Women’s Health: November 2019

Louise Newson, BSc (Hons) Pathology, MB, ChB (Hons), MRCP, MRCGP, DFFP, FRCGP

GP menopause specialist Dr. Louise Newson provides an overview of the evidence relating to HRT use and practical tips to help GPs prescribe appropriately.

Oct. 23, 2019 (GPonline.com) – The menopause is a normal life event for women and not an illness nor a medical condition. However, there are health risks of the menopause as women have an increased future risk of heart disease, osteoporosis, type 2 diabetes, osteoarthritis, depression and dementia as a result of low estrogen levels that occur.

Symptoms of the menopause

As the life expectancy of women has increased over the past century this means that on average, women spend nearly one-third of their lives being postmenopausal. Many women suffer in silence and do not realise how effective hormone replacement therapy (HRT) can be at dramatically improving both their symptoms and also their quality of life.

The most common menopausal symptoms are vasomotor symptoms (i.e. hot flushes and night sweats). Other symptoms include mood changes, memory loss, vaginal dryness and soreness, reduced libido, sleep disturbances, joint pains and muscle stiffness.^1,2

These symptoms can be non-existent, last for a few years, or even decades. Around 75% of menopausal women experience symptoms, with around one third of these experiencing severe symptoms.³

Negative perceptions of HRT

Many women and healthcare professionals are worried about the perceived risks of taking HRT. Much of the negativity regarding HRT stems from the misinterpretation of the Women’s Health Initiative (WHI) study in 2002, which led to a worldwide reduction in HRT use.⁴

The results of this study were leaked to the press early, before they had been properly analysed. The subsequent sub-analysis of this study showed some really reassuring and positive results to support the use of HRT, especially in younger women.⁵

Another recent paper in the Lancet has led to more concern but this analysis did not include studies involving body identical HRT, which is known to be safer and has less risks associated with it.⁶

Benefits of HRT

There are numerous potential benefits to be gained by women taking HRT. Symptoms of the menopause such as hot flushes, mood swings, night sweats and reduced libido improve.

Numerous studies have shown that shown that when HRT is started in women who are within ten years of menopause onset, it can reduce future risk of osteoporosis, type 2 diabetes, osteoarthritis and all-cause mortality.⁷

It is not just the timing of HRT that is important. The type of HRT also affects a woman’s risks and benefits. HRT containing micronised progesterone appears to be associated with a lower risk of breast cancer, cardiovascular disease and thromboembolic events compared with androgenic progestogens.^8,9

Women who have had a hysterectomy and only require estrogen have a lower risk of breast cancer compared with women taking combination HRT.

In addition, the mode of delivery of estrogen is also important because, in contrast with oral estrogen, transdermal estrogen (given as a patch or gel) is not associated with an increased risk of venous thromboembolism.¹⁰

Numerous studies have shown that adding testosterone to hormonal therapy can improve sexual function and general well-being among women during their menopause.¹¹ In addition, using transdermal testosterone can improve cognition, verbal learning and memory.

Breast cancer risk

Most women and healthcare professionals are concerned about the possible risks of breast cancer in women taking HRT. However, the risk is far lower than many realise.

Women who take estrogen-only HRT (women who have had a hysterectomy) do not have a greater risk of breast cancer. Women who take estrogen and a progestogen may have a small increased risk of breast cancer. However, this increased risk is a similar magnitude to the risk of breast cancer for women who are drinking a glass or two of wine each night and less than that associated with being overweight over the age of 50.

Clearly HRT is only one part of the management of perimenopausal and menopausal women. Lifestyle recommendations regarding diet, exercise, smoking cessation and safe levels of alcohol consumption should be encouraged.

It is important that women are given accurate, evidence-based information so they can have an individualised consultation regarding their perimenopausal and menopausal symptoms. This will then have a positive effect on their future health.

Ten tips on prescribing HRT

• The benefits of HRT outweigh the risks for most women who start HRT aged < 60 years.
• HRT is much safer than many people realise. NICE guidance provides evidence and reassurance.¹
• HRT should be recommended routinely to women who are menopausal aged < 45 years.
• Young women often need higher doses of estrogen to improve symptoms.
• There is no limit to length of time taking HRT.
• Body identical HRT (which is the same molecular structure as a woman’s hormones) is the safest way of a woman having HRT.
• Estrogen through the skin as a patch or gel is the safest way of administering estrogen as there is no risk of VTE.
• Micronised progesterone is body identical progesterone, which is given as an oral capsule and is safer than older types of progestogens.

• Testosterone is also a female hormone that can improve libido, mood, energy and concentration.
• Testosterone as a cream or gel can be especially beneficial in young women with early menopause and premature ovarian insufficiency (POI) and also those women who have had a surgical menopause.

Dr. Louise Newson is a GP menopause specialist in the West Midlands.

References

1. Menopause: diagnosis and management. NG23, May 2017. https://www.nice.org.uk/guidance/ng23
2. Baber RJ, Panay N, Fenton A, Group IMSW. 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric 2016; 19: 109-50
3. Hamoda H, Panay N, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal women. Post Reproductive Health 2016; 22: 165-83
4. Rossouw JE, Anderson GL, Prentice RLet al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 2002; 288: 321-33
5. Manson JE, Aragaki AK, Rossouw JE et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. 2017; 318(10): 927-38
6. Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet 2019; 394: 1159-68.
7. Boardman HM, Hartley L, Eisinga A, al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015:CD002229
8. Stute P, Wildt L, Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018; 21(2): 111-22.
9. L’Hermite, M. Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal. Climacteric 2017; 20(4): 331-38
10. Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ 2008; 336:1,227-31
11. Davis SR, Baber R, Panay N, Bitzer J et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. Climacteric. 2019; 22(5): 429-34. DOI: 10.1080/13697137.2019.1637079