Hormone Replacement Therapy (HRT) in the Menopause

The menopause is a natural phase in a woman's life, in which the production of the sex hormones oestrogen and progesterone declines. These hormonal changes can bring on a wide range of symptoms — hot flushes, sleep problems, mood swings, dry skin and many others — which we looked at in detail in the article „Understanding the Menopause". We have also seen how women can come „Through the Menopause with Ease" by adjusting how they live and raising certain nutrients.

In this article we turn to a supporting option for easing menopausal complaints: hormone replacement therapy (HRT).

Hormone replacement therapy is among the most effective ways of easing menopausal symptoms. By supplying synthetic (conventional or bioidentical) oestrogen and, where appropriate, synthetic (conventional or bioidentical) progesterone, the body can be brought back into hormonal balance. There are concerns here about possible side effects and risks, particularly regarding breast cancer, which we will look at more closely in this article. But let this much be said already: a great many misunderstandings have grown up around hormone replacement therapy and breast cancer.

It matters that women are fully informed about the advantages and disadvantages of hormone replacement therapy, and about the different options within it, so that together with their doctor they can make an informed decision. In this article I want to gather some important information on it. This information of course does not replace advice from a specialist. Please note as well that such a therapy must always be closely supervised by a doctor.

What are bioidentical hormones?

Bioidentical hormones are synthetically produced hormones, but ones whose molecular structure — that is, chemically — is identical to the hormones the human body produces naturally. Because they are structurally the same, the body recognises and processes them in the same way as its own. They are obtained from plant sterols, mostly from soya or yam.

In conventional hormone replacement therapies, synthetically produced hormones are often used which are similar to but not identical with the body's natural hormones. They can behave differently in the body than the identical ones do. Once a decision for hormone replacement therapy has been made, that should certainly be taken into account when choosing the preparation.

Among the commonly used bioidentical hormones are:

• 17β-oestradiol: a form of oestrogen.
• Progesterone: a naturally occurring progestogen.

Bioidentical hormones come in various forms:

• transdermal patches
• gels and creams
• tablets
• vaginal pessaries or creams

Advantages of bioidentical hormones:

• Naturalness: because they are identical to the body's own hormones, they are said to be better accepted by the body.
• Individual adjustment: in some cases bioidentical hormones can be dosed and combined individually.
• A reduced risk of side effects: some studies suggest that bioidentical hormones could have fewer side effects than synthetic ones.

Concerns and risks of bioidentical hormones:

• A lack of standardisation: not all bioidentical hormones are approved by medical regulators such as the EMA (European Medicines Agency).
• Insufficient evidence: there is limited scientific data on the long-term safety and effectiveness of bioidentical hormones.
• Risks similar to conventional hormone replacement therapy: the risk of breast cancer, stroke or thrombosis can be similar to that of conventional HRT.
• Interactions: bioidentical hormones can interact with other medicines and food supplements.

Possible side effects of bioidentical hormones

Although bioidentical hormones are identical in molecular structure to the body's own, they can still cause side effects. They should always be taken under medical supervision, to keep the risks as low as possible.

Possible side effects:

• A raised risk of thrombosis: as with conventional hormone replacement therapies, taking oestrogen can raise the risk of blood clots, which can lead to thrombosis, stroke or pulmonary embolism.
• Breast cancer risk: long-term use of hormone replacement therapy, particularly combining oestrogen and progesterone, can slightly raise the risk of breast cancer.
• Cardiovascular disease: there is a potentially raised risk of heart attack or other cardiovascular events, particularly in women with existing risk factors.
• Digestive complaints: nausea, bloating or abdominal pain can occur.
• Headaches and migraine: hormonal changes can trigger or worsen headaches or migraine.
• Mood swings: changes in hormone levels can lead to mood swings, depression or anxiety.
• Skin reactions: with transdermal preparations such as creams or patches, skin irritation or allergic reactions can occur where they are applied.
• Weight gain and fluid retention: some women report gaining weight or a feeling of holding water.
• Breast tenderness or pain: sensitivity or pain in the breast can occur.

To understand why hormone replacement therapy has such a poor reputation, I want to look at what happened in the 1990s. At that time the Women's Health Initiative (WHI) carried out an extensive study investigating how postmenopausal women could be protected against heart disease, breast and bowel cancer, and osteoporosis. That study led, however, to the widespread but mistaken belief that every form of hormone replacement therapy raises the risk of cardiovascular events and breast cancer.

The study consisted of two research groups, and these two groups produced different results, which were often misunderstood. In one group women received both horse oestrogen (Premarin) and synthetic progestogen (Provera), while the other used horse oestrogen (Premarin) alone.

Surprisingly, the group taking oestrogen alone showed no statistically significant rise in breast cancer risk. Despite using a stronger, more oestrogen-rich medicine, the breast cancer rate stayed unchanged. In the group taking both oestrogen and progestogen, by contrast, a slight rise in breast cancer risk was observed over time.

The media reporting that followed, partly misinformed and partly misinterpreted, left the medical community with lasting fear and mistrust of hormone replacement therapy that persists to this day. HRT thus became linked with a higher breast cancer risk, although that is not what the study showed. But once something is lodged in people's minds it is hard to shift, especially when fear is attached to it.

That does not of course mean hormone replacement therapy is free of side effects. It is an intervention in the body, one that can go well and in rare cases does not. As with any intervention, the risks and benefits should be weighed individually, since there are women for whom this option is not suitable.

Certain health conditions or risks rule out hormone replacement therapy or call for particular care.

Hormone replacement therapy should not be used with:

• Current or previous breast cancer: HRT can raise the risk of it returning.
• Known or suspected oestrogen-dependent tumours: endometrial cancer (cancer of the womb lining), for example.
• Unexplained vaginal bleeding: the causes must be established before HRT is begun.
• Active or previous venous thromboembolism: including deep vein thrombosis or pulmonary embolism.
• Active or recent arterial thromboembolic disease: such as heart attack or stroke.
• Severe liver disease: hormone metabolism can be impaired.
• Known hypersensitivity to the active substances in HRT: allergic reactions are possible.
• Porphyria: a rare metabolic disorder.

Care and individual weighing required with:

• A family history of breast cancer or other oestrogen-dependent tumours.
• Risk or presence of cardiovascular disease: high blood pressure or high cholesterol, for example.
• Clotting disorders: a raised risk of blood clots.
• Migraine with aura: can raise the risk of stroke.
• Diabetes mellitus: particularly where there are vascular complications.
• Endometriosis or fibroids: hormone-dependent growth stimulation is possible.
• Gall bladder disease: the risk of gallstones can rise.
• Epilepsy or asthma: hormonal changes can affect the symptoms.

Also worth noting:

• Age and when it begins: women over 60, or those starting HRT more than 10 years after the menopause, have a raised risk of certain side effects.
• How you live: smoking, being overweight and too little movement can raise the risks.
• Pregnancy: HRT is contraindicated during pregnancy.

If hormone replacement therapy is not an option for you, for whatever reason, nature holds many helpful plants that can ease menopausal symptoms as well. Information on the plant-based options in the menopause is coming soon in an article of its own.

How long hormone replacement therapy (HRT) lasts varies from person to person and depends on several factors, among them how severe the symptoms are, the woman's age, her health history and personal preference. There is no set maximum duration for HRT, but the recommendation is to use the lowest effective dose for the shortest necessary time. Many women use HRT for two to five years, to ease acute menopausal complaints such as hot flushes, sleep problems and mood swings.

If you would like to go deeper into hormone replacement therapy and bioidentical hormones, or into the menopause generally, I can recommend these two wonderful books.

Hormoncoaching erlernen & gezielt anwenden: Wechseljahresbeschwerden lindern. Erkrankungen heilen. Alterungsprozesse aufhalten. Bioidente Hormontherapie richtig einsetzen (Marianne Krug)

and

Heilen mit bioidentischen Hormonen: Wie chronische Krankheiten und Wechseljahresbeschwerden erfolgreich behandelt werden können (Jens Keisinger, Nadja Keisinger, Petra Mayr)

A very informative website on the menopause and on hormone replacement therapy is wechseljahre-verstehen.de

Hormone replacement therapy (HRT) can be an effective way of easing the many symptoms of the menopause and improving women's quality of life at this stage. It is important to stress, though, that even bioidentical hormones can have side effects and are not suitable for every woman. Weighing the risks against the benefits individually is indispensable. Certain health conditions rule out HRT or call for particular care.

All in all, hormone replacement therapy, particularly using bioidentical hormones, can be a valuable support for many women in the menopause. Close medical supervision and regular checks are decisive in making the therapy safe and effective.