Hormone Replacement Therapy (Risks and Benefits). HRT …

Approximately 80% of menopausal women experience symptoms. While a quarter of those are thought to have severe symptoms, only a small proportion of menopausal women currently take hormone replacement therapy (HRT).

Symptoms of the menopause last far longer than most women anticipate. Frequent menopausal vasomotor symptoms, including night sweats and hot flushes, persist in more than half of women for more than seven years[1].

HRT is an effective treatment for the typical menopause-related symptoms. There are also other long-term health problems associated with the menopause - the risk of osteoporosis, cardiovascular disease and stroke all increase after the menopause. HRT can also have a positive influence on these health problems.

This article discusses HRT in detail. The separate Menopause and its Management article discusses menopausal symptoms, differential diagnosis and possible investigations (although the diagnosis is usually clinically based on the typical symptoms). It also discusses health problems associated with the menopause and gives an overview of management.

See also separate HRT - Initial Consultation, HRT - Follow-up Assessments and HRT - Topical articles.

Current guidelines advise that HRT should be considered for troublesome vasomotor symptoms in perimenopausal and early postmenopausal women without contra-indications and after individualised discussion of likely risks and benefits[2].

Starting HRT in women over the age of 60 years is generally not recommended.

For women with premature (age <40 years) or early (<45 years) menopause, current guidelines recommend sex steroid replacement until the age of 51 years for the treatment of vasomotor symptoms and for bone and cardiovascular protection[2, 3].

Current indications for the use of HRT are:

The benefits of HRT outweigh the risks for many women aged under 60 years[2, 4].

Benefits of HRT include:

Reduction in vasomotor symptoms

Improvement in quality of lifeHRT can also improve sleep, muscle aches and pains and quality of life in symptomatic women.

Improvement in mood changes

Improvement of urogenital symptoms

Reduction in osteoporosis risk

Reduction in cardiovascular disease

Lower risk of colorectal cancer

Other benefits

The principal risks of HRT are thromboembolic disease (venous thromboembolism (VTE) and pulmonary embolism), stroke, breast and endometrial cancer, and gallbladder disease.

Large studies, including the WHI and the Million Women Study (MWS), raised concerns and controversy over the use of HRT[18, 26].

However, data accumulated from the WHI and other studies over a period of a decade have shown that, in women with symptoms or other indications, initiating HRT near menopause usually provides a favourable benefit:risk ratio[2].

VTE[2]

StrokeThe risk of ischaemic (but not haemorrhagic) stroke[2]:

Breast cancer

NB: there is no evidence of an increased risk of breast cancer in women on HRT under the age of 51 years compared with menstruating women of the same age.

Endometrial cancer

Ovarian cancer

Investigations are not usually necessary before starting HRT unless:

It is important that an individualised approach is undertaken at all stages of diagnosis, investigation and management of menopause[2].

The dose, regimen and duration of HRT need to be individualised. There is no maximum duration of time for women to take HRT. Discussion with women who continue to have symptoms generally show their benefits from HRT usually outweigh any risks. Systemic HRT should not be arbitrarily stopped at age 65 years; instead treatment duration should be individualised based on patients' risk profiles and personal preference[35].

Micronised progesterone is a natural, 'body-identical' progestogen, devoid of any androgenic as well as glucocorticoid activities but being slightly hypotensive due to anti-mineralocorticoid activity. It may be the optimal progestogen in terms of cardiovascular effects, blood pressure, VTE, probably stroke and even breast cancer but this evidence is only from observational studies[36]. There is only one currently available to prescribe in the UK.

As transdermal oestrogen is associated with fewer risks than oral HRT, a transdermal route may be preferable for many women. This route is also advantageous for women with diabetes, history of VTE and also those with thyroid disorders. In addition, transdermal HRT is preferable to those women with a history of migraine or gallbladder problems.

Delivery routes include:

The choice of delivery route depends partly on patient preference but there are also other advantages to certain delivery routes.

By avoiding the first pass metabolism through the liver, non-oral preparations (ie patches or gels):

Other considerations

See separate HRT - Follow-up Assessments article for a discussion of how to manage these side-effects.

See separate HRT - Initial Consultation article.

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