The most widely discussed and promoted treatment these days is hormone replacement therapy (HRT). The basis for its use is that it replaces a woman’s naturally circulating oestrogen (and in some cases also testosterone), which have dropped in concentration, leading to many of the symptoms a woman may be experiencing. Oestrogen is the only medicine or supplement which has been shown to affect the long-term risks of osteoporosis and heart disease. The dose and method of delivery can be individualised to meet a woman’s needs.
If a woman still has a uterus (that is, she has not had a hysterectomy), then it would be recommended that as well as oestrogen she receive progesterone. The reason behind this is that studies have shown that using oestrogen alone can lead to a build up of the lining of the uterus and if this is continued indefinitely there is a small chance of developing abnormalities of the endometrium, and potentially cancer of the endometrium. This risk is abolished if the woman is also taking a small amount of progesterone, either daily, or in a cyclical dose (for a couple of weeks per month or so), because this stops the oestrogen from over stimulating the lining of the uterus.
If a woman has had a hysterectomy, then oestrogen alone poses no threat to her endometrium, because she doesn’t own one.
Getting the oestrogen into the system can be done in a few different ways. Oestrogen comes in different dose tablets, which can be taken daily. It is also available in skin patches, which deliver a dose of oestrogen through the skin and into the blood stream. The patches are changed every three to four days. There are also little oestrogen pellets which can be put under the skin (under local anaesthetic, by a doctor), and can be replaced every few months, or longer, depending on the dose.
At the moment, the only way of taking progesterone in an HRT regimen is by taking a tablet. This can be for a couple of weeks each cycle (and an HRT cycle may be once each calendar month or two, but usually not at a greater interval than once every three months). Taking the progesterone usually results in the endometrium changing, and shedding, as in a period, towards the end, or after the progesterone tablet phase each cycle. This is why most women on cyclical HRT have ‘periods’. Like the periods people have on the oral contraceptive pill, they are bleeds related to the withdrawal of a hormone (progesterone), and are called withdrawal bleeds. Some women will not have withdrawal bleeds on cyclical HRT, particularly after taking it for a couple of years. This is not a problem, it just means that there is no endometrium being built up each cycle.
Progesterone can also be given continuously, at a lower dose, and most women taking it in this way will not have bleeding at all after a few months. This may be more suitable for some women who find the withdrawal bleeds unacceptable. The method of delivery of the hormones, and the dose, should be tailored to a woman’s own requirements, and adjusted if it is not satisfactory.
Local oestrogen cream can be applied directly to the vagina, if that is where most of the symptoms are. The amount of oestrogen which gets into the blood stream this way is negligible, so it will not have any affect on hot flushes, etc., but can be useful for women who only want local treatment for vaginal or urinary symptoms. It is usually not necessary to take progesterone if using only local vaginal oestrogen.
Occasionally testosterone is recommended for post-menopausal women. Women usually have a small amount of circulating testosterone, which is thought to affect the sex drive (or libido as it is sometimes called). Replacing this with a continuous dose of testosterone, usually in a little implant put under the skin every three months or so, or by regular infections, can be helpful for some women. This is not part of the routine menopausal HRT at the moment.
Before starting HRT a doctor should take a thorough medical history, and perform a physical examination, to exclude other conditions which may be present. Some baseline tests, like a smear test and a mammogram are recommended. A curette or hysteroscopy may be indicated if there has been abnormal bleeding. Other tests, like blood lipid tests and bone density studies may be performed if there are other risk factors.
A woman should have the principles, possible benefits and side-effects explained. If she does decide to try HRT it is reasonable that she consider it a trial. Many woman have told their doctor they thought that once you started it you had to stay on it. Not true. Certainly it is a good idea to give it a few months before tossing it in, as most of the nuisance side-effects usually diminish after the first few months. Often a different dose or method of delivery (tablet, patch or implant) may be more suitable.
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