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Hormone Replacement Therapy - HRT

Every woman during perimenopause should consider hormone replacement therapy (HRT) and have the opportunity to discuss your individual risks, benefits and preferences with your health professional to optimise your health and reduce long-term risks of chronic disease.

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Menopausal Symptoms

During perimenopause, the amount of estrogen produced by a woman's body fluctuates and eventually reduces. These changes result in non-ovulatory cycles which also result in low progesterone levels. These hormonal changes can cause symptoms such as:

night sweats,
hot flushes,
sleep problems,
muscle and joint pains,
mood changes (low mood, fluctuating mood and anxiety),
irregular, heavy or longer periods,
vaginal dryness and discomfort with sex.

What is HRT Therapy?

Hormone replacement therapy (sometimes also called menopause hormone therapy or MHT) is the use of hormonal therapy to replace the oestrogen and progesterone (and sometimes testosterone) that your ovaries no longer make during and after menopause. It can help relieve some of the symptoms of menopause and support the function of body-wide tissues and organs.

Hormone replacement therapy can be used in every stage of menopause. During perimenopause it helps even out the higher and lower than phyiological hormone fluctuatons. After menopause hormones are replaced to minimise the inflammatory and deficiency states in every organ system created after menopause.

It is the most effective way to control menopausal symptoms while also providing other health benefits such as reducing the development of heart disease, diabetes and osteoporosis. It is safe for most women to use during perimenopause, menopause and post-menopause.

There are multiple options available that come in tablets, gels, patches and creams, and they come as separate hormonal preparations or in combination products.

The Women's Health Initiative Study

The Women's Health Initiative (WHI) study was two large clinical trials that looked at the effects of combined hormone replacement therapy (HRT) and estrogen only HRT. The results from this study led to a dramatic decline in prescribing of HRT, fear-mongering among the media and 20 years of suffering for many women as they experienced perimenopause.

Additionally it has contributed to increased risk of heart attacks, diabetes, osteoporosis, fractures, chronic pain, decline in brain health for a generation of women who were denied access to hormone therapy.

The WHI reported an increase in breast cancer and stroke risk in women taking HRT and a decrease in colorectal cancer and hip fracture risk. The studies were stopped prematurely.

Looking back through the data, following up the women for 20 years and with more recent clinical trials has shown that estrogen therapy without progestongen pose no increased risk breast cancer risk.

It also showed that using combined HRT (estrogen + synthetic progestogen) is increased by less than drinking alcohol daily and significantly lower than if your body mass index is high.

Types of HRT regimes

There are a number of different hormone replacement regimes.

Cyclical combined HRT

This mimics the normal menstrual cycle. Estrogen is taken every day and natural progesterone or progestogen for 12 to 14 days.

When the progestogen is stopped, there is some bleeding as the progestogen is “withdrawn” so the uterine lining (endometrium) is shed. Progestogen regulates bleeding and protects the endometrium from harmful pre-cancerous changes

Continuous combined therapy HRT

This type of HRT combines an estrogen and progestogen. They are prescribed continuously to achieve period-free HRT.

Estrogen Therapy

Estrogen only therapy is normally prescribed to women who have had their uterus removed (hysterectomy). It is also used for women whose only symptoms are vulval/vaginal or urinary symptoms (genitourinary symptoms of menopause) who are prescribed vaginal estrogen cream.

Body identical hormone replacement therapy is safer than non-body identical hormones.

Estradiol is a body identical estrogen. It has no increased risk of blood clot when used via the skin in a patch, gel or vaginal cream.

Oral micronised progesterone has advantages over synthetic progestins as it is converted to allopregnanolone in the liver which helps support sleep, brain health and mental health. Funding for this type of HRT therapy is now funded by PHARMAC in New Zealand.

What is Early Menopause?

Women who experience an early natural menopause (menopause before 45) or primary ovarian insufficiency (menopause before age 40) or medical or surgical menopause should take hormones until at least until age 51.

This is because they are at increased risk of early onset osteoporosis, heart disease and osteoporosis. It will work to prevent early onset of these chronic diseases, improve quality of life, and can be continued beyond the natural age of menopause if needed/desired and there are no reasons to stop use.

What are the benefits of HRT?

Symptom relief. There is clear evidence that HRT use during perimenopause is beneficial:

reduce the number and severity of hot flushes and night sweats,
improve symptoms of vaginal dryness and soreness,
improve sexual desire, and reduce pain with sex,
help to reduce recurrent urine infections,
improve mood and sleep
improve quality of life.

Use of oestrogen and progestogen HRT is also associated with some important improved long-term women's health outcomes, including reduced risks of:

osteoporosis fractures (44 fewer cases per 10,000),
diabetes (14 few cases per 10,000),
colon cancer (6 fewer cases per 10,000).
cardiovascular mortality
cancer mortality
premature death

What are the risks of HRT?

It is really important to talk to your health provider about YOUR individual health risks both as you transition through perimenopause about the use of hormone replacement therapy.

Perimenopause and menopause are a time of hormonal transition which increases women's risks of:

autoimmune disorders such as thyroid disease and rheumatoid arthritis
high blood pressure and heart disease - the biggest cause of death of women
cancers
metabolic disorders such as less stable blood sugars and diabetes.
reproductive depression and anxiety - hormone related mood disorders.
alzheimers dementia.

Your risk of these conditions need to be be considered alongside any potential risk to health that hormone replacement therapy could contribute.

Health risks of using hormone replacement therapy to treat menopause symptoms vary from woman to woman and will change as you age and depending on your health, when you start hormone replacement therapy and the length of time it is used.

There are minimal risks for using HRT in healthy women.

Starting HRT early, ie in perimenopause or early menopause has fewer risks than when it is started over a decade after your last period.

Risks generally increase as you get older.
The risks of developing blood clots while taking MHT is much higher for women who are obese, have severe varicose veins or have a close family member who has had deep vein thrombosis or pulmonary embolism.

Blood Clots

Hormone replacement therapy estrogen tablets do increase the risk of blood clots. This includes:

deep vein thrombosis (DVT) - leg vein blood clots
pulmonary embolus (PE) - lung vein blood clots
stroke - brain vessel blood clots.

The risk of developing a blood clot is higher in women who have higher body mass index, severe varicose veins or have a family history of bleed clots.

Endometrial cancer

There is an increased risk in women who have a uterus who use systemic estrogen (oral, patch or gel estrogen) if they do not also use progesterone or a progestin to protect the endometrial lining.

There is no increased risk of endoemtrial cancer if you are only using vaginal estrogens.

Breast Cancer risk

Breast cancer risk with HRT is complex.

Estrogen alone therapy is associated with both a reduced risk of breast cancer and a reduced risk of dying for breast cancer if you did get it while using HRT.

Different progestogens have different risk ratios for breast cancer.

Micronized progesterone (body identical progesterone) and dydrogesterone (similar in structure to natural progesterone) have low-no risk of breast cancer.

In women using combined HRT, there is apporixmately 8 extra cases per 10,000 for estrogen plus synthetic progestogen use.

For women with a family history of breast cancer, their risk of breast cancer is the unchanged by use HRT, except in women who carry breast cancer genes.

Women with a high body mass index (BMI) have an increased baseline risk of breast cancer. HRT use in these women does not further increase their risk of breast cancer.

The risk for breast cancer is NOT seen in women using hormone replacement therapy during the first 7 years of use.

Some recent studies have shown that vaginal estrogen cream use does not increase the risk of recurrence of breast cancer as vaginal estrogen is very low dose.

Conditions where HRT is not routinely recommended and needs special consideration

Hormone replacement therapy or MHT is not recommended for women with certain conditions, or careful consideration about what forms of hormones can be used needs to be discussed. Certain conditions include:

women who have had hormone-sensitive cancer such as breast cancer,
women at risk of heart disease,
women who have had a blood clot or at risk of having a blood clot.

Women who are at risk of heart disease/blood clot are recommended to use transdermal estrogen options and avoid oral estrogen.

Women with a history of hormone sensitive cancers or breast cancers and are wishing to use HRT should have a consult to discuss their specific risks and benefits of using and not using HRT so they are able to make the best informed decision for their own health.

If HRT is not for you there are other lifestyle, supplements and non-hormonal medications that may help reduce your symptoms.

HRT and contraception

Most forms of HRT do not provide contraception. Only the Mirena as the progestin component of HRT can be used as contraception.

Although fertility declines during perimenopause if you are wanting to prevent pregnancy it is recommended that contraception should continue 2 years after your final period if this occurs prior to 50 years, and for 1 year if your final period occurs after age 50 years of age.

What Are the Side Effects of HRT?

MHT can cause side effects such as breast tenderness, fluid retention, mood changes, menstrual spotting and bleeding. If you get any of these side effects, talk to your doctor or nurse prescriber as you may need a change of dose.

Frequently Asked Questions

Does HRT cause breast cancer?

No. Hormone replacement therapy does not cause cancer. In certain women it may give a small absolute increase in risk, in combination with other factors but hormones are not the cause of cancer.

Estrogen and progesterone receptors are sometimes found on breast cancer cells. These are called hormone dependent cancer because the cancer relies on the hormones for ongoing function.

These hormone receptors are also found on healthy breast cells as this is how the body triggers changes in breast tissue at puberty, through the menstrual cycle, during pregnancy, during breast feeding and at perimenopause.

Does HRT cause weight gain?

There is a decline in female hormones estrogen and progesterone at menopause as well as testosterone. These changes trigger metabolic changes and influence other hormones such as insulin. They also cause a decline in bone and muscle turnover which results in declining muscle and bone mass through the late 30s and 40s and an increase in abdominal weight gain.

HRT, alongside a whole food diet, aerobic and resistance exercise, adequate sleep and stress management can help stabilise blood sugars, reduce insulin production, chronic inflammaton and maintain a healthy weight during perimenopause.

What are alternatives to HRT?

There are a number of lifestyle habits, supplements and non-hormonal medications that can be used if you cannot use hormone replacement therapy.

Read more about 5 Pillars of Menopausal Health

Are bioidentical hormones available and funded in New Zealand?

Yes. Estrogen patches and vaginal estrogen creams use body identical estradiol. Estrofem tablets and estrogel is also made from body identical estradiol.

Micronised progesterone, also known as utrogestan is body identical progesterone.

Estradiol patches and vaginal cream and utrogestan are fully funded body identical hormones by PHARMAC.

For women who cannot take these or prefer not to there are alternative forms of HRT that may suit them.

Welcome to Ōtepoti Integrative Health Menopause Clinic

Let's get started!

Ōtepoti Integrative Health is a holistic menopause clinic. We care about how hormones, perimenopause and menopause are impacting the whole of your life, including work and relationships as well as your health and wellbeing.

At Ōtepoti Integrative Health, Dr Deb Brunt can tailor the type of hormone replacement therapy best suited to you, depending on your medical history, family history, symptoms, risk factors and your preferences.

She also provides comprehensive well woman health assessments and supports your to create healthy lifestyle habits.

Let's work together

Menopause Resources

Australasian menopause society

North American menopause society