Please note that we believe the information offered here is up to date and accurate. However, it is general information and is not individualised to a particular patient’s circumstances. It is not a substitute for a consultation with a menopause clinician and no treatment decisions should be based on it.
The bottom line is that the best treatment for the symptoms caused by fluctuations and reduction of oestrogen in the perimenopause is oestrogen replacement. There are lots of options; different ways of giving oestrogen, different combinations of hormones and different doses. No two women are the same which is why you will need individualised therapy tailored to you.
Many women initially feel that they don’t want hormone replacement therapy due to exaggerated fears about the risks (see risks of HRT section). But modern HRT used appropriately is very safe; it closely mimics our natural hormones. And delivery through the skin in the form of a patch or gel makes it even safer. Women previously felt to be ‘high risk’ and so unable to take HRT can usually be offered it after careful consideration of the individual benefits and risks.
Sequential vs Combined
Unless you have had a total hysterectomy you will need to take progesterone along with your oestrogen as oestrogen alone can cause thickening of the lining of the womb. This is called combined HRT. Combined HRT is either continuous (progesterone given with oestrogen every day, no bleeds expected) or sequential (progesterone only given for 12-14 days a month, associated with a monthly bleed) and we will discuss which regimen we would recommend for you and why
Oestrogen is the mainstay of HRT; it is oestrogen that will make you feel better when you are struggling with symptoms from oestrogen fluctuations or deficiency.
0estrogen can be given as tablets or through the skin as patches, gel or a spray – this is known as transdermal oestrogen. Though oral oestrogen is very safe for most women, transdermal can be safer in those women whose risk of blood clots is higher.
If you have a womb it is ESSENTIAL that you take progesterone along with oestrogen to prevent the thickening of the lining of the womb. This thickening, if left unchecked, can lead to unwanted changes and even endometrial cancer. There are even more ways of giving progesterone than oestrogen. It can be given as a tablet, through the skin in gel or patch form, or directly into the womb in the form of a coil (progesterone-releasing intra-uterine system).
Local (vaginal) HRT
Genitourinary symptoms of the menopause from lack of oestrogen in the genital tract and bladder are very common. And they tend to get worse with time; whereas other menopausal symptoms usually improve in the years post menopause GSM can get progressively worse. Oestrogen can be given directly into the vagina as local (vaginal HRT). This is a very low dose and can be given in various ways – creams, pessaries, gel or a ring that you insert yourself. It can be used alongside systemic (whole body) HRT. It is usually safe even for women with a history of breast cancer as the doses are TINY.
Testosterone can be indicated for low libido in menopause once oestrogen has been replaced. Though it is usually seen as a ‘male’ hormone, our ovaries and adrenals produce testosterone and it is an important hormone for women’s wellbeing. Productions reduce with age and during the menopause Replacement can help symptoms that are not eased with oestrogen supplementation. Testosterone replacement is not a panacea and not all women respond, but for some women it can be beneficial.
Body vs Bioidentical
Body identical HRT hormones are precise duplicates of hormones produced naturally in your ovaries and adrenal glands. They are derived Yam, a root vegetable. They are recommended by the British Menopause Society and regulated which means they have been subject to close scrutiny and testing by the Medicines Regulatory Agency. These need to be distinguished from so called ‘bio-identical’ or compounded HRT which is unregulated and unlicensed and often prescribed at vast expense.
Benefits of HRT
HRT can quite literally be life changing. It is the best treatment we have to treat a wide range of menopausal symptoms and many women who choose to take it to feel ‘themselves’ again.
There are also long-term health benefits of HRT mainly bone and heart protection. Our bones gradually lose density after the age of 30, and this process accelerates as oestrogen levels decline in the menopause transition. By replacing oestrogen HRT can help to prevent osteoporosis (brittle bone disease). Used at the right age (started within 10 years of your last period or under the age of 60) HRT can also decrease the risk of cardiovascular disease (heart attacks and stroke) which otherwise become far more common in women after their menopause.
There is emerging evidence about HRT’s role in longterm brain health and especially in younger women it may reduce the risk of dementia in later life.
There is not enough evidence yet to recommend HRT to every woman; it should be used to treat troublesome menopausal symptoms with the long-term health benefits being a huge bonus.
Safety of HRT
Public and professional perception of the safety of HRT has been on a rollercoaster over the last few decades. Misinformation and unfounded fears about the risks of HRT have meant countless women have been denied the chance to benefit from hormone replacement. HRT was readily recommended to many women in the 1990s and early 2000s, but its popularity then dropped off a cliff due to misinterpretation of a landmark clinical trial which suggested (falsely) that HRT was linked to a significant increase in breast cancer and heart attack. This study has since been shown to be flawed, the results were inaccurate and misinterpreted.
The risks associated with HRT use are overall very low. Individualising treatment for each woman and considering the timing and route of administration can keep risks as low as possible. HRT can be associated with a small increase in a woman’s background breast cancer risk, though this needs to be kept in context. The small added risk is much lower than the increased risk associated with obesity or smoking and can be counteracted by lifestyle changes. And there is no increased risk of death from breast cancer.
There is a small increased risk of DVT (clots in the legs) with some oral HRT. Again, it all comes down to choosing the right HRT for each individual woman.
ALTERNATIVES TO HRT
Though (with careful choice of dose and preparation) HRT is very safe for the vast majority of women, some women don’t want or need to use it. We would always suggest that HRT be used in conjunction with lifestyle measures.
- Antidepressants – low doses of antidepressants do help some women with hot flushes, night sweats and sleep. They can also help with psychological symptoms of menopause, though HRT does tend to work best for these.
- Clonidine – this is a rather old-fashioned blood pressure medication that can help hot flushes in some women. Any benefits need to be weighed against side effects that often occur.
- Cognitive Behavioural Therapy (CBT) is a therapeutic approach that has long been used for anxiety and depression but can also help with flushing and insomnia during menopause transition. Women’s Health Concern has a helpful leaflet about this https://www.womens-health-concern.org/wp-content/uploads/2023/02/02-WHC-FACTSHEET-CBT-WOMEN-FEB-2023-A.pdf
- Mindfulness – this term seems to be everywhere right now, and for good reason. Oxford Dictionary defines mindfulness as ‘a mental state achieved by focusing one’s awareness on the present moment, while calmly acknowledging and accepting one’s feelings, thoughts, and bodily sensations, used as a therapeutic technique’. Menopausal symptoms can be distressing and cause our minds to race. Mindfulness can be taught by a qualified practitioner, though there are plenty of self-help options out there. Try the Headspace App to get started.
- Breath work – slowing our breathing helps anxiety and flushing and overlaps with mindfulness. There are several paced breathing techniques that can be tried, a simple one is called 3-4-5 breathing. Breathe in for 3 seconds, hold your breath for 4 and then breathe out for 5 seconds. Repeat several times to slow your breathing and heart rate and calm your thoughts.
Consultations around the menopause transition are a brilliant opportunity to look at our health as a whole. There are some simple lifestyle changes that can help ‘future-proof’ long-term health as well as help with hormonal symptoms. These include;
- Stopping smoking. Smoking exacerbates menopausal flushing and also has huge detrimental effects on our long-term health. Smokers have a smaller choice of HRT preparations available to them as they have increased risks of clots and breast cancer. Smoke Free Norfolk offers free support to anyone wanting to quit. https://www.smokefreenorfolk.nhs.uk/
- Alcohol – moderating alcohol intake improves flushing and again reduces long-term health risks. Many women use alcohol as a crutch when they are struggling with menopausal symptoms but finding healthier ways of managing these will reap benefits. Drinking under 14 units of alcohol a week is considered low risk, though there are no ‘safe’ levels. NHS UK has good advice about the risks of drinking too much. https://www.nhs.uk/live-well/alcohol-advice/the-risks-of-drinking-too-much/
- Eating a balanced, varied, plant-rich diet can help menopausal symptoms and overall health. There is increasing evidence that ‘feeding’ our gut microbiome has a big effect on our overall health and wellbeing. The scientist and nutritionist Tim Spector is fascinated by this area and writes brilliantly about it. The Zoe Nutrition site is a good place to start exploring this area. Rather than 5-a-day try to think 30-a-week (sounds daunting but this includes herbs, spices, nuts and seeds.)
- A good calcium and vitamin D intake is essential for bone health. We would recommend a vitamin D supplement of 400-1000 units daily. And a daily calcium intake of at least 1000mg daily. The Osteoporosis Society has very good information about this and a ‘Calcium Calculator’ to easily allow you to see if your diet needs supplementing. https://www.osteoporosis.foundation/educational-hub/topic/calcium. Other supplements may be recommended depending on your individual circumstances.
- Exercise – weight bearing exercise helps support bone health. This is easily combined with cardiovascular exercise which is important for maintaining a healthy heart. Two and a half hours of moderate intensity exercise a week is recommended, though anything is better than nothing. Cardiovascular exercise improves energy levels and the release of endorphins boosts mood. Strength training and core exercises support our bones and posture which can prevent falls in later life. Try something new, how about climbing or body pump? Yoga and Pilates are gentler but still great for core strength and overlap with mindfulness.
- ‘Me time’, relaxation and self-care can help support your mental wellbeing. Often easier said than done but worth investing in
- Marinating a healthy weight – vital for cardiovascular health and also reduces the risk of many chronic illnesses including cancer. The increased risk of breast cancer from obesity is far higher than the very small increased risk from HRT. https://www.womens-health-concern.org/wp-content/uploads/2019/10/WHC-UnderstandingRisksofBreastCancer-MARCH2017.pdf
- iCBT – CBT for insomnia – can be helpful for many. Try Sleepio https://www.sleepio.com/ or SleepStation https://www.sleepstation.org.uk/