Practical advice for GPs on prescribing HRT

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

Woman using HRT patch
(Photo: Newson Health Menopause Society)

The menopause is a normal life event for women and not an illness nor a medical condition. However, there are health risks associated with menopause as women have an increased future risk of heart disease, osteoporosis, type 2 diabetes, osteoarthritis, depression and dementia as a result of the low estrogen levels that occur.1

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 their quality of life in both the menopause and perimenopausal years that can begin 7-10 years before periods end.

The most common menopausal symptoms are vasomotor symptoms (i.e. hot flushes and night sweats). Other symptoms include mood changes, memory loss and ‘brain fog’, the genito-urinary symptoms of the menopause (known as GSM and encompassing vaginal and urinary symptoms), reduced libido, sleep disturbances, joint pain and muscle stiffness.2,3

These symptoms can be non-existent or last from a few years to decades. The genito-urinary symptoms can worsen with time and be lifelong.4 Around 75% of menopausal women experience (peri)menopausal symptoms, with around one third of these experiencing severe symptoms.5

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.6

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.7

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.8

For many types of HRT there are no or few risks and it is important to understand that for most women the benefits of taking HRT outweigh any risks.

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 and this can have a major impact on quality of life.

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 cardiovascular disease, type 2 diabetes, dementia, colorectal cancer, osteoarthritis and all-cause mortality.9 HRT started at any age can have a positive impact on bone health and prevent osteoporosis and associated fractures.

It is not just the timing of HRT that is important. Women who have had a hysterectomy and only require estrogen have a lower risk of breast cancer compared with women taking combination HRT.

The type of profesterone 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.10,11

In addition, the mode of delivery of estrogen is also important because, in contrast with oral estrogen, transdermal estrogen (given as a patch, gel or spray) is not associated with an increased risk of venous thromboembolism.12

Unfortunately, there is currently a nationwide shortage of one form of oestrogen gel known as Oestrogel. This has impacted on supplies of other transdermal options in many areas. The shortage is related to increase demand and this outweighing current supply. The manufacturers have stated that the supply issues will be short term and resolved as soon as possible but this situation has left many women desperate and without the hormones they require to function and maintain their future health.

Numerous studies have shown that adding testosterone to hormonal therapy in the form of a gel or cream can improve sexual function and general wellbeing among women during their menopause.13 In addition, using transdermal testosterone can often also improve cognition (improving the symptoms of brain fog and memory), verbal learning and memory.

It can increase lean muscle mass and help improve motivation amongst women. Recent studies have shown that keeping testosterone within the optimal range can have a positive impact on cardiovascular health as well.14

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; they actually have a 22% lower risk of breast cancer. Women who take estrogen and a progestogen may have a small increased risk of breast cancer but this has not shown to be statistically significant.

However, this increased risk is a lower magnitude to the risk of breast cancer for women who are drinking a glass or two of wine each night or areoverweight. This small risk can be minimised by offering micronised progesterone or the Mirena coil instead of a synthetic progestogen.

Futher information about HRT including prescribing tips is available here.

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.

The decision on treatment should be in line with the recent NICE guidelines on shared care decision making with the patient.15

Vaginal hormonal preparations

Symptoms of genito-urinary syndrome of the menopause (GSM) are very common and are progressive with time.

Treatments for GSM are usually effective, safe and cost effective. Vaginal hormonal treatments can be absorbed from the vagina and surrounding area via a pessary, cream, gel or vaginal ring. They are not absorbed systemically so are different to HRT and they can also be given in conjunction with HRT.4

Ten tips on prescribing HRT

  • The benefits of HRT outweigh the risks for most women, especially those who start HRT aged <60 years.
  • HRT is much safer than many people realise. NICE guidance provides evidence and reassurance.2
  • HRT should be recommended routinely to women who are menopausal aged <45 years and continued at least up to the age of a ‘natural’ menopause at least, ie 51.
  • Young women often need higher doses of estrogen to improve symptoms.
  • There is no limit to length of time taking HRT so women can usually take it for ever.
  • 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, gel or spray is the safest way of administering estrogen as there is no increased 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 often 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 and Dr Olivia Jones are GPs and menopause specialists. Dr Newson is the director of the menopause information website www.balance-menopause.com and the free menopause app balance . She also runs a not-for-profit company Newson Health Research and Education and has founded the Newson Health Menopause Society, which brings together healthcare professionals from around the world to transform the care, treatment, education and research of the perimenopause and menopause

Health professionals can access the free Confidence in the Menopause education programme here.

This is an updated version of an article that was first published in October 2019.

References

  1. Nappi RE, Chedraui P, Lambrinoudaki I, Simoncini T. Menopause: a cardiometabolic transition. Lancet Diabetes Endocrinol. 2022 May 4:S2213-8587(22)00076-6. doi: 10.1016/S2213-8587(22)00076-6. Epub ahead of print. PMID: 35525259.
  2. NICE. Menopause: diagnosis and management. NG23, May 2017. https://www.nice.org.uk/guidance/ng23
  3. 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
  4. British Society for Sexual Medicine. Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM)
  5. 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
  6. 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
  7. 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. JAMA. 2017; 318(10): 927-38
  8. 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.
  9. Boardman HM, Hartley L, Eisinga A, al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015:CD002229
  10. Stute P, Wildt L, Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018; 21(2): 111-22.
  11. L’Hermite, M. Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal. Climacteric 2017; 20(4): 331-38
  12. 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
  13. 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
  14. Heinze-Milne S, Banga S, Howlett SE. Low testosterone concentrations and risk of ischaemic cardiovascular disease in ageing: not just a problem for older men. Lancet Health Longevity 2022; 3: E83-E84.
  15. NICE. Shared decision-making. NG197. June 2021. https://www.nice.org.uk/guidance/ng197

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