Most frequently asked questions about the menopause

What is the menopause?

That time in a woman’s life when the ovaries cease to produce the female hormone, oestrogen. Oestrogen is the hormone which is responsible for puberty, that stage in a woman’s life when the girl becomes a woman. When the ovaries cease to produce oestrogen menopause symptoms occur. The average age at which this happens is 51 but it can occur naturally in the 20s or as late as early 60s.

Usually the menopause is preceded by a premenopausal phase of 1-3 years. During this time the woman still has periods but because the oestrogen level is beginning to fall, she may begin to experience menopause symptoms. The term perimenopausal is used for the period of time from when the menopause begins to when the menopause is completed, usually a transitional period of 3-5 years.

What is hormone replacement therapy (HRT)?

Ideally the term HRT should be replaced by the term Oestrogen Replacement Therapy:  the principle of replacement therapy is simply to provide the woman with the oestrogen which she would have been making naturally had her ovaries not ceased to function. 

Because most women using HRT still have a uterus it is necessary to combine the oestrogen with a hormone called progesterone. The reason for this is simple.  Oestrogen makes the lining of the uterus, the endometrium, grow just as it does in a natural menstrual cycle. If left unchecked the endometrium gets thicker and thicker and eventually the woman will have prolonged heavy bleeding: in some cases the overgrowth can become malignant but this has never been a problem in the U.K. because in women who have a uterus oestrogen has always been combined with progesterone. The role of progesterone is to prevent the growth of the endometrium, just as it does during a natural menstrual cycle, i.e. it is progesterone which controls the growth of the endometrium and which dictates when the uterus bleeds (sheds its endometrium.)  Women who don’t have a uterus (because they have had a hysterectomy) don’t need to use progesterone – they use oestrogen alone. When oestrogen is used alone we refer to it as “unopposed oestrogen” because there is no need for women to use progesterone.

Are there different types of HRT? 

Yes. Women without a uterus use unopposed oestrogen, i.e. oestrogen without progesterone.  Women with a uterus must use progesterone.  Progesterone can be given for 12 days each month, in which case it produces a monthly bleed: this is used most often in women who are perimenopausal. Women who are 1 year or more past the menopause can be given progesterone every single day in which case there will be no monthly bleed – this is sometimes referred to as a “no bleed” HRT. Sometimes it can be given for 12 days every 3 months or so, thereby reducing the amount of progesterone given but this will produce a bleed every 3 months.  Finally, progesterone can be inserted directly into the uterus using a MIRENA intrauterine device.  The MIRENA device has progesterone incorporated into it – it releases minute amounts of progesterone directly into the uterus and thereby minimises the amount of progesterone to which the rest of the body is exposed. The beauty of the MIRENA is that it prevents any build-up of the endometrium and, therefore, there is no bleeding. The MIRENA device will function for about 5 years.

How can HRT be administered.

It can be given in one of several ways. It can be given as a tablet, taken once a day. It can be administered in the form of a small skin patch which stays in place for 4-7 days depending on the type of patch used. It can be applied as a gel which is simply rubbed into the skin once a day. There is also a nasal spray which is used once a day. Finally, there is a subcutaneous implant, a small pellet which is inserted under the skin under local anaesthesia about twice a year.

 What are the benefits of HRT?

The benefits can be assessed in two ways – short term and long term. The short term benefits are relief from menopause symptoms such as flushes, night sweats and emotional problems. For these symptoms it may be used for only 1-3 years. Increasingly, however, women are using it for longer periods of time for the long term benefits which accrue. 

Does HRT protect against osteoporosis?

In the first year without oestrogen women lose about 3% of their bone mass and although the rate of loss decreases as the years go by, nevertheless there is an ongoing loss of bone for the rest of the woman’s life. Oestrogen can slow down this bone loss significantly and at the moment is the only practical way in which bone loss can be controlled.

Does HRT protect the joints?

Women who use HRT long term have a measurably reduced incidence of hip and knee replacement.

Does HRT increase the risk of breast cancer?

Unopposed oestrogen (oestrogen alone) does not increase the risk of breast cancer even if it has been used in this way for 25 years or more. However, when oestrogen is combined with progesterone there is an increased risk.

There is also evidence to suggest that using unopposed oestrogen may actually REDUCE the risk of breast cancer by 28%.

How can the risk of breast cancer be reduced?

Since progesterone is the culprit we can modify the way in which the progesterone is given so that much less is given over a period of 12 months as compared to the past.

We can also use an oestrogen-like substance called Tibolone (LIVIAL). Tibolone has less than half the increased risk of breast cancer than a combined oestrogen/progesterone preparation does. However, it has all of the advantages of oestrogen. 

There are recognised high risk factors for breast cancer such as smoking, excessive alcohol intake, and being overweight:  attention to these lifestyle factors can reduce significantly the risk of breast cancer.  

Does the risk of breast cancer decrease when HRT is stopped?

The answer is yes – it is thought that the increased risk of breast cancer may revert to normal within a year or two of discontinuing HRT.

Does HRT affect your Cholesterol level?

 YES – it reduces the level by 10%.

Does HRT affect the incidence of coronary heart disease.

A report by the Medical Research Council (MRC) U.K. in March 2005 showed that women who use HRT had a lower incidence of coronary heart disease than women who don’t use HRT or have used it only for a short period of time. This confirms the findings of the American WHI (Women’s Health Initiative) Study in 2002.

Does HRT increase the risk of stroke?

Oestrogen does in fact increase the risk of stroke but this risk is small and minimised if other risk factors are eliminated. Factors which increase the woman’s risk of stroke are smoking, excessive alcohol intake, obesity, hypertension and raised Cholesterol. There is also an advantage to using transdermal oestrogen by way of a patch or gel, as compared to a tablet:  oestrogen given in a tablet form has to be processed in the liver and this produces a slight increase in coagulation factors.

Does it have any effect on bowel cancer?

The answer to this is yes – long term HRT use reduces the risk of bowel cancer.

Does HRT affect the incidence of Alzheimer’s disease?

Recent evidence has shown that women who use oestrogen for 10 or more years from early to mid 50s, i.e. until mid 60s or beyond, reduce their risk of Alzheimer’s by two-thirds.

Does HRT cause weight gain?

The answer to this is an emphatic NO!  Most women using HRT will report some weight gain but studies over the years have shown that the weight gain, fat distribution and central obesity commonly observed in older women, is exactly the same whether HRT is used or not.  The average woman aged 55 is about 8-10 lb. heavier than the average woman aged 45 – this is due to a combination of things such as changes to the metabolism which occur at the menopause, and a change in lifestyle factors such as a reduced physical activity and an increased calorie intake through use of alcohol and “eating out” a little more frequently.

Can anyone use HRT?

 There are no absolute contraindications to the use of HRT.  Under certain circumstances it can even be given to women who have been treated for breast cancer.

Who should supervise HRT?

Women using HRT should be seen at least once a year by a doctor or nurse with special expertise in dealing with HRT and the menopause. Each woman should be regarded as an individual and the risks and benefits of HRT assessed according to her individual needs and personal profile.

Does it affect lifespan?

The most important study to be published in the last few years was published in October 2004 in the Journal of General Internal Medicine. This was a Meta analysis of 30 studies which assessed almost 30,000 women. The report concluded that women who started using oestrogen before the age of 60, and who used it long term, had a longer life expectancy than women who had never used it. In addition the HRT users had one-third less incidence of death and serious illness during the study period.  To me this study “says it all!”

The reports linking HRT with adverse effects need to be taken in perspective. For example, women who have had a hysterectomy and use unopposed oestrogen are at no increased risk of breast cancer – this is because it is the progestogen which is the culprit and not the oestrogen. In women who have a uterus we simply reduce the amount of progestogen taken over a period of 12 months. There were further reports, widely quoted, in 2002 and again in 2004 – these were the Women’s Health Initiative reports from the United States which mentioned an increased risk of stroke in HRT users. The study has been very seriously criticised as being flawed. It has been criticised for a number of reasons, the most important being that women who were entered into the study were known already to be at high risk of stroke, for one reason or other, and almost all were over the age of 60. Even that study showed that women using HRT before the age of 60 had only 80% of the risk of coronary heart disease as compared with women who had never used HRT. Other studies have quoted an increased risk of endometrial cancer but this has never ever been a problem in the U.K. because women who have a uterus and are using HRT are always given appropriate advice on the use of progestogen to eliminate the risk of endometrial hyperplasia and subsequently endometrial malignancy.

Joe Jordan, MD, FRCOG, FRCPI(Hon)

January 2007