HRT and the menopause

Menopause, Hormones, Oestrogen, Testosterone

Hormone treatment for the menopause is now much more complex than simply giving oestrogens for hot flushes, sweats and vaginal dryness as there are many new developments to deal with specific problems and to improve acceptability and continuation therapy. There are many reasons why women do not continue with HRT, such as bleeding and fear of breast cancer but perhaps the most important is that they do not feel any better. It therefore seems a waste of time taking hormones to prevent a fractured hip at the age of 80 which may not occur anyway. Firstly, I think that we should avoid using Premarin which contains about 20 equine oestrogens that the human body has never seen before. It is true that it has worked well for about 50 years but we now have a better option, using oestradiol by tablet, patch, cream, implants, intravaginal application and even intranasal application. This is a human oestrogen found in men and women and can be measured by simple assays so that we can have a better understanding of absorption rates and response to treatment.

When to Start

The traditional way of giving oestrogens for women after the menopause is to treat the characteristic climacteric symptoms with continuous oestrogens and the addition of cyclical progestogens for 10 or 12 days per month producing a withdrawal bleed or by continuous combined oestrogen/progestogen therapy with daily low dose progestogen as a non-bleed preparation.

However, there is often an indication to start therapy before the cessation of periods in women who have hormone responsive depression. This depression may be cyclical as in severe premenstrual depression or continuous with possible premenstrual exacerbations in the 2 or 3 years before the periods cease. It is very important to realise that climacteric depression is at its worst in these years when the woman is still having periods and therefore the association with a hormonal aetiology is not apparent. These women in fact do very well on a slightly higher dose of oestrogens, particularly in the form of patches, gels or implants with doses of 100 or even 200 mcgs of oestradiol patch twice weekly with cyclical oral progestogen is more effective than low dose oral therapy in this group of patients

When to Stop

There is a view that breast cancer may be increased in women having 10 years or more HRT. Although it must be stressed that there are more high quality publications showing no increased risk than publications showing a slight increase in risk. They do not get the same publicity in the Press. The apparent increase in the incidence of breast cancer may be an artefact but certainly there is read more