The management and treatment of menopausal symptoms depend on each individual woman’s experience.

Opening up a conversation about Hormone Replacement Therapy (HRT) or Menopausal Hormone Therapy (MHT) as it’s also commonly called, is like opening up any conversation about health and choice – there will always be strong opinions swinging on either side of the argument.

In fact, the majority of folk will give themselves whiplash trying to keep up with the pros and cons, ultimately putting any decision in the too-hard basket until it’s actually relevant to them.

Menopausal Hormone Therapy certainly isn’t immune from this. For every woman who says that hormonal treatment saved them from insanity, there are plenty of others who would prefer to go au natural for the sole reason of avoiding the major newsworthy complications like breast cancer, blood clots, or heart disease.

It’s worth understanding a few things, however: the study these claims were originally based on is almost 20 years old, it used a medically questionable testing group, and medicine has progressed significantly since then.

Also, not all hormone treatments are the same and – most importantly – not all women are the same, so expecting the same outcomes and effects as your friend, sister, aunt or mother needs to be looked at objectively.

“We need to go back to basics and look at exactly what menopause is, what MHT is, and join the dots from there in order to make informed decisions for ourselves,” says Dr. Jane Reffell, a Bangalow-based GP for women’s health and active member of the Australasian Menopause Society. “When I first started to specialise in this area and actually go through this passage myself, finding information was challenging.

“Even as a doctor, I thought menopause was when periods stopped and that was it. People weren’t speaking about menopause, and certainly not interested in studying it. Thankfully, things have changed, there is information available, but we’ve still got a long way to go.

“We need to understand that menopause is an oestrogen withdrawal, it’s puberty backwards. MHT is keeping a little bit of oestrogen there in reserve just to manage symptoms.”

– Dr. Jane Reffell

Still, it’s quite overwhelming amidst hot flashes and sometimes unravelled brains to make sense of all the data. So, let’s clear up the confusion and give clear guidance on the good, bad, and ugly of Menopausal Hormone Therapy.

THE WOMEN’S HEALTH INITIATIVE STUDY

Okay, so let’s talk about the elephant in the room. Hormone Replacement Therapy (as it was historically known), started in 1942 with the release of a conjugated oestrogen pill called Premarin, relieving women of their menopause symptoms. Apart from relieving women of these symptoms, studies showed that HRT also helped prevent osteoporosis and heart disease in postmenopausal women. By 1992, Premarin was the highest-selling drug in the world.

In 2002, things changed drastically. The Women’s Health Initiative was a randomised study of 27,000 women in the United States that began in 1990. The study was designed to find out whether older women who started on HRT after menopause (ie not for its intended purpose of managing menopausal symptoms) would enjoy the same heart-health benefits as younger women who started taking it during peak menopause symptoms.

The average age of participants was 63, with 25% of participants over 70 years of age. Essentially the study was trying to find out whether the known health benefits of HRT meant you’re “never too old” to start.

While results from the WHI showed that there was a slight increase in breast and endometrial cancer risk, there was a distinct decrease in DVT, stroke, heart disease, along with decreases in the risk of bowel cancer and hip injuries.

However, with the release of the news that HRT had a link to breast and endometrial cancers, the reputation of HRT was irreparably damaged, with governments immediately issuing new guidelines saying HRT should only be used for managing ‘severe’ cases of menopausal symptoms.

MENOPAUSAL HORMONE TREATMENT TODAY

“Menopausal Hormone Therapy is never unidimensional,” says Dr. Raffell. “These days, we use transdermal MHT treatments (gels, patches, creams) frequently, which have far lower doses of oestrogen, and the risks associated with a transdermal application are significantly decreased, especially with clotting.

“MHT is also known to reduce the risk of cardiovascular disease and diabetes, so clinicians needed to carefully weigh the costs and benefits for the individual patient.”

DO NATURAL OPTIONS WORK?

Let’s be super clear here, though. In no way are we saying that the choices in handling menopausal symptoms are split between MHT or suffer in silence.

In fact, for many women, more natural remedies work wonderfully. “It really depends on the severity of the symptoms,” says Dr Raffell. “Naturopaths can make great mixes – black cohosh, red clover, and ginseng have excellent qualities and some fantastic testing results.

“Exercise is essential and be aware that alcohol tolerance goes down. If symptoms like hot flushes and migraines are occurring frequently, maybe natural isn’t enough to manage this pathway. They are an excellent place to start, though.

“And always remember, what works for one might not for another. This experience and all treatments are all highly individual.”

WHO CAN TAKE MHT AND WHEN CAN YOU START?

MHT is safe for healthy women around the time of normal menopause. Women with premature or early menopause are usually recommended to take MHT until the normal age of menopause (about age 50 years).

Some women should avoid MHT including women with a personal history of breast cancer (note that having breast cancer in the family is not a contraindication), a history or increased risk of blood clots, a history of heart disease or stroke, or untreated high blood pressure

Most women will tolerate MHT well. However, any side effects (such as bloating or breast tenderness) should be discussed with the prescribing doctor.

WHAT ARE THE RISKS AND BENEFITS OF MHT?

While all medical treatments pose some risk, are the risks of treating menopause symptoms worth the benefits that hormone therapy can deliver?” asks Dr. Jane. “That’s the question that women have been asking and hoping that research can clarify.”

The main benefit of MHT is that it effectively treats menopausal symptoms and can significantly improve quality of life. It also protects bones from osteoporosis and reduces the risk of fracture, but only while it is taken. Any risks associated with taking MHT will depend on a woman’s previous medical history and current health. Risks also vary between oestrogen alone MHT and oestrogen plus progestogen preparations.

For risks, both kinds of MHT (oestrogen alone and combined MHT) increase the risk of blood clots in the legs and lungs. MHT may also increase the risk of stroke, though this risk is very small and may depend on a woman’s age. Oestrogen alone increases the risk of endometrial cancer, but adding progestogen prevents this. Studies show combined MHT increases the risk of developing breast cancer after 5 years of use, but this is not seen in women taking oestrogen alone. Always discuss the individual risks of taking MHT compared to the likely benefits with your doctor.

Lifestyle choices are always going to play a huge part in any and every chapter of our health lives. But sometimes, green smoothies and active wear just aren’t enough. Menopause also isn’t going to discriminate – there is no way of telling who’s going to need all the tools in the tool kit to survive this phase and who’s going to breeze on through. The key is to not be ashamed to ask for help from your GP.

“As little as 100 years ago, the life expectancy of women was around 40 – 45 years of age,” says Dr. Jane. “There were two very distinct periods in a woman’s life – childhood and childbearing.

“These days, our life expectancy is 85, meaning there are 30 years of life after menopause. We need to reframe our thinking – women go into this part of their lives thinking it’s the end when really, it’s the gateway transition through to the next phase.

“We are so youth-obsessed. Instead, let’s look ahead and create beauty in this phase. Let’s empower each other to do that.”

Whatever stage in peri-to-post menopause you are, it’s important to know that there are valid options available to everybody. Finding an expert and somebody who is working in conjunction with the latest research is essential. Heading over to the Australasian Menopause Association website is a great starting point where you can look for a menopause specialist in your area.

FURTHER READING

Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials.  (2017) JE Manson, AK Aragaki, JE Rossouw, et al.  

Experts rip into HRT-cancer study (2019) as reported in The Australasian Menopause Society

The Controversial History of Hormone Replacement Therapy (2019) A. Cagnacci and M. Venier

Managing Menopause

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