Hormone replacement therapy (HRT)

From the 1970s hormone replacement therapy (HRT) was heavily promoted for the relief of menopausal symptoms and the prevention of osteoporosis and heart disease. In the early 2000s, when some medical research began to suggest that it caused harm, attitudes to HRT changed. However this medical research has been reviewed and most experts agree that if HRT is used on a short-term basis (no more than five years), the benefits outweigh the risks (NHS Choices 2016 HRT).

National Institute for Health Care Excellence has also published Menopause: diagnosis and management (NG23 November 2015) in which it states that women should be offered HRT for vasomotor symptoms (hot flushes and night sweats) after discussing with them the short-term (up to 5 years) and longer-term benefits and risks.Taking HRT does increase the risk of breast cancer to 2 in 1000 women (Million Women Study) but the more recent long-term results from the Women’s Health Initiative study* shows that HRT will not shorten how long you live. 

Here women we interviewed talked about their experiences of HRT, how they saw its risks and benefits, and their concerns about long-term use. Women also explained why they had chosen not to take HRT.
Why women don’t take HRT
Although HRT can alleviate menopausal symptoms, most women we spoke to in 2009 and 2010 choose not to take it. They felt the risks associated with its use were too high after the publishing and media coverage of two studies, the Women’s Health Initiative (WHI) study in the US in 2002 and the Million Women Study (MWS) in the UK in 2003. These studies raised concerns over the safety of HRT, particularly over a possible increased risk of breast cancer with HRT and also a possible increased risk of heart disease and were widely reported in the UK and the low use of HRT in our study reflects the views of the time.

Findings from the MWS published in The Lancet in 2007 also showed a small increased risk of ovarian cancer.  Findings from another study published in The Lancet in February 2015** have also shown an increased risk of ovarian cancer. “It is important to put the risk in context; in real terms, for every 1,000 women using HRT for five years, there will be just one additional ovarian cancer diagnosis. And if prognosis is typical, there will be one additional ovarian cancer death for every 1,700 users.” (NHS Choices, February 13 2015, reporting on the study)
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After the WHI and MWS studies, the number of women taking HRT fell by 66% (Women's Health Concern 2013). The value of these studies has since been reviewed and findings of risk reconsidered and although HRT does increase the risk of developing certain problems the increased risk is very small in most cases. HRT is still a very effective method of controlling menopausal symptoms for some women. 
Controversy arising from the WHI and MWS study findings has added to the confusion women feel about the safety of HRT (see  Women's Health Concern website in 'resources and information' for an analysis of the findings of the two studies). Recent studies continue to examine the effects of taking HRT. In 2012 The British Menopause Society reported studies from Denmark and the US (KEEPS study) which showed beneficial effects of taking HRT.  National Institute for Health Care Excellence (NICE) examines all the evidence with a panel of experts and their findings in recent guidelines also suggest women should be offered “HRT for vasomotor symptoms after discussing with them the short-term (up to 5 years) and longer-term benefits and risks.”. 
As with any medication, HRT has benefits and risks and these should be discussed with your doctor as it may not be suitable for everyone. HRT is not recommended for women who:
  • have a history of breast cancer, ovarian cancer or womb (uterus) cancer
  • have a history of blood clots
  • have a history of heart disease or stroke
  • have untreated high blood pressure – your blood pressure will need to be controlled before you can start HRT
  • have liver disease
  • are pregnant
Some women we spoke to said their symptoms were not serious enough to justify using HRT; others just did not like ‘putting chemicals’ into their body. For others, pre-existing health conditions or a family history of cancer made HRT unsuitable. Some women were determined to go through the menopause as a ‘natural process’, trying complementary therapies if necessary rather than go down the medical route (see ‘Complementary therapies’).
Why women chose HRT
HRT can help relieve menopausal symptoms such as hot flushes and vaginal dryness by replacing declining levels of oestrogen (see ‘Hot flushes and night sweats’ and ‘Libido, vaginal dryness and urinary problems’). Although in the past some women took HRT to prevent diseases such as osteoporosis, today it is usually the debilitating effects of hot flushes and sweats, lack of sleep, and inability to function effectively at work which send women to their GP (see ‘Consulting the doctor’, ‘Sleep’ and ‘Work’).
Some women descibed feeling that they have no choice but to take HRT. Women described HRT as being ‘like a miracle’, ‘completely rejuvenating’, ‘unfailingly excellent’, and ‘the most wonderful drug in the whole wide world’. As hot flushes and night sweats eased, they noticed improvements in their sleep, concentration and stamina. For women who have experienced an early menopause the benefits and relative risks of HRT are different and HRT is recommended at least until the average age of the natural menopause and is often prescribed up until the early 50s to help prevent osteoporosis as well as to relieve symptoms (see ‘Early (premature) menopause’).
Yet while women who take HRT speak positively about its effect on their quality of life, some said that ‘at the back of your mind there’s a bit of a worry’. Deciding to take HRT and to stay on it long-term involves a careful weighing up of risks versus benefits. There had been lots of media coverage in the UK about he risks of HRT after the WHI and MWS studies were published and women were very aware of the negative publicity, women stressed the importance of studying the available research, discussing the pros and cons of HRT use with their doctor, having regular blood pressure checks, and ensuring they attended routine mammograms and cervical smears.
Finding the right HRT
There are many different types of HRT. What suits one woman may not suit another. Women who are still having periods (a bleed) or who stopped within the last year are usually given a combined (oestrogen plus progestogen) cyclical form of HRT and will continue to have a monthly period. Postmenopausal women who have not bled for a year may be prescribed a ‘period-free’ continuous preparation with a constant dose of both oestrogen and progestogen, but for the first 12 months they need to take a sequential preparation with graded doses and will need to have a monthly bleed. Women without a uterus can take an oestrogen only HRT which is bleed free. Women troubled by vaginal dryness sometimes chose to use a vaginal treatment such as oestrogen tablets, creams or rings to help raise local levels of oestrogen without affecting the whole body.
Women may experience side effects and it may take them some time to find a suitable type of HRT. On some types of HRT, women experienced diarrhoea and nausea, facial hair, and weight gain (see ‘Changes in the body and keeping healthy’). If women have unexpected bleeding or unusual bleeding on HRT they should see their GP promptly (see ‘Changes in periods’). HRT patches are often better for patients experiecing nausea as they aren't absorbed by the gut but some of the women we interviewed who had been prescribed HRT patches complained about allergic reactions and skin rashes or disliked the ‘filthy plaster marks’ left when the patch was removed.
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Despite its benefits, HRT is not a miracle cure for all menopausal symptoms. While pleased that HRT had stopped her hot flushes, one woman complained that she’d put on weight and lost interest in sex. Another pointed out that HRT didn’t relieve her night sweats for ‘quite some time’. Weight gain is common in the menopause because after the age of 40 the Basal Metabolic Rate (the rate at which calories are burnt off) slows down. HRT can only partly help to stop this so women can still gain weight on HRT.
How long to stay on HRT
Women we spoke to had been on HRT for periods up to 15 years. Current guidelines, however, recommend restricting HRT to the ‘lowest effective dose for the shortest possible time’. ‘The shortest time possible’ seems generally to be taken to mean between 2-5 years (see ‘What is the menopause?’). While some women were willing to come off HRT, others were reluctant to stop taking HRT despite their doctor’s advice and encouragement. One of Dr Sally Hope’s patients is still taking HRT at age 82 and ‘just will not stop’. She records in the patient’s notes that ‘it’s her evidence based patient choice’.  A new oral low dose HRT has been introduced.
Women reported that coming off HRT ‘cold turkey’ could lead to a return of symptoms such as hot flushes and memory problems because of the change in hormone levels. One woman described the sudden return of hot flushes and ‘memory gone to bits’ as ‘absolutely horrendous’. Another, who came off HRT in her 70s after long use, once again got hot flushes.
Other women, however, found that coming off HRT slowly over a period of weeks or months helped to minimise withdrawal symptoms; some remained symptom-free.
Used short-term to relieve menopausal symptoms, HRT can restore well-being and quality of life for many women. But the available evidence indicates that long-term use has more significant risks. Women should be guided by their own research and by discussions with their doctor before making a decision.

*Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Chlebowski RT, Howard BV, Thomson CA, Margolis KL, Lewis CE, Stefanick ML, Jackson RD, Johnson KC, Martin LW, Shumaker SA, Espeland MA, Wactawski-Wende J, for the WHI Investigators. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific MortalityThe Women’s Health Initiative Randomized Trials. JAMA. 2017;318(10):927–938. doi:10.1001/jama.2017.11217
**Collaborative Group on Epidemiological Studies of Ovarian Cancer: Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. The Lancet published online: 12 February 2015.

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Last reviewed July 2018.
Last updated July 2018.


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