Is it time we changed the way we think about HRT? Some doctors argue menopause needs a rebranding so we no longer think of HRT as the treatment of last resort.
Many women talk about HRT in terms of ‘struggling on,’ ‘braving it out’ and ‘not succumbing’ by taking it because it’s ‘not natural’ – but is that correct?
Dr Sarah Ball, a GP with a special interest in the menopause says it is time menopause was rebranded as a ‘chronic hormone deficiency’ rather than accepting it as natural part of getting older, and that HRT was seen as a ‘natural’ first choice treatment rather than last thing to try.
Dr Ball says it’s something she and her colleagues at Newson Health – a clinic dedicated to improving the lives of menopausal women are passionate about.
“Often women think HRT is harmful, but not having it could be worse for our long term health,” she says. Here are some of her thoughts from an interview we did recently which you can see here.
Q. Why do we think HRT isn’t natural and that we shouldn’t take it?
“I think we have become this gender where we think we have to ‘man-up’ and ‘brave things out’ and there’s a sort of sense of failure if we ‘give in’ to taking HRT. And I think that’s come about for a number of reasons, one being the fear of HRT that’s developed over the past 20 years and the perception that we should try everything else first and HRT should be the last resort.
“But it’s really hard. We’re the ‘sandwich generation’ when we reach menopause. … Many of us have children or elderly parents that are dependent on us and many of us work, and when these symptoms come along, it’s very hard to find the right information.
“We do talk a lot more about menopause now which is fantastic, but it’s only been a few years, so many people suffer in silence. And now we’re reached this stage where there is a lot of move toward ‘natural’ – which is good, but it’s important to understand the decisions they’re making and the impact they’ll have. So it’s all about having information.”
Q. HRT is very different now though isn’t it to the HRT used in the studies that scared us 20 years ago? Could you argue it is now ‘natural’ and vital, especially as we are living longer?
In the past “people generally died a few years after they reached menopause, but now we are living 30-40 years longer and we’ve run out of the hormones that were actually fuelling most of our functions. Oestrogen helps our brain and our mood and our skin, hair and our bones to stay strong.
“It keeps our blood vessels strong, so it’s helping to prevent things like heart disease. When you then run out of it- the most natural thing in the world is to replace it. If your thyroid was under active you’d go to the doctor and get something to fix that. So really we’d like to re-brand the menopause and call it a ‘chronic hormone deficiency’ – which is essentially what it is.
“If a man runs out of testosterone, we very much rush to replace it as its so important to their brain function and heart and things, and yet us women have been left behind and almost put on the scrap heap, and we’re now only just starting to gain strength and doing something about it.
“And you right, unfortunately many of us are still suffering from the hangover of the WHI study in 2002 where they did use what’s regarded as ‘old fashioned’ HRT now – the ‘horse wee’ oestrogen and a synthetic progesterone – which to be fair was still an awful lot better than nothing and it actually did many women a lot of good.
“And actually the bad effects that were seen in that trial were because the trial wasn’t designed very well and they were often giving quite high doses to women who were older – a long way past the menopause – so it wasn’t really a fair trial of HRT.
“But we’re really lucky in this country, we are now using a well studied plant based version – made from yams – that is ‘body identical’ and works even better than the old fashioned stuff, is safer and is more flexible in terms of how you can use it. So you’d have to have a pretty good reason not to use it as your first choice these days.”
Q. If your symptoms aren’t bad should you take HRT?
“I think we’ve got to move past this idea that it’s a type of competition as to how well you’re doing because some women fly through it with virtually no symptoms and other’s will be on their knees.
“It’s relative, and it doesn’t really matter how bad the symptoms are, it’s the impact they’re having on your life. If you sweat every night and aren’t sleeping then that’s going to have a knock on effect.
“The other crucial thing – HRT has two functions – one is to help with symptoms and the other is to protect our future health. So there is an argument that those who appear to sail through HRT may be at a long term disadvantage as they don’t seek out the HRT and therefore don’t got the protection it offers for our future health.
“It reduces heart disease, osteoporosis, diabetes, mental health problems, osteoarthritis – so yes, you don’t have to be on your knees to get the benefits from HRT.”
Q. Does birth control mask menopause symptoms?
“The combined pill is giving you oestrogen and progesterone, in quite high doses, so you may not notice your symptoms. If women were on the 3 weeks on 1 week off, some women would really notice the symptoms.
“If you’re on progesterone only then you may not notice any changes to your period – so it will mask that cardinal symptom – changes in periods. So it’s very important that women understand the concept of menopause, where your ovaries haven’t stopped working but they aren’t at full capacity. For most women this will be in their 40’s.
“So, be aware, if you do start to experience they myriad of other symptoms – moods changes, libido, – just have them on the radar that it could be my hormones.”
(Read more about the symptoms of menopause here.)
Q. What can you do about night sweats or hot flushes that are uncontrolled even when you’re on HRT?
“Interestingly the dose of oestrogen that women need to control their symptoms varies widely – some will need just a little bit and others will need a lot to help them. Like most conventional medicines there are pretty set doses, but we’re lucky with the transdermal oestrogen – the oestrogen that goes through your skin – that we have some flexibility, but we are limited by what the licensing says we can do [in terms of dosage].
“They can be overly cautious as what matters is not necessarily how much you put on your skin but how much your skin absorbs, which can vary due to our skin type. So a 100 mg patch may be too much for some women and for others it won’t be enough. The dosages have been set for women who are post menopausal but there are more and more women who are perimenopausal who are taking it, and they should be, and we often tend to increase the dosage for them as they may need more.
“One of the main reasons for taking HRT is to get rid of the symptoms, so if you still have symptoms then you’re not having enough.”
Q. Should I ignore hot flushes and soldier on?
“They’re actually not good for you. The research shows that women who have more of these are more likely to get heart disease and dementia. It is perfectly logical and wise to want to get rid of them with fans or whatever you have at your disposal, but nothing will get rid of them like HRT to replace the hormones that you’ve lost.
“The other thing is that alcohol will make hot sweats and flushes worse.”
Q. Alternatives if you can’t take HRT for hot sweats and flushes?
“For women where HRT isn’t appropriate you can use certain anti-depressants or blood pressure medications to help combat hot flushes, but doctors need to explain very carefully why they are required so women understand why they’re being prescribed and don’t’ walk away unhappy thinking ‘I came for my hot sweats but they offered me anti-depressants.’
“The thing to remember though is that they don’t offer the long term protection of HRT when it comes to bones, heart and the brain.
“The blood pressure drug, clonadine, isn’t well tolerated by many women and the downside of anti-depressants is they often lower libido – so you may fix one problem but find you have another.”
Q. Can I have HRT if I’m still having periods or in my 40’s?
“That is another myth that really upsets me. The perimenopause is often more difficult than what comes later as the hormones are on a rollercoaster – and women can take a long time to get help as sometimes they feel fine and other times they’ll have moods swings or awful night sweats, so they can really benefit from having HRT to even these out.
“And the studies show that the sooner you start talking HRT the better the long terms health effects are.”
Q. If your over 60 can you start HRT?
“It’s never too late but there is a concept of ‘a window of opportunity’. Ideally it should be in perimenopause or within 10 years of menopause or before you are 60. So if a woman’s last period was say 56, she’d have that window of opportunity until she was 66. If you’re beyond the window of opportunity it only means that benefits of HRT aren’t as high and the risks aren’t as low. That means that the potential gains have come down and the potential risks have gone up a smidgen.
“Another really important thing for women over the age of 60 to think about is that about 70% of us will have genitourinary problems – vaginal dryness, stress incontinence, vulval discomfort – burning or itching, frequent UTIs – all of those can be treated with localised oestrogen too.
“I very frequently start women in their 60’s on systemic HRT because their risk from their symptoms outweighs the risk of taking the HRT.”
Q. Histamine intolerance – what role does that play?
“This is really interesting. Most women’s lives really improve with HRT but when you see a lot of women like we do, there is a small group that don’t do well, and then you really have to think about why. So I started to look into it and have found that some of us have ‘histamine intolerance‘.
“We all have histamine in our bodies but if you have too much of it the excess start to cause problems. It can give us symptoms like allergies, irritable bowel, migraines, anxiety and depression and mental health issues. So with those ladies it’s like recognising that the histamine has to be dealt with because it has a funny link with oestrogen as it makes you make more oestrogen.
“So if someone isn’t having a good reaction and progesterone isn’t an issue for them then you have to think about whether there is a dietary issue and histamine intolerance may be the answer. We’re a bit behind on it here in the UK, it’s talked about much more in Europe.
“So you may need to minimise certain foods in the diet or prepare them in a different way. It’s in almost every food group so it needs some thinking about.”
Q. If you GP isn’t sympathetic about your menopause symptoms what can you do?
“Ask at the surgery if there is a GP who is interested in menopause. If there isn’t don’t take no for an answer. There are some things you can do to help your GP. Go onto the Newson Health website and there is a questionnaire that you can fill in and take back and give to your doctor and say ‘look I’ve got all of these symptoms’. That’ll save a lot of time in your consultation.
“On the same website there’s also an easy prescribing guide for GPs that Louise Newson wrote and that’s very helpful. Try to be mindful of the fact that they’re not always clued up on HRT but ask if they’d be prepared to look at the documents and say you’re prepared to come back in the few weeks if that helps. So don’t accept ‘no’ but be constructive in asking for help.”
You can find Dr Sarah Ball at Newson Health