When it comes to menopause, the perception of symptoms and ways to reduce their effects are changing. The main treatment that has brought about a makeover is hormone replacement therapy (HRT).
Many women are wary of such drugs due to concerns about increased risk of breast cancer, but they have recently been the focus of high-profile campaigners such as Davina McCall, who have recently highlighted the risks associated with low mood. It emphasizes its benefits in symptom management. For hot flashes.
So what is HRT? What benefits does it offer? And is it the right option for you?
What is HRT?
Menopause is often defined as starting 12 months after a woman’s last menstrual period, while perimenopause refers to the earlier transition period, which can last several years.
During perimenopause, levels of the hormone known as estrogen drop, causing many of the symptoms associated with menopause, such as hot flashes, mood swings, and vaginal dryness. Levels of another hormone, progesterone, also decrease.
HRT increases the levels of such hormones, thereby reducing many symptoms. It also helps maintain muscle strength and prevent osteoporosis, a condition in which bones become weak due to low estrogen levels. By increasing your estrogen levels by taking HRT, you can prevent bone loss and reduce your risk of fractures.
How many women are using HRT?
According to the Department of Health and Human ServicesApproximately 15% of women aged 45 to 64 in the UK are currently prescribed HRT, and that figure is rising.
Not everyone prefers the term HRT, with some preferring the term menopausal hormone therapy (MHT), including Dr Ruth Brauer, lecturer in pharmacoepidemiology and drug safety at University College London.
“The word ‘replenishment’ suggests that something goes missing during menopause, which of course is not true. Menopause is a natural transition in the life of every woman with a uterus. So if you lose estrogen, it’s a natural part of life and doesn’t need to be replaced,” says Brauer.
However, for clarity, this article uses the term HRT instead of MHT.
What types of HRT are there?
As Dr Channa Jayasena, an expert in reproductive endocrinology at Imperial College London, points out, in the UK and Europe, all forms of HRT contain estradiol, the main estrogen found in women. must be. It can be administered in a variety of ways, from tablets to patches, sprays, gels, and even applied vaginally.
However, while estrogen-only HRT can be given to women who have had a hysterectomy, women with a uterus are also given another hormone to prevent endometrial thickening. “The problem with giving estradiol alone is that it thickens the uterus, which can cause problems over time and potentially increase the risk of endometrial cancer,” Jayasena says. says.
This second hormone is a progestogen, either the progesterone found in the body or a non-natural progestogen that is similar in structure and action.
This additional hormone can be administered continuously, as in the case of the Mirena intrauterine system, which completely prevents bleeding. It can also be given intermittently in pill form if the woman prefers to bleed.
“Estrogen works well, but progesterone is given because it needs to be given for safety,” says Jayasena.
Combined HRT provides both hormones in one product and comes in a variety of forms, including tablets and patches. “Combined tablet” [used for contraception] It basically contains the same ingredients as HRT: estrogen and progesterone, but at a much higher dose,” says Jayasena.
However, one concern is that HRT tablet associated There is a slight increased risk of blood clots and stroke, but this risk varies depending on dose and other factors and is lower with patches, gels, or sprays. When it comes to stroke, your risk also depends on your age.
Another concern is that HRT containing progestogens is associated with a small increased risk of breast cancer in those who use it, and the risk is related to the duration of use.
however, British Menopause Society (BMS) points out that for most women at low potential risk of breast cancer, the benefits of using HRT for up to five years outweigh the potential harms, as it reduces menopausal symptoms. Masu.
What about testosterone?
Jayasena says there is debate over whether women who are taking HRT but still have problems with low libido should be offered an additional hormone, testosterone, to improve their libido. “[Testosterone] is a male hormone, but for women [it] at lower doses,” he says.
Testosterone is not currently licensed for women in the UK and can only be prescribed ‘off-label’. However, a recent study by a pharmaceutical journal found that Prescriptions for testosterone have increased tenfold among women in recent years, with the number of women aged over 50 receiving testosterone gel via NHS prescription increasing from 429 in November 2015 to 2022. In November 2017, it was revealed that the number had increased to 4,675.
In addition to helping libido, some women report taking Testosterone improves mood, concentration, motivation, and energy levels. but, Not everyone is convinced This means that testosterone needs to be widely prescribed.
“Lack of sexual desire is very complex,” says Dr. Paula Briggs, sexual and reproductive health consultant and chair of BMS. “As you get older, it’s natural for your sex drive to decrease a little bit,” she says, adding that in some cases, women simply don’t like their partners anymore.
“Now that I think about it, what were the patient’s expectations for? [information] They’re fed, but all women need testosterone and that’s the missing piece of the jigsaw, and that’s just not true,” says Briggs.
BMS also says that while some people have reported a myriad of benefits from taking testosterone, more research is needed. “Randomized clinical trials of testosterone to date have not demonstrated beneficial effects of testosterone therapy on cognition, mood, energy, or musculoskeletal health.” society pointed out in 2022, adding that taking testosterone may also come with side effects, such as acne. It can also lead to thicker body hair, and Jayasena warned that taking testosterone can cause male pattern baldness in some women.
However, further research may still be a long way off. As BMS itself points out, there is reluctance within the pharmaceutical industry to fund such research.
What is bioidentical and body-identical HRT?
Bioidentical hormones have the same chemical structure as hormones that occur naturally in the human body, but are manufactured in a laboratory to ensure purity.
“HRT used to be derived from horse urine and had a much higher risk of blood clots,” Jayasena says.
Bioidentical hormones are already available on the NHS as some forms of HRT and are subject to rigorous testing and regulation. There is also some evidence that they may have benefits. For example, early research suggests that HRT containing bioidentical progesterone is associated with a slightly lower risk of breast cancer than HRT containing non-natural progestogens.
Some experts have called for HRT that uses biologically identical hormones to be referred to as “body-identical” HRT. That’s because in recent years, the term “bioidentical HRT” has been confused with preparations manufactured by specialized pharmacies and sold on a custom-made basis to individuals. These preparations, called complex bioidentical HRT, often contain estrogen, progesterone, and testosterone.
Experts say that while formulated bioidentical HRT may sound good, such drugs have not gone through the rigorous drug development and regulatory pathways that traditionally prescribed HRT has gone through. warns.
Furthermore, despite claims of its superiority, formulated bioidentical HRT has not undergone randomized controlled trials to compare its efficacy or safety with placebo or conventional HRT. yeah. “They may be helpful, but we don’t know what the risks are in the short or long term,” Brauer says.
Briggs added that another concern is variation in prescription composition. “You never know what you’re going to get from one prescription to the next,” she says. “And they sell it as bespoke HRT. They test hormone levels in the blood and saliva and say, ‘This is your unique product,’ but the hormone levels continue You can’t do that because it changes.”
Who should take HRT?
This is a controversial point. Many activists argue that the drug is underused because of the horror stories and that far more women would benefit from receiving HRT than are currently prescribed it. However, some experts are concerned that the message currently being sent is that all women going through perimenopause need their HRT.
“In fact, some women have little or no symptoms. [of menopause]And there are other women who have very severe and debilitating symptoms,” says Jayasena. “The advice is that if HRT works for you, you should take it. Obviously, if you’re feeling perfectly well and there’s no benefit, the advice is that you shouldn’t take it.”
Briggs agrees. “There are extremes who say women are over-medicalized. [saying] That means everyone should take HRT because it is a deficiency condition. And neither of those are correct.
“It should be there for women who have symptoms, have no contraindications, and want to take it,” Briggs says. “[But] It’s also not right to be made to feel like you need to take something when you don’t want to. ”
It is also important to note that some women cannot take HRT because it is not compatible with other aspects of their health or simply do not want the medication. One concern about increased intake is that the risks from HRT (such as the slightly increased risk of breast cancer associated with progestogen-containing preparations) are low but real.
According to the NHS, approximately 5 extra breast cancer cases occur per 1,000 women who take combination HRT for 5 years. This is a small increase in risk, but if all women took such HRT, the number of women who would suffer from rare complications would be huge, Jayasena says.
“The more people who take this without any tangible benefit, the more cases of breast cancer we’re going to have, unnecessarily,” she says, adding that increased awareness of HRT is helping women move from being undertreated to being overtreated. He added that he is concerned that treatments are changing drastically.
However, HRT is not reaching everyone who could benefit from it.
Brauer said research suggests prescribing rates are higher among wealthier women, but there are also differences based on ethnicity and access issues may exist among some groups. said that it has become clear. she also I received a call This is to make HRT more accessible to women experiencing mental health issues, as some women who experience anxiety and low mood as a result of hormonal changes may prefer HRT over antidepressants. may benefit.
Are new drugs coming soon?
Yes, there have been some exciting developments in recent years. Among them, Jayasena and his colleagues are working on a drug called Veoza (also known as fesolinetan) to prevent hot flashes.
“It’s something completely new,” Jayasena says. “This is not what we call HRT because it has no overall effect. In other words, it’s not going to improve bone density, and it’s not going to improve mood. It’s not going to help sex drive. But what it does is target why people get hot flushes when estrogen drops.”
Veoza has been approved by both the FDA in the US and the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK, but is not yet available on the NHS. Reviewed by National Institute for Health and Care Excellence (Nice) is scheduled to start this year and things could change.
Jayasena said the active ingredient is a neurohormone, making it suitable for some women who cannot receive traditional HRT. “For people who have breast cancer and can’t take HRT because they have severe flushing, this is a great treatment that can make life much better,” he says.
