Hormone Replacement Therapy - 2024 World Menopause Day Theme

The International Menopause Society (IMS) established World Menopause Day held each year on October 18th in 2009, with the aim of demonstrating support for all women experiencing health issues as q result of their perimenopause and menopause. This single day has now developed into an awareness month with the additional objective of raising knowledge and understanding around menopause in all areas of women’s lives. Every year the IMS choose a specific health related theme on which to focus attention, and to help women better understand the wide-ranging health implications resulting from the hormonal changes experienced. This year the IMS is focusing its attention on Hormone Replacement Therapy (HRT) / Menopause Hormone Therapy (MHT), a topic that still divides expert opinion, can be scary and confusing to many women and is often portrayed on social media as a panacea that will solve all of their problems. The IMS are using this year’s focus on HRT to address many of the myths and misconceptions surrounding its use.

Misconceptions about HRT:

A number of established organisations, including the Australian Menopause Society and the UK’s The (sic) Menopause Charity have produced factsheets to help dispel some long-standing misunderstandings and misconceptions around HRT. Both organisations cite two studies: The Women’s Health Initiative (WHI) completed in the US, and the UK’s Million Women Study (MWS) both publishing their results in the early 2000’s, as the two biggest causes of misinformation and confusion in the world’s press and within the global medical community. The most concerning misconceptions these studies helped foster included: HRT causes breast cancer; HRT increases the risk of heart attack and stroke; HRT causes weight gain; a blood test is necessary to confirm menopause; and natural or complimentary remedies are safer than HRT. If you would like to read more details about the evidence disproving these misconceptions then the underlying information is available here for the Australian Menopause Society: https://www.menopause.org.au/health-info/fact-sheets/9-myths-and-misunderstandings-about-mht and here for The Menopause Charity: https://www.themenopausecharity.org/wp-content/uploads/2021/04/The-myths-vs-the-facts-.pdf).

Origins of the misconceptions:

Not surprisingly any one of the statements listed previously could be enough to deter any woman from wanting to take HRT to help with menopause symptoms. So how is it that a $2billion research study - the WHI involving over 27,000 women, and the MWS (over 828,000 women), could release such confusing and misleading data to the world? In summary it comes down to some key factors. The WHI study only assessed one dose and type of combined HRT or estrogen only HRT; in addition, experts considered the doses given to participants to be high for the age group studied. The women in this study were of an average age of 63 and the majority were overweight so were already at a higher risk of strokes, heart disease and breast cancer. With regards to the MWS, the study methodology used was not a randomised controlled trial (where half the women would be given a placebo and the other half HRT), all the women in the study were already using HRT and were recruited at the time of their mammogram, so they may have already suspected or have identified a breast lump. No changes in HRT use after the initial registration were recorded, so true longer-term affects could not be studied. (The Women’s Health Concern (the patient specific resource of the British Menopause Society) provides a more detailed explanation of both studies and their impact on global use of HRT in the noughties here: https://www.womens-health-concern.org/wp-content/uploads/2022/11/10-WHC-FACTSHEET-HRT-The-history-NOV22-A.pdf).

HRT Options:

Today women have a multitude of choices available to them if they want to consider HRT and your GP should be happy to discuss all the alternatives with you. HRT can be a combination of different hormones, so (o)estrogen, progesterone and testosterone. It can be taken orally (tablets) or applied transdermally via patches, gels and sprays. Transdermal oestrogen is absorbed straight into the body and is not digested and can be a safer form of oestrogen for women with other health issues such as migraines or high blood pressure. It can also be used locally to help with specific genitourinary syndrome of menopause (GSM) i.e. vaginally via pessaries, creams or vaginal rings. It can also be taken or used at different time i.e., in cycles (so sequentially) or on a continuous basis. GPs should start women on a minimal dose and should review its impact after three months on symptoms, any side effects and increasing the dosage or changing the type of HRT if necessary. You should also be prescribed combined (oestrogen and progesterone) HRT unless you have had a hysterectomy removing your uterus, in which case your GP would prescribe oestrogen only HRT. If you still have your uterus then taking progesterone helps protect the lining of the uterus from uterine cancer. If you are using an intrauterine system (e.g., the Mirena coil) for contraception then this will provide the appropriate progesterone. Testosterone is not routinely prescribed by NHS GPs as standard as part of a HRT regime, primarily because it is only licensed for women who complain of very low sexual desire after all other possible causes have been excluded. Additionally, it would only be prescribed in conjunction with oestrogen and progesterone and once these had been proven to be working on all other symptoms and without any side effects. However, there are a growing body of private GPs who are willing to prescribe testosterone as part of a broader HRT regime. Primarily as a result of their own anecdotal experiences with patients and due to an observational study carried out by Newson Health and published in May 2023. The study of 905 women across their clinics who had been prescribed testosterone as part of their HRT regimes found that it significantly improved mood and poor concentration as well as libido. Despite this there is still a reticence to endorse the prescribing of testosterone for broader menopause symptoms by numerous menopause societies due to the lack of detailed long -term research studies, so it remains contentious and difficult to obtain via NHS GP’s.

Accessing HRT:

Despite all the media coverage of menopause and HRT in the last few years, it can still be a problem for many women to access a GP who has both a good understanding of menopause along with an up to date and comprehensive knowledge of all things HRT. This means that many women face a lottery in terms of their experiences when they go to their surgery to discuss any issues they may have. There are steps you can take to help prepare for an appointment to discuss any symptoms and these include: tracking any symptoms that you may be experiencing for at least 8 weeks using a symptom tracker such as the Balance menopause app; asking for a double appointment with either the GP or practice nurse that is most experienced in menopause; know what your GP should and should not do as per the National Institute of Care and Excellence (NICE) Menopause guidelines. (There is a really good document produced by the British Menopause Society for GP’s which summarises all the guidelines that is also very patient friendly, which you can access here:https://thebms.org.uk/wp-content/uploads/2022/12/09-BMS-TfC-NICE-Menopause-Diagnosis-and-Management-from-Guideline-to-Practice-Guideline-Summary-NOV2022-A.pdf

Alternatives to HRT:

Unfortunately, should you not want or be able to take HRT, the various menopause societies around the world agree that the only alternative treatment where there is definitive research supporting its effectiveness in treating vasomotor symptoms is Cognitive Behavioural Therapy (CBT). The research studies are broadly divided between those with results showing that herbal or natural remedies /complimentary therapies work and those that show them to be a placebo effect. What is imperative is that if you are considering a herbal or natural remedy, that you check the impact of that remedy on any other medication you take or pre-existing health condition as there may be a negative interaction. There is a good website for looking at specific natural remedies, in terms of their interactions with other health conditions / medications: https://www.nccih.nih.gov/health/herbsataglance. My advice would always be that if you have found a remedy that does not negatively interact with any other medication you may take or any existing health issues and you feel that it works for you, then stick with it subject to taking appropriate medical advice.

Taking HRT:

If we are to believe everything you hear, read in the mainstream media and see on social media, then HRT appears to be the immediate solution to all of your menopause problems. But like any prescribed medication it can take time to find the right combination in terms of types, dosage and dosing cycle. Therefore, women should set realistic expectations as to the immediacy of its benefits and be prepared to review their HRT on a regular basis with their GP so as to optimise the effect. I know of women who have tried to self-determine their dose, as well as women who have come off it within 3-6 months because they didn’t see an immediate effect, the common factor being that they did not go back and speak to their GP. If you are having any issues with your HRT then it is imperative you go back to talk to your doctor. If you still feel that it isn’t right or that you can’t get answers to your questions then perhaps consider going to a private menopause specialist if you have company healthcare or are prepared to pay. Anecdotally I understand the present waiting time for an appointment with an NHS menopause specialist is currently over 6 months!