Yorkshire Menopause Group
Hormone Replacement Therapy (HRT)


The benefits of HRT
HRT is beneficial for the management of short term symptoms associated with the menopause and also for the prevention of long-term complications.
Osteoporosis*

  • HRT should be taken for a minimum of 5 years, after the menopause, to reduce the risk of vertebral, hip and wrist fractures by up to 50%. Ideally HRT should be continued for as long as possible to maintain this benefit.

  • If HRT is discontinued, an alternative form of bone-sparing treatment should be considered, as bone loss will immediately recommence after HRT is stopped.

Coronary Heart Disease (CHD)

  • Current, observational evidence suggests that HRT reduces the incidence and mortality from CHD by as much as 50% in current users. The benefits are greatest to those women with risk factors and are lost within 5 years of discontinuing use.

  • The progestogen component of HRT does not appear to reduce the benefits of oestrogen.

  • Recent studies suggest that HRT should not be started within 1 year of a myocardial infarction (MI). However, current users need not discontinue treatment in the event of an acute MI.

Alzheimer's Disease

  • Preliminary studies suggest that the incidence and severity of Alzheimer's disease may be reduced by up to 30% in those taking HRT

Other benefits of HRT

  • A cardioprotective lipid profile

          Lower

    • Cholesterol
    • LDL Cholesterol
    • Lipoprotein(a)
    • Triglycerides (Transdermal therapy only)

          Higher

    • HDL Cholesterol       

  • Improvement in Rheumatoid arthritis and possibly osteoarthritis

  • Improved skin and hair quality and reduced dryness of the eyes

  • Reduced incidence of bowel cancer

Risks associated with HRT
Endometrial Cancer

  • Unopposed oestrogen in non-hysterectomised women increases the risk of endometrial cancer six fold. The addition of a progestogen for a minimum of 10 days in the second half of the cycle, reduces this risk.

  • Recent evidence suggests that switching to continuous-combined HRT, as soon as appropriate, may reduce the risk to background levels.

Breast Cancer
The background risk of breast cancer in women between 50 and 70 years is 45 per 1000 women;

  • HRT taken for 5 years after the age of 50 increases the risk to 47 per 1000 women (Extra 2 cases per 1000 women)

  • HRT taken for 10 years after the age of 50 increases the risk to 51 per 1000 women (Extra 6 cases per 1000 women)

  • HRT taken for 15 years after the age of 50 increases the risk to 57 per 1000 women (Extra 12 cases per 1000 women)

Venous Thrombo-embolism (VTE)
VTE is increased from 1/10 000 to 3/10 000 in HRT users, with most risk being in the first year of use. Only 1% of VTE episodes are fatal. Routes of administration

  • Oestrogen may be administered vaginally, orally, transdermally by patch or gel, nasally and subcutaneously by implant

  • A progestogen must be included for non-hysterectomised women

  • Women in the perimenopause and within one year of the menopause should be prescribed a sequential, monthly bleed preparation; women with infrequent periods may be prescribed a 3-monthly bleed preparation

  • Women who are a year or more after the menopause may be prescribed a continuous-combined (period-free) preparation

  • Progestogens may be administered orally, transdermally, vaginally or by intrauterine system ( not currently licensed for use as HRT)



Other Treatments for the Relief of Menopausal Symptoms


  • Clonidine may reduce hot flushes

  • Beta-blockers may reduce anxiety and panic attacks

  • Continuous progestogens can help relieve menopausal symptoms e.g. 10-20mg MPA, 5mg Norethisterone, when oestrogen treatment is undesirable

  • Limited data suggest that some phyto-oestrogens may be of benefit in the relief of menopausal symptoms

Other Treatments for the Prevention of Osteoporosis*

  • Selective Oestrogen Receptor Modulators (SERMs) prevent osteoporosis and reduce fracture risk, but DO NOT relieve menopausal symptoms. Recent studies suggest a reduction in newly diagnosed breast cancers.

  • Bisphosphonates

  • Calcium and Vitamin D

* See Leeds osteoporosis guidelines