Menopause: is HRT a safe option?

Published May 2017 | 4 min read
Expert contributor Professor Susan Davis, Director of the Women’s Health Research Program at Monash University
Words by Karen Burge

There’s a lot of confusion around the safety of Hormone Replacement Therapy. We look at the evidence.

Menopause can mark the start of a complicated relationship with your body. After experiencing somewhere between 400 and 500 periods in your lifetime, hormone levels shift bringing on a host of symptoms, such as hot flushes and night sweats.

Most women reach menopause between the ages of 45 and 55 years, the average age in Australia is 51. While some are fortunate enough to have only mild menopause symptoms or even none at all, very few get through unscathed.

When you’re no longer able to release an egg, your periods stop and you experience a shift in three important hormones: oestrogen, progesterone and testosterone.

Consultant endocrinologist and Director of the Women’s Health Research Program at Monash University, Professor Susan Davis, says it’s the dramatic fall in oestrogen that brings on most symptoms.

Hot flushes and night sweats are common and can range from being mild to quite severe. Other issues include sleep disturbance, joint pain, heightened anxiety, mood changes, vaginal dryness, getting up at night to pass urine and bladder discomfort.

Professor Davis says many women’s symptoms last for around five to 10 years, although the duration and severity vary.

“We know that about 50% of women in their early 60s are still having hot flushes, and for about 10% of these women, they’re quite severe.”

HRT: what is it?

Hormone Replacement Therapy (HRT) – the medical replacement of oestrogen, progesterone and sometimes testosterone – is known to be the most effective therapy for troubling menopause symptoms.

Most women take a combined HRT with oestrogen and progesterone – or a synthetic form called ‘progestin’. While oestrogen is the main hormone, alone it can overstimulate the cells lining the uterus increasing the risk of cancer – the addition of progesterone helps to neutralise this risk. Oestrogen-only HRT is usually only recommended for women who’ve had a hysterectomy.

Some women also benefit from a low-dose testosterone replacement to help with loss of libido, lack of energy and fatigue, according to women’s health organisation, Jean Hailes for Women.

Is HRT safe?

While HRT can bring much-needed relief for many menopausal women, there has been a lot of confusion about its safety, risks and benefits among patients and even doctors. 

Current guidelines recommend that if you take HRT for menopausal symptoms, you should take the lowest effective dose for the shortest time period to alleviate symptoms. If you stay on HRT for up to five years this is called ‘short-term HRT’, if you take it for more than five years it’s called 'long-term HRT'. Your doctor should reassess and review your case every six months.

Pros and cons of HRT

It’s important that you know the risks and benefits of using HRT and discuss any concerns with your doctor as the risks vary from one woman to another and depend on many factors.

On the plus side, using HRT brings relief from hot flushes and night sweats, which can be so severe you need to change your clothes or sheets.

“Most women who go on HRT because they have severe menopausal symptoms feel much better physically, with better sleep, more energy and less aching,” says Dr Roisin Worsley, an endocrinologist at Jean Hailes for Women’s Health. Some experience a better mood and less anxiety too.

“It [also] reduces the risk of breaking bones due to osteoporosis, getting diabetes and colon cancer.”

Like all medications though, there can be side effects. “Common ones are nausea, breast tenderness, headache and menstrual bleeding. More serious risks include blood clots in the legs and lungs, an increased risk of gallbladder problems and an increased risk of some cancers,” Dr Worsley says.

The evidence around HRT and cancer is where the message can get confusing. Many studies on HRT have been published over the past 15 years that highlight differing results. If you’re considering taking HRT it’s important to discuss the risks and benefits with your doctor.

The National Institute for Health and Care Excellence (NICE) guidelines from the UK state that for women around menopausal age, oestrogen-only HRT causes little or no change in the risk of breast cancer. However, HRT that contains oestrogen and progesterone may increase breast cancer risk. It’s important for all women, but especially if you’re taking combined HRT, to have mammograms every two years. The longer you take HRT, the higher the risk, but the evidence also shows that your risk of developing breast cancer reduces back to normal when you stop taking HRT.

If you have early menopause (before you’re 45), the advice is to take HRT until you’re 50 to protect your bones and heart.

“In these women, HRT has a completely different risk profile and actually increases life expectancy,” Dr Worsley says.

When to steer clear of HRT

If you’ve had a blood clot in your legs or lungs, or breast cancer, HRT for menopause isn’t advised, she explains. Your doctor will talk through your medical history and discuss what is appropriate for you.

Looking to alternatives

If HRT isn’t suitable or if you’ve chosen not to take it, Dr Worsley says there are other prescription medications which have been shown to reduce hot flushes, although none of them are as effective as HRT.

She says common options include low-dose antidepressants and a medication called clonidine. Psychological approaches, such as cognitive behavioural therapy, can also be helpful, even though hot flushes are a 'biological' problem.

No matter how complicated it all seems, if menopause symptoms are causing you concern, get medical advice.

“We have a lot more research now than before so we have more accurate information available for women.”