Menopause

5.1. Weighing up the pros and cons

Hormone therapy (HT) often used to be called 'hormone replacement therapy' (HRT). Behind this name lay the idea that during and after the menopause, women needed to have oestrogen in particular 'replaced' or else they would have, in effect, an oestrogen deficiency. The term also gave the impression that a woman did not have to worry about adverse effects, because it was only giving back something that was always there naturally.

But this idea has been shown to be misleading. Using hormones for the menopause is not just a 'natural' replacement of hormones, but rather a drug treatment that, like all others, might have benefits which need to be weighed against potential harms. That is why we no longer use the term 'hormone replacement therapy'. That term is also not appropriate for treatments with so-called 'natural' or 'bio-identical' hormones, that are supposed to be identical to the body's own hormones.

Hormone treatments are drugs that need to be prescribed by a doctor. The aim is to relieve symptoms caused by the menopause. During the 1980s, it was proposed that HT could protect women against some illnesses that become more common as we age, such as heart disease. This belief led to more and more women taking hormones for longer and longer, even when there were no menopausal symptoms.

However trials have shown that longterm use of HT does not have the health benefits it was thought to have. For example, trials showed that a particular combined HT if anything increases the risk of heart attack and breast cancer [35]. Some of the side effects of HT happen straight away, while others slowly increase with use over years. These adverse effects are an important element in making a decision for or against HT. You can read more about this below.

HT has risks and does not overall offer protection against illnesses in older age. However oestrogen-based HT is the most effective treatment for hot flashes and sweats. And for women who are having particularly severe symptoms, this might be the only option that really helps.

Susanne

"I advise every woman to be more informed than I was, so that they can find out what will be best for them. I wouldn’t necessarily rule hormones out if the symptoms are so strong and you cannot manage them with natural remedies."

A woman should be able to decide for or against HT without pressure from others. The arguments for and against also depend on the type of hormones and how long they are taken.

Karin

"How did women manage before? Without drugs. I don’t want to talk anyone out of hormone patches. It is alright if someone takes hormones. It just wasn’t right for me. "

Maria

"I got more informed and went to talks. Then there was that trial from America, and taking hormones was no longer a question for me. I didn’t take any drugs."

Hormones

There are now several varieties of hormone treatment (HT). The central option is a combination of oestrogen with a progesterone. Both of these types of hormone were produced by the ovaries before the menopause, but the production drops a lot during menopause. Small amounts continue to be produced by the body after the menopause though, for example by fatty tissues.

However oestrogen has been shown to cause changes to the endometrium (lining of the uterus) that can increase the chances of cancer of the endometrium or uterus. The chances of this are reduced if a progesterone is added to the oestrogen.

That is why there are two main types of oestrogen therapy. For women who have had their uterus removed by a hysterectomy, there are preparations that include only oestrogen. This is called monotherapy or unopposed oestrogen. For women with a uterus, the option is combined oestrogen therapy, which includes one of the progesterones. The progesterones have additional adverse effects, which we will explain below.

There are three other options types of hormone therapy that are available in some countries and are sometimes used. These are testosterone, tibolone and so-called 'bio-identical hormones'. More research is needed on all of these treatments [11]. Testosterone is not licensed for use for the menopause in Germany, and tibolone is not often used.

Tibolone is a synthetic hormone that works in a similar way to oestrogen and progesterone. There is some evidence that tibolone might be able to relieve hot flashes and other symptoms, but this has not been as well-established as oestrogen-based treatment [11]. Taking tibolone can cause vaginal bleeding or spotting, as well as weight gain and headaches [11]. European drug regulatory agencies have expressed a suspicion that longterm use of tibolone might increase the risk of breast and uterine cancer [36],[37], [38], [39], [40].

Oestrogen and progesterone

There are now dozens of different hormone preparations for menopausal symptoms. The choice begins with the question of whether or not a woman has a uterus. Progesterone is added to protect the uterus from cancer, but it is not needed if the woman has had an hysterectomy. They would usually then use oestrogen alone.

These hormones are available in the following forms:

• Oral - tablets or capsules to swallow
• Nasal - a spray for the nose
• Patches or gels - applied to the skin
• Injection
• Vaginal - creams or gels inserted with an applicator, tablets or rings made out of soft plastic to insert in the vagina

The different types of HT also need to be used at different times. For example, oral tablets are usually taken every day, while a new patch will need to be applied once or twice a week. A vaginal ring needs to be replaced about every three months [41].

Susanne

"I got a hormone patch, at first with a 25µg dose, but later increased to 50µg. After a few years, when the hot flashes weren’t so strong any more, I went back to a 25µg dose."

For combined HT, there is also another variation. With continuous HT, the woman takes both hormones every day. With cyclic HT, the usual monthly cycle is followed more closely. This means that particular hormones will only be used some days of the month. It could mean that there is still a treatment for every day, but the contents might be different.

Vaginal treatments

Using HT in the vagina is also called local treatment. This is primarily aimed at relieving vaginal dryness. Creams and other preparations can help relieve this symptom [11]. Even with local treatment, though, some of the hormone spreads through the body. This is why women with a uterus will use a preparation with progesterone as well as oestrogen. Vaginal treatments can cause some of the same side effects as oral therapy [13]. This includes:

• Vaginal bleeding that is similar to a light period
• Breast soreness or tenderness

Below we list the most important possible benefits and harms from HT. These depend a lot on how long the treatment is used. Short-term therapy is usually enough to handle symptoms of the menopause.

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