The US Food and Drug Administration (FDA) announced that warnings on hormone replacement therapy (HRT) products used for menopause will be removed. Warnings about serious risks such as breast cancer, heart attack, and stroke had previously been issued.
The US Department of Health said this is a historic step towards restoring the “gold standard” scientific approach to women’s health.
The statement mentioned that there has been a climate of fear and misinformation surrounding HRT for over twenty years.
According to the latest guidance from NICE, the UK’s healthcare regulation body, hormone replacement therapy (HRT) is recommended as the first line of treatment to alleviate menopausal symptoms such as hot flashes and night sweats.
Detailed new analyses show that HRT does not affect lifespan, but it has benefits and risks that should be evaluated by each individual and their doctor.
The updated guidelines also note that speech therapies can help with symptoms.
So, what is HRT and how can it assist women during menopause?
WHAT IS HRT?
As women approach menopause, estrogen hormone levels fluctuate and begin to decline.
Estrogen helps regulate menstrual cycles, contributes to strengthening bones, and affects skin temperature.
As levels become unbalanced, women may experience a range of symptoms such as hot flashes, night sweats, anxiety, and joint pain.
HRT supplements and balances the declining estrogen levels.
HRT is typically used to assist with the transition through menopause. Many patients report that HRT has made a significant difference in their health.
This treatment can also help prevent osteoporosis and fractures.
It can provide some protection against heart disease for women under 60.
Although there are mentions of potential benefits like brain health preservation and improvements in skin and hair, evidence on these remains limited so far.
HOW IS HRT USED, AND WHICH TYPE IS MOST SUITABLE?
The number of women using HRT to relieve menopausal symptoms is increasing gradually.
The UK’s National Health Service (NHS) prescribed an estimated 13 million HRT products to 2.6 million patients in 2023-24.
In 2022-23, 11 million products were prescribed to 2.3 million women.
HRT can be administered in many forms, such as pills, patches, gels, and rings.
The main component is estrogen, but there are also combined HRT options containing a synthetic version of progesterone hormone.
Adding progesterone helps protect the uterine lining, since estrogen alone can sometimes increase the risk of uterine cancer.
Most HRT medicines act broadly in the body, but vaginal creams only alleviate symptoms in that area.
This minimizes the absorption of estrogen in other parts of the body, but it also means these treatments do not relieve other symptoms like hot flashes.
The most effective type of HRT varies from person to person and depends on individual symptoms and lifestyles.
Patients usually start at the lowest possible dose.
HOW LONG DOES IT TAKE TO SEE THE EFFECTS OF HRT?
The full effects of HRT may take up to three months to be felt. Adjustments to the correct dose and form may be necessary.
Most experts recommend starting treatment as soon as menopausal symptoms appear.
There are conflicting data about starting treatment after age 60, but some women report relief of persistent symptoms.
You can take the treatment for an indefinite period.
While some experts support long-term use of HRT, the UK’s Medicines and Healthcare products Regulatory Agency (NICE) recommends using the lowest dose for the shortest duration.
WHAT ARE THE RISKS OF HRT?
Two studies published in the early 2000s suggested that HRT’s harmful effects outweighed its benefits.
These studies caused a significant impact, and HRT use decreased.
Despite increasing evidence of potential benefits, some remain cautious.
NICE’s latest guidelines include detailed tables outlining potential risks and benefits to aid individual decision-making.
For example, according to a NICE consultant, women aged 45 and over who take combined HRT do not have a higher risk of coronary heart disease compared to those who never used it.
However, combined HRT may be associated with a small increase in breast cancer risk.
Women over 65 starting HRT see a slight increase in dementia risk. No increased risk has been observed in younger women.
There is a small risk of blood clots, which is also influenced by other factors such as smoking, weight, and age.
However, the risk of blood clots is much lower than when using birth control pills or during pregnancy.
Using HRT patches or gels instead of pills may reduce some risks.
It is recommended that patients discuss the potential benefits and risks of different HRT options with healthcare professionals.
WHAT ARE THE SIDE EFFECTS OF HRT?
Possible side effects of HRT include:
• breast tenderness
• headaches
• nausea
• indigestion
• stomach ache
• vaginal bleeding
Most these symptoms resolve within three months of starting treatment.
Weight gain is common in women approaching menopause, but there is no evidence that this is caused by HRT.
WHO SHOULD NOT USE HRT?
HRT may not be suitable in cases such as:
• history of breast, uterine, or ovarian cancer
• uncontrolled high blood pressure
• blood clotting disorders
• liver disease
• pregnancy
WHAT OTHER TREATMENT OPTIONS ARE THERE?
According to the latest NICE guidelines, women over 40 can be offered cognitive-behavioral therapy (CBT) instead of or alongside HRT, depending on their individual situation.
The previous draft guideline recommended CBT as a first-line treatment instead of HRT, which was controversial.
Regular exercise can also improve sleep, reduce hot flashes, and enhance mood.
Healthy eating, reducing caffeine, alcohol, and spicy foods, and quitting smoking can help alleviate hot flashes.
Weight-bearing exercises like walking, brisk walking, or tennis also help keep bones strong.
Other medications, such as Tibolone, which mimic the activity of estrogen and progesterone, or some antidepressants, may be helpful but can cause side effects.
Bioidentical hormones, which are exact copies of human hormones, are available in different forms:
• Unregulated bioidentical hormones not recommended by NHS – because they are unregulated and their safety is uncertain
• Regulated and approved bioidentical hormones shown to be safe and effective in treating menopausal symptoms
If you are considering complementary treatments for menopause, consult a doctor or pharmacist. These treatments may be unregulated, and their contents cannot always be guaranteed.
