflets are reviewed annually. Last published: Sep 16, 2015 page 5 of 5

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