HRT – benefits, side-effects and risks

Benefits of hormone replacement therapy

For the relief of symptoms (hot flushes, night sweats, dry skin, discomfort during intimacy due to dryness in the vagina, poor libido, dry skin and many others) – NOTHING BEATS HRT. While there are alternatives to HRT, it is simply true to state that nothing is as good / effective as HRT.

Here is a list of some of the benefits:

  1. HRT abolishes hot flushes and night sweats: within two weeks of commencing treatment, sometimes sooner, HRT dramatically reduces and more often than not completely abolishes hot flushes and night sweats. No currently available alternative therapy is as effective for these symptoms.
  2. HRT improves quality of life: this has been shown by all research that has studied quality of life in the menopause, and the impact of HRT. This is important, since menopausal symptoms can impact negatively on quality of life, but are not life threatening. Women find that the eradication of muscle aches and pains, the improvement in mood, the better quality sleep, the perking up in libido and more – all contribute to an improvement in quality of life.
  3. HRT improves vaginal dryness and urinary symptoms: intimacy becomes more comfortable, and the desire for it also often improves. The nuisance of losing small amounts of urine when one coughs or plays a game of tennis is also reduced, as is the need to rush to the loo to empty the bladder.
  4. HRT reduces the risk of developing osteoporosis (brittle bones): while there are other treatments that reduce the risk of developing, or treat established osteoporosis, no treatment is as effective as oestrogen replacement.
  5. HRT reduces cardiovascular disease risk: The use of HRT until the age of natural menopause is associated with reduced incidence of coronary heart disease.
  6. HRT has additional (miscellaneous) benefits: HRT has a protective effect against connective tissue loss in tissues such as skin, bones, joints and mucous membranes. There may be a possible reduction in the long-term risk of Alzheimer's disease and all cause dementia in those women who take HRT. Most studies have demonstrated a reduction in risk of colorectal cancer with use of oral combined HRT.

Side effects of HRT

Common aspirin, taken by multitudes for the effective eradication of common symptoms such as a headache, causes side effects in a proportion of the populace, as does paracetamol – most, if not all, treatments have the potential for side effects. This is therefore to be expected and true too for HRT. For some women their negative reaction to components of HRT is so severe that they are unable to take it, while for others the benefits of HRT outweigh the impact of the side effects. Quite often the side effects, such as headaches, bloatedness or breast fullness are transient and resolve once the woman settles on the HRT, usually within a couple of weeks. Sometimes it is necessary to change the type of HRT to minimize side effects.

Here is a list of the more frequently experienced side effects:

  1. Side effects related to the hormone Oestrogen – breast tenderness, leg cramps, skin irritation, bloating, indigestion, nausea, headaches.
  2. Side effects related to the hormone Progesterone - premenstrual syndrome-like symptoms, fluid retention, breast tenderness, backache, depression, mood swings, pelvic pain.
There are effective ways of minimizing, or indeed even eradicating, these side effects. Thus nausea can be reduced by taking the HRT tablet at night with food instead of in the morning, or by changing from tablets to another type of HRT such as transdermal patches. While some women will complain that they put on weight as a result of taking HRT, in fact research has shown that HRT does not cause weight gain. Researchers have found that, although women may put on some weight when they first start to take HRT due to a degree of reversible fluid retention, after a while their weight is the same as it was before treatment. Women whose energy levels and positive outlook on life following commencement of HRT find that they exercise more, and are therefore more likely to lose weight.

Irregular bleeding on HRT: Monthly sequential preparations should produce regular, predictable and acceptable period like bleeds. Erratic breakthrough bleeding is common in the first 3-6 months of continuous combined and long-cycle HRT regimens (with no regular period like bleeds). If there is persistent irregular vaginal bleeding after six months of starting HRT, you will need to have further investigations. If you experience significant nausea or migraine headaches with oral preparations, patches can often be a better option. Progesterone related side-effects can often be minimised if the Mirena coil (intrauterine system) is used as the progesterone arm of HRT.

Risks associated with the use of HRT

At the Premature Menopause Clinic London, we are great advocates of HRT. However, this does not blind us to the fact that HRT does carry risk for some women. We do not seek to minimize the risks, but rather to explain them as clearly as possible, and guide women to make informed choices. Life choices are often about balancing risks against benefits, and it is arguably true that, based on current knowledge and the results of research, for the vast majority of women who need HRT the benefits far outweigh the risks.

Current received wisdom says that women who experience premature menopause should be offered hormone replacement therapy until the age of natural menopause (50 years). For young women, the risks associated with HRT are very small. The information contained in the leaflets provided with HRT packages can be misleading as it mainly refers to women taking HRT after the age of the natural menopause (above 50 years). The biggest studies on risks of HRT (the Women's Health Initiative and Million Women studies) were undertaken in women aged over 50. Younger women who take HRT because of POI have higher benefits and fewer risks than older women.

1. Venous thromboembolism
HRT tablets increase the risk of venous thromboembolism (blood clots), pulmonary embolism (blood clot in lungs) and stroke (1-2 extra cases per 1000 HRT users). HRT patches have lower risk of blood clotting than tablets. Overall the risk of all types of HRT is lower than taking the contraceptive pill. Your risk may also be higher if you are overweight or a smoker.

2. Stroke
The risk of stroke does not appear to be significantly increased in women under 50 years old.

3. Breast cancer
If you are under the age of 50 and taking HRT there is no increased risk of breast cancer, although you still have the same risk as the rest of the population (this is called background risk).

4. Endometrial (womb) cancer
Oestrogen is always given with progesterone, unless you have had a hysterectomy. This is because oestrogen on its own causes thickening of the womb lining, which can lead to heavy irregular bleeding, and over time this increases the risk of cancer in the womb lining (endometrial cancer). Adding progesterone for at least 10-12 days every month, or continuously, eliminates this risk.

5. Other risks
There is a chance that taking HRT for a year or more could increase your risk of gallbladder disease (gallstones).

When HRT should not be taken

HRT is not prescribed in the following conditions:

  • pregnancy and breast-feeding
  • undiagnosed abnormal vaginal bleeding,
  • venous thromboembolic disease (blood clots),
  • active heart disease,
  • current or past breast cancer,
  • other oestrogen dependent cancer,
  • active liver disease
  • uncontrolled high blood pressure.
Women who would like to consider HRT but have one of these conditions should seek specialist advice.

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