What is hormone therapy?

Hormone therapy (HT), also known as hormone replacement therapy (HRT), means taking female hormones – either oestrogen on its own or with progestogen – because you are having menopausal symptoms. This may be due to menopause or because your ovaries have been surgically removed. HT is available in pills, implants, skin patches, vaginal pessaries or creams.

What happens in menopause?

In menopause, your ovaries stop releasing eggs and they stop producing the female hormones oestrogen (estrogen) and progestogen so that your periods stop. For some women, that is all they notice. However, because the female hormones affect other parts of the body, some women may have other symptoms, which include hot flushes, sweats, vaginal dryness, urinary symptoms and problems sleeping. Your bones may also grow thinner (osteoporosis).

Should I take HT?

Menopause is a normal part of life, and many women enjoy having no periods and get through this time without HT. It depends on whether you have symptoms and how much the symptoms affect your life.

Most symptoms, such as flushes and disturbed sleep decrease with time and are gone in a few years. You can lower your chance of thinning bones by living a healthy life; by keeping up a healthy, calcium-rich diet and regular physical activity.

You may want to consider HT if:

• you are very troubled by menopause symptoms
• menopause starts early (before 45 years of age)
• you and your doctor think the pros of taking the hormones outweigh the cons in your case.

For women currently taking HT:

• you are advised to review the need for continuing this treatment with your doctor every six months.

What are the pros of HT?

• Flushes and sweats usually improve within a few days or weeks of starting HT.
• Within a few weeks or months, sleep problems and vaginal dryness are usually relieved.
• HT has not been shown to directly affect the emotional problems that can go with menopause, however, having better sleep and no flushes may significantly improve your overall sense of wellbeing.

Women who have their uterus (womb) need to take a progestogen with the oestrogen to prevent cancer of the lining of the womb (endometrium).

Osteoporosis

Interior of healthy bone.	Interior of thin, porous bone.

Oestrogen stops calcium from being lost from the bones and so helps keep them dense and strong. After menopause, because you have less oestrogen, your bones tend to get thinner and more porous. About 30% of women will get severely thin bones (osteoporosis), which are more liable to break. Some women get shorter and more stooped.

Although HT stops your bones from thinning, it is no longer a first-choice therapy as it needs to be taken lifelong, and, for most women, the risks outweigh the benefits. Other medications called bisphosphonates are now considered first-line therapy for women with low bone density.

Osteoporosis is more likely if others in your family have osteoporosis or you have already had a fracture, if you smoke or drink heavily, do not have enough calcium in your diet, are thin, have had no periods for a long time, do not exercise, began menopause before the age of 45, or if you take steroids.

What are the cons of HT?

• With some types of HT you may have ‘periods’ (regular withdrawal bleeding). This is not necessarily a disadvantage if you have irregular bleeding, which can happen around the menopause, or if using HT formulated to eliminate periods.
• Oestrogen can cause breast pain, bloating, nausea and leg cramps.
• Progestogen can cause breast pain, fluid retention, bloating, increased appetite, irritability, aggression and mood swings.
• If the balance of the two is wrong, you may get irregular bleeding. Changing the dose or the type of HT may help. Irregular bleeding should go away with time, but always have it checked by your doctor.
• Taking oestrogen and progestogen can increase the risk of breast cancer diagnosis due to the hormones increasing the growth of already present breast cancer. The breast cancers diagnosed are larger and more advanced than for women not taking hormones.
• The risk of getting gallstones is slightly higher.
• Taking oestrogen alone increases the chance of cancer of the womb lining. To stop this happening, women who still have their uterus (ie, have not had a hysterectomy) are therefore also given progestogen.
• Long term HT use may increase the risk of ovarian cancer.
• HT increases the risk of blood clots forming in the leg. These can dislodge and travel to the lung (pulmonary embolism) or brain (stroke). See table below for the most recent risk-benefit figures for women taking combined oestrogen/progestogen HT and oestrogen-only HT.

Change in number of adverse events per 10,000 women aged 50-79 years in one year compared to women not using hormones
(figures from WHI - Women's Health Initiative study)

Adverse event	Use of oestrogen and progestogen	Use of oestrogen alone
Stroke	8 extra	12 extra
Pulmonary embolus	8 extra	7 extra
Breast cancer	8 extra	-
Dementia (> 65 years)	23 extra	-

Can I take HT?

Most women can take HT. Exceptions are those who have had breast cancer, a heart attack, heart disease, a stroke, a blood clot in the legs or those with irregular vaginal bleeding. Women at high risk of cardiovascular disease are best to avoid HT. There are alternatives to HT that have been shown to help flushes. Discuss this with your doctor. Also, report any unusual bleeding before or after taking HT.

If you are having surgery, are bedridden or otherwise inactive for a long time (eg, on a long-haul flight), you may need to consider stopping HT to minimise the risk of blood clots. Talk to your doctor.

How long should I take HT?

To help with hot flushes, a few years of treatment is usually long enough. Stopping HT will let you know if your flushes have gone. Many women prefer to do a slow withdrawal from hormones.

Women with vaginal dryness may need to use oestrogen vaginal cream long term. Oestrogen given locally in this way has not been shown to lead to adverse events.

How can my doctor help?

HT must be given on prescription. Your doctor can supply information specific to you about the pros and cons of HT and about the different available treatments. You may have to try several before finding one that suits you.

Before starting HT, your doctor will want to know your full medical history. You will probably have your blood pressure taken, a breast examination, a cervical smear test if you have not had one recently, and possibly a mammogram. If you are at high risk for thin bones you may need a bone scan. It is important to see your doctor after you have been on HT for three months (earlier if you have problems) to discuss how you are feeling. You should also have regular check-ups (as advised by your doctor) after that to monitor your progress.

Further information and support

A lot of information is available on HT. Be well informed so you can decide what is best for you. Ask your doctor or health clinic for information or contact your local Family Planning centre [contact details below], specialist menopause clinics or women’s groups.

Original material provided by UBM Medica (NZ) Ltd and reviewed in May 2011 by Dr Helen Roberts, University of Auckland.