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)
Rebecca decided not to use HRT after her sister died of ovarian cancer
Did you ever think at all about going on HRT?
I did think at a stage, I thought maybe, I wonder will I when I’m coming up to the menopause but then I never seemed to get around to it and then, as I say, when my sister had been on it for about ten years. And I think at that stage, that was the, do you remember there was a big survey done worldwide and they had identified that there was people it had caused cancer so she came off it at that stage. And at that time I thought no, I wouldn’t. I wouldn’t be interested. I thought if I can manage. It’s not because I had discussed it with my other two sisters and they were saying, “Sure it’s, if you can manage with hot flushes so”. But I said, “It’s more than that. It’s about protecting your bones and protecting your heart”, things that people aren’t aware of, however, because of my sister’s experience I would be reticent, or hesitant to start HRT.
My eldest sister as I say was on HRT for ten years but she developed ovarian cancer and died February a year ago. So I don’t know whether it was HRT or whatever but, she didn’t realise that she had ovarian cancer until they discovered secondaries and she had always led a healthy [life] she never smoked. She didn’t drink or anything like that so I don’t know whether that has anything to do with it but because of that I wouldn’t consider it.
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’).
Christinas health problems mean she cant use HRT to relieve her hot flushes and night sweats
I have a problem with my blood which means I can’t take HRT so it was hot flushes, night sweats and not being able to take anything to help relieve this and being told, “Sorry, you’ve got to suffer it on your own.”
Oh, yes. I said, “I want HRT.” And he said, “You can’t have it. You cannot have it whatsoever.” And then I checked with my female GP when I went back for the test and she said, “You can’t.” She said, “We cannot give it to you.” She said, “There’s no low dose one or anything else.” She said, “You’re just going to have to go through it and hopefully it’ll reduce as you come through the other side.” And it hasn’t.
But I was told by my GP that it’s not that she wouldn’t prescribe HRT. I could have HRT as long as I knew what the risks were and she said that the risks overcome your need for HRT. She said, “It’s extremely serious.”
And you agreed with that.
I agreed with that because I want to be around for a few more years.
Barbara wasnt keen on tablets made from pregnant mares urine
Several GPs I went to, this is out of the Army, after the Army. Some were better than others, some were sympathetic, some would say “HRT, take HRT”. And I didn’t want to take HRT but at one stage they got so bad I went back and I saw them and they said, “Look what are you worried about” and I said, “Well we’ve got a history of cancer in my family and” I said, “there’s that” and we talked, he talked me through it and he looked at the different types and he says, “Look” he says, “I think you should try this one”. So he gave it to me and I came away and I thought “Not sure about this” because I just think you’re putting something off, so I then went on the internet and looked it up and then realised it came from a pregnant mare’s [urine] and I thought “God, they’re keeping these and not giving them enough water and keeping them constantly pregnant and” I thought “Oh, I can’t take that”. They’re still upstairs in the cupboard not been touched. And I just think, I’ve spoken to lots of women and I’m not knocking HRT because it seems that for a lot of women they’ll stand by it, and they say it’s great. It’s only when it got really bad and the depression got bad and I thought I’ve got to take something but I just couldn’t bring myself to take it. Because I thought I’m just putting off the inevitable. I’ve got to go through it at some stage.
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’).
Rose felt she had no option but to take HRT even though she had concerns
The first time I went I saw a female GP and I think that was quite useful, she put it into perspective for me. I was very afraid that if I went onto HRT I’d be on it for the rest of my life or I’d be on it for 15, 20 years and it’s still to a certain extent an unknown quality and quantity. She said, “You have to deal with the here and now, you have to deal with the 50 mile journey, the busy job, the two children going through their own problems, the husband with M.E.” she said, “Look upon it as a safety plaster to get you through the next two to three years”. She said, “Don’t think upon it that you’ve got to be on it the rest of your life, think upon it as a short term solution to get you through this period in your life”. And I think putting it into perspective like that I was more able then to consider it and give it a go and that’s what I did. And again, after five years, I just thought “Right let’s come off it, let’s see if I can manage” and I have and I am.
Did you have any concerns about the HRT, about going on it in terms of risk?
Yes I did because obviously it was big in the press at the time, the long term effects of it. I was quite concerned particularly six years ago, the year before I started going through the menopause, I had a lump on my breast removed which turned out to be benign. But having had that removed I was very conscious going onto HRT was I encouraging more lumps to come, would the next one be malignant. It was a big big decision for me to make and I was very anti the HRT for that reason. I think I was really concerned that I might get breast cancer from it. I think that was my biggest concern having had this lump removed. But I just got to the point well it was, I couldn’t have functioned without it and it was, well do I risk breast cancer or do I risk losing my job, my home, my family and everything else. So I felt at the end of the day I didn’t really have a choice to be perfectly honest.
Lornas experience of taking HRT has been incredibly positive. It has transformed her life
I was at my wits end. And when I went to see the GP I think I sort of went in there and said something along the lines of “I’m menopausal, and this, and this, and this, and this is happening to me. Do something about it, do something about it now. I’m not leaving this room until you do something about it”. So it was really quite that surprised me that the symptoms didn’t come on gradually. It was as though I’d hit a threshold of hormone level and suddenly all these things appeared. So the GP I think I must have come across as a little bonkers but I’m sure the GP was used to that. And he looked at me very kindly and said, “Well it certainly sounds like you’re perimenopausal”. And I went, “It does doesn’t it”, and he said, “Look, here, I’m going to put you on HRT if that’s what you want me to”. Sorry we actually discussed that because I said, “Get me HRT now”. And he said, “I’ll find you a low dose but I’ll take some blood and get your hormone levels done so you can, don’t start taking your pills until I’ve spoken with you”. So a few days later he spoke to me, “Guess what? Your hormone levels are coming down and you’re definitely perimenopausal and start taking your pills and come back and see me”. My experience, and I’ve been on HRT for the last four and a half years.
My experience of HRT has been incredibly positive. If you threatened to take my HRT away, I’d probably kill you. It’s that positive. It has transformed, I mean I feel great. I think that’s all I can really say. I feel like the woman I was and what’s great about it is that I don’t get premenstrual, so my life is much more evened out but it’s a great even out. Not a bad even out. I don’t feel any of the symptoms that you hear about with the menopause.
Jane has used HRT for 15 years. After extensive research she believes the advantages outweigh the...
Well, I suppose I started thinking about the menopause when I was in my forties because I read about it and HRT hit the headlines and at that stage, HRT was said to be wonderful and there didn’t seem to be any disadvantages. HRT was said to reduce osteoporosis, reduce cardiac troubles in those days. There was nothing negative about it so I think when I got to the age of about 50 and started to have just the odd hot flush my reaction was immediately to go on to HRT, partly because my mother had osteoporosis and other members of the family had had osteoporosis and I dreaded getting osteoporosis and I felt it was the right thing to do. I think I started, it’s quite a long time ago now so I think I started on some tablets and then I tried patches but the patches gave me some skin reactions so I went back to tablets. And there was no problem at all. I never had any side effects. I just felt great.
Then of course the headlines changed a little bit. There was more research on HRT, people started to talk about dangers of increased risk of breast cancer, dangers of increased risk of cardio-vascular problems. So I started looking at the literature and read articles in the BMJ [British Medical Journal] and the Lancet, the British Journal of General Practice, the newspapers, everything I could find. And it seemed to me that the dangers and the risks of HRT had been exaggerated in that people didn’t understand risk.
And for me, the advantages outweigh the disadvantages because I dread getting osteoporosis. The risk of osteoporosis is reduced, also I think the risk of bowel cancer is reduced when you’re taking HRT and the quality of life, for me, has been terrific on HRT so I’m carrying on still taking it.
What is your doctor’s attitude to you being on it for so long?
She’s terrific. She knows I look at the literature and have done the research and understand the risks and in fact I went to see her yesterday partly because I knew this interview was coming up. I thought I’d have a discussion about it since I’ve been on it for about 15 years now, and she agreed with me that the extra risk for breast cancer is actually quite small. And she said that you have a similar extra risk if you’re overweight. So we discussed the other reasons for having extra risk of having breast cancer and she was perfectly happy for me to go on with it.
Nancy suspects a link between her breast cancer diagnosis and taking HRT for 10 years
Did you think about any link with the HRT you were on?
I did, I talked to the consultants about it and I talked to the GP about it. They all think it’s very unlikely that that was the cause of it. I accept what they say but I’ve still got a niggling suspicion that it might have been, because I didn’t seem to be a high risk in any of the other ways that they described. They asked me all the questions and I didn’t really seem to come up with much of a risk factor in any of the other respects. So, that was, it’s still a niggling doubt in my mind and I’m glad I don’t take it, well I can’t take it anymore because of the risk but again if I hadn’t taken it perhaps I’d have really dodgy bones by now so you can never tell what would have happened can you. I think given the choice, if I knew then what I know now, I probably wouldn’t have taken it but then other treatments didn’t exist when I was prescribed it so.
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.
Janets doctor suggested she try a no-bleed HRT to stop her having periods in later life
So I went back to him to talk about it, the GP, and I said, “The only thing that puts me off, I don’t really want to be having periods if I get to 80 and I’m still on it and I don’t want to be having periods. That’s ridiculous.” So he said, “Well, I could put you on another one where you don’t have the oestrogen.” And he said, “Most.” I remember him saying something like, “Most of the ladies that I’ve prescribed this find it much better and they don’t really have bleeding. Occasionally, you might get a bit of spotting.” So I said, “Fine.” So he prescribed this so I started taking that and I suppose I was taking it, I don’t know how many years, perhaps two three years, which was, on top of the previous years I’d been taking the combination one.
Dr Sally Hope advises women to consult their doctor regularly while on HRT as they may need to...
Well, I think it’s good medical practice to see your GP or whoever is prescribing your hormone replacement therapy at least once a year and understand the pros and cons. Because as you get older, you need less hormone replacement therapy than you do, for example, women who have a premature menopause, who are in their thirties or forties, need about five times as much oestrogen as a woman of 55. So as you get older it should be tailored down and changed because there are also a number of different preparations. When you’re in the perimenopause you should have a cyclical preparation. That means you cycle so you have a withdrawal bleed and then as you go through to the menopause and postmenopause you can have what’s called a continuous combined preparation of oestrogen and progesterone, which you don’t have a period with and that’s been shown to have less risk of womb cancer than a cyclical one. So again, as you get older beyond that, the dose needs to come down so you actually shouldn’t be stuck on the same preparation for years and years and years. What I talk to my patients about is the risk of breast cancer, make sure they’re having mammograms regularly, make sure they’re having cervical smears regularly as all women should be doing along the current national guidelines and talk through the pros and cons.
Carole went back and forth to her GP, trying in vain to find an HRT patch that suited her.
I said, “I am going through the menopause, I’m on HRT and I’m having a bit of trouble settling with the tablets”. I went back to the GP and she said, “Don’t worry Carole,” she said, “we’ll try you on another one”. Excellent I thought, so I tried another one, that was okay for a while but then the nausea came back again. So, bless my lady doctor, she’s got such patience, I went back again and she said, “Well let’s try patches, because they’d be absorbed through the skin rather than through the stomach and the liver”. So I went on Evorel 50, two patches a week on the thighs. Great. Fantastic. Relief. After about six months I started to get a reaction to the patches on my thighs. I would have square patches like that red raw, itching and I was using a different leg each time hoping that that red patch would heal before I got back to that side and I had at the end of about I suppose about another six or seven weeks I looked like a patchwork quilt. It did, it was red raw, it was stinging, it was itchy. I did a bit of research on the internet mainly with the help of Menopause Matters and one of the ladies on there suggested I might try a different patch but I went back to the doctors and she said, “It does sound like you’re allergic to the adhesive, although I was a bit apprehensive about that. But anyway she tried me on a Fem 7 patch. I put one on and it was even worse, it looked like somebody had got a Hoover, put it on suck on my thigh and just bluk, and it was within about one day. So that had to come off. So then I tried the gel which was top half of your arms, once a day and that was alright for about two weeks and then it all flared up again. Doctor said to me, “You’re probably allergic to oestrogen full stop.”
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.
Janices doctor refused to give her another prescription for HRT after 5 years. She was...
I liked being on it actually. It seemed to give me some kind of energy boost and it sharpened my memory. So I felt better on HRT. Anyway, all this story took about five years to come round. I went down to the GP. It was a female doctor who said, “Oh, you’ve been on it for five years I’m not going to give you another prescription for it.” And I said, “But I want to be on it.” She says, “Yes, but there’s research coming out what’s showing there’s a higher risk of breast cancer.” And I did say, “Well, I don’t smoke. I don’t drink a lot, maybe half a glass of lager or something a night, maybe five nights, four nights, nothing heavy. Could I stay on it?” But the doctor was adamant I couldn’t continue on that.
So I was brought off HRT and I found after that oh, it were terrible, absolutely. I were weepy. I were feeling depressed well, I’ve had depressed days. I just imagined this must be what depression feels like. I just couldn’t remember things. I were dull. I needed a sharp memory, a clearer memory in my job and it were terrible. So I went back to the GP and it were a male GP I got this time and I just begged, “Could I have HRT please?” And he said, “Well, we’d rather not.” And I said, “Well, I’ve got all the pressures from being a carer. I’m getting really weepy. I’m driving along the road and I just want to cry.” And he prescribed me some red clover and I tried that for about three months but it made no impact whatsoever.
So I just felt, this is it then. I’ve had my five years worth or whatever they consider you can have and I were just devastated. And I just think it was I’ve had my choice taken away from me. I wanted to stay on it. I felt better much better on it and I just couldn’t understand why somebody else had made that choice for me. They weren’t in my body and they weren’t living my life but yet a decision were made to sort of deny me a therapy which I found beneficial. And I did get the feeling somewhere along the line that it were viewed as women trying to clutch on to youth and really we should go into older age more gracefully, not need pharmacological, crutches or interventions. It were, “So get on with it”. And I’ve never been back since although I bet once a week at least I think, “Oh, I wish I could have my HRT.”
Is there a reason why you wouldn’t shop around and go elsewhere?
I would say in [city] there’s a culture of you stay with the same GP unless you move. I would say in [city] not many people do shop around, it’s often, “Oh, better the devil.” And then you hear shock, horror stories of other GPs and you think, “I’d better stop with mine.”
Cynthia fears her symptoms will return when her GP cuts off her supply of HRT after 5 years
He doesn’t know yet but from the time I went on it I’ve been weaning off it, so going on was my weaning off programme. I take a full tablet every other day and the days in between I take half and in another month or so I’m going to cut that back a little bit more because I don’t really like being on it. When I very first went to see him in 2004 or whatever, he said, “You can have HRT.” And wanted me to have HRT, “For five years or until you’re 55.” Well, as I was nearly 50, five years and I did say, “What then?” And he went. So he said, “It might just get you over the hump of the worst of the menopause.” And I think now that demonstrates a total lack of understanding because if your own hormones are misfiring you’re making less progesterone and less oestrogen and you’ve got all these symptoms. What does he think is going to happen when you’ve had your five years of taking an artificial substitute and then you withdraw it? The same thing is going to happen. So what then? And if it’s nothing well, what’s the point in going on it, so I’m weaning off. I’m keeping a little stash of all these half pills and when he cuts off my supply, which is likely to be this September, a) he’s going to have a fight on his hands, b) I might go private and get it that way or c) I’ll take my little stash that I’ve got in the cupboard without his knowledge. But that’s it really.
Marys experience of HRT had been unfailingly excellent. Her symptoms returned when a new GP...
And so I was referred by my GP in London to a specialist, I suppose they are obstetrics and gynaecology people but she was actually a specialist in managing the menopause, and she put me on HRT; which was like a miracle. I mean it was completely rejuvenating. I was still having occasional periods, maybe once every three, two maybe two, three, four months, and it was something called, “Do you want me to mention the name of the drug?” it was called Premique Cycle and I went on to that and it was like being rejuvenated. All that weight I was putting on dropped off, I felt my libido came back, my whole ambition, all that kind of I want to make my work really work. I was running a medical research charity at that time called [name], and it was a very very busy job and a lot of pressure with lots of staff and very hard work. And I felt I was capable of doing it again. It was really marvellous. So my experience of HRT was unfailingly excellent.
It was about six years ago when I came to live in [city] and when I was obviously transferred from my old GP to a new GP that she said she was very opposed to women staying on HRT and that I should come off and I’m an obedient woman and didn’t think twice and so I just simply stopped taking it. And it wasn’t until quite a lot later that I discovered that that was completely not the right thing to do and so all of those symptoms that I’d been complaining about previously, the hot flushes, the loss of libido, the lack of concentration, the weight gain, they all came back in such a massive rush I thought I was dying. I mean I thought I was literally on, I just couldn’t believe it. But I did cold turkey and I came through it.
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.
Last reviewed July 2018.
Last updated July 2018.