How women benefit from HRT
Professor Studd, one of the world’s foremost researchers and expert on hormones, wrote this excellent article on the benefits and risks of HRT. Also look in my archives for August 14th, where I outlined all the lovely things oestrogen does for women.
Ten reasons to be happy about hormone replacement therapy: a guide for patients
Professor John Studd, DSc,MD,FRCOG was Consultant Gynaecologist at the Chelsea & Westminster Hospital, London and also Professor of Gynaecology at Imperial College. He qualified in 1962 and has worked and trained in Birmingham. Zimbabwe and London. He was Consultant Gynaecologist in Salisbury, Rhodesia and Consultant and Senior Lecturer at the University of Nottingham and moved to London in 1974 as Consultant Obstetrician and Gynaecologist at King’s College Hospital. Six years ago he was invited to join the staff at the new Chelsea & Westminster Hospital, London.He is Founder and Vice-President of the National Osteoporosis Society and has been a Council Member of the Royal College of Obstetricians and Gynaecologists for 12 years and a Past-President of the Section of Obstetrics and Gynaecology at the Royal Society of Medicine. In 2005-2007 Professor Studd was Chairman of the British Menopause Society.
- London PMS and Menopause Clinic, London, UK
- Correspondence: Professor John Studd, London PMS and Menopause Clinic, 46 Wimpole Street, London W1G8SD, UK. Email: firstname.lastname@example.org
In spite of the negative press reports following the 2002 Women’s Health Initiative (WHI) publication, women can be reassured that in the correct circumstances, hormone replacement therapy (HRT) is beneficial and safe, particularly if treatment is started below the age of 60. Transdermal estradiol is probably safer than oral estrogens as coagulation factors are not induced in the liver and HRT is safer if a minimal duration and dose of progestogen is used. HRT is effective for the treatment of estrogen-deficiency symptoms of flushes, sweats and vaginal dryness. Estrogens prevent osteoporotic fractures and should be first-choice therapy, rather than bisphosphonates. Similarly, HRT protects the intervertebral discs in a way that non-hormonal preparations do not. Estrogens perhaps with the addition of testosterone help certain sorts of reproductive depression, as well as improving energy and libido. There is new evidence to support the previous observational studies that HRT reduces the incidence of heart attacks. Estrogen therapy has a beneficial effect upon collagen, thus improving the texture of the skin, the nails, the intervertebral discs and bone matrix. Discussion of side-effects should not be avoided, particularly the 1% extra lifetime risk of breast cancer. This should be balanced against the fewer heart attacks, fewer deaths and less osteoporotic fractures in those who start HRT below the age of 60.
(1) HRT will stop your hot flushes and sweats
Troublesome hot flushes, severe night sweats and headaches causing chronic insomnia are characteristic symptoms of the menopause. These symptoms may last for many years. Apart from being socially embarrassing they result in tiredness and depression because of lack of sleep. These symptoms can almost invariably be cured with the correct small dose of estrogen. Although selective serotonin reuptake inhibitor antidepressants have been suggested for the treatment of vasomotor symptoms, no other treatment is nearly as effective as estrogens. Women who still have a uterus should still have 7–12 days of progestogen in order to produce a withdrawal bleed and prevent endometrial hyperplasia.
(2) Estrogens will treat vaginal dryness and many causes of painful intercourse and lack of libido
Thinning of the pelvic tissues producing vaginal dryness and occasionally bleeding is another characteristic result of estrogen deficiency that occurs after the menopause. This also can be successfully treated with estrogen either by tablets or through the skin by patches or gels or implants. Transdermal estrogen therapy is probably the safest and most effective route as hepatic coagulation factors are not stimulated. Local estrogens can also be given for this symptom using local vaginal applications of weak estrogens such as oestriol that are hardly absorbed. Other related problems of painful intercourse, loss of libido and recurrent ‘cystitis’, if due to pelvic atrophy are also effectively treated by systemic or long-term local vaginal estrogens.
(3) HRT increases bone density and prevents osteoporotic fractures
Every study confirms that estrogens are the most effective way of increasing bone density and preventing osteoporotic fractures even in low-risk women. This treatment is very safe when started in women under the age of 60. It is more effective and beneficial than the bisphosphonates that are frequently used by bone physicians as first choice and by general practitioners unsure about the safety of estrogen therapy. These non-hormonal drugs with their considerable long-term complications should have no place in maintaining bone density in women under the age of 60. For the recently menopausal women receiving estrogen therapy for climacteric symptoms such as flushes, sweats or vaginal dryness, there will be a considerable increase, up to 15% in 10 years to such an extent that osteoporotic fractures 20 years later in the older women are much less likely to occur. If these women have low bone density, even without typical menopausal symptoms, estrogens must be seen as first-choice therapy. For those younger women with severe osteopenia or osteoporosis due to premature menopause, early hysterectomy and oophorectomy or anorexia with amenorrhoea, estrogens are an essential long-term treatment.
(4) HRT protects the intervertebral discs
Important recent studies from several centres have shown conclusively that estrogens prevent collagen being lost from the intervertebral discs, thus maintaining their strength and function. These discs make up one-quarter of the length of the spinal column and act as cushions preventing crush fractures of the vertebral bodies. It is these crush fractures that lead to loss of height and the lordosis of the upper spine known as the Dowager’s hump. This important protective effect of estrogens seems to be unique as bisphosphonates and the other non-hormonal treatments of low bone density do not have any beneficial effect upon the discs.
(5) HRT does reduce the number of heart attacks
There are about 30 years of evidence from many observational trials that estrogens reduce the incidence of coronary heart disease. This has subsequently been questioned by the 2002 WHI Study, which showed an increase in heart attacks. However, this study looked at patients of the wrong age and who were using the wrong dose of estrogen and progestogen. Subsequent reports from the same investigators have shown a very much reduced incidence of heart attacks in women who start HRT below the age of 60. This is particularly apparent in women who have had a hysterectomy and can have estrogens without progestogen. The view now is that HRT, particularly estrogen alone, is very safe and is associated with a reduced number of heart attacks if started below the age of 60. Thus there is primary prevention of coronary heart disease, but there is no evidence of protection in women with established coronary damage.
It would appear that the factor that is associated with the apparent increase in severe side-effects such as breast cancer and heart attacks and possibly stroke is the progestogen component of HRT. As progestogen also produces unwanted PMS-type side-effects of depression, anxiety, bloating and loss of libido in patients who are progestogen intolerant, it is sensible to keep the dose of oral gestogen to a minimum. The alternative is to insert a Mirena intrauterine system, which produces amenorrhoea and avoids the use of oral progestogen with its side-effects for five years or more.
(6) Estrogens help depression in many women
Estrogens are more effective in the treatment of depression in premenopausal or perimenopausal women than post- menopausal women. However there is no doubt that depression is helped in postmenopausal women who have been suffering from night sweats, insomnia or vaginal dryness, painful intercourse and marital problems in that most of these problems can be effectively treated and removed. However, it is true that the most impressive effect on mood is seen in younger perimenopausal women in the 2–3 years before the period cease in the menopausal transition. This cannot be diagnosed by blood tests but by a careful history. This depression often occurs in women who are sensitive to abrupt changes in their hormones, either endogenous oestradiol or progesterone. These women had previously had postnatal depression and premenstrual depression in what should be known as reproductive depression. They often also have cyclical headaches/migraines that occur with the cyclical hormonal fluctuations at menstruation. As premenstrual depression becomes worse with age, it blends into the more severe depression of the transition phase and is very effectively treated by moderately high-dose transdermal estrogens used by patches, gels or implants.
(7) HRT improves libido
HRT certainly improves libido if estrogens are used to cure vaginal dryness and painful intercourse. Even without these characteristic symptoms, estrogens can improve sexual desire. However, if necessary, the addition of testosterone has a more dramatic effect upon libido, frequency of intercourse and intensity of orgasm. Testosterone patches licensed in women after hysterectomy and testosterone gels in the appropriate dose are often and should be used ‘off license’ with full consent and explanation.
Women must be aware that testosterone is not only a male hormone but it is an essential female hormone present in women in about 10 times the blood levels as estrogen. It is an essential hormone, important for energy, mood and sexuality.
(8) HRT improves the texture of the skin
After the menopause, women lose about 25% of their body collagen, which is manifested by thin inelastic skin, brittle nails, loss of hair and loss of the collagenous bone matrix. This latter loss is an essential cause of osteoporosis and osteoporotic fractures. Estrogen therapy replaces the lost collagen in the skin and the bone. Its affect on the facial skin is a very obvious useful cosmetic effect.
(9) ‘I am a nicer person to live with’
This is a quote from a patient. Many women say that when estrogen therapy stops their depression, their loss of libido and their irritability, they become more agreeable people for their partners to live with. The depression, irritability, grumpiness and loss of energy and disinterest in sex can usually be improved considerably by the appropriate doses of the appropriate hormones that may include testosterone as well as estrogen.
(10) HRT is safe
In spite of the press reports stressing bad news, virtually all claims of major adverse effects from the WHI study have been reconsidered even by the investigators. It seems quite clear that the reported major side-effects of breast cancer, stroke and heart attacks occurred in women who started the wrong dose of HRT over the age of 60. In women who started below the age of 60 there were fewer heart attacks, fewer deaths, fewer osteoporotic fractures and even less breast cancer in this study. It is probable that the one residual side-effect is a small 1% extra lifetime risk of developing breast cancer, but this is no more than the breast cancer risk of being overweight, drinking wine, having no children or even taking statins.
- © 2010 The British Menopause Society
Professor of Gynaecology, The London PMS Menopause Centre, London.
Until recently it was believed that HRT was an extremely safe treatment for vasomotor symptoms, osteoporosis, depression and a major preventative measure for heart disease, colon cancer, Alzheimer’s disease and probably strokes. This has all been turned upside down by two greatly flawed studies, The Women’s Health Initiative, (WHI) and the Million Women Study (MWS). These will be discussed.
There is no evidence that oestradiol given in the appropriate dose in women below the age of 60 is associated with serious side effects although the addition of continuous progestogen may be the harmful factor in the causation of cardiovascular disease.
The WHI study studied a single preparation, Prempro (not available in this country), in the belief that one dose fits all patients. This is untrue because different women require different dose via a different route with different combinations of different hormones for different symptoms for different symptoms with different surgical status and for different ages. There was an added fault in that patients were recruited who were without symptoms – hence none of them needed this inappropriate therapy anyway.
This paper describes the different therapies required in women after hysterectomy and bilateral salpingo-oophorectomy, for premature menopause, for the perimenopausal patients with depression or libido problems, for women in the early post menopausal state and for older women in the late menopausal state.
Women with vasomotor symptoms or pelvic atrophy are easily treated with low dose oestradiol either by the oral route or by transdermal gel or patch. The treatment can last for the duration of the symptoms and there is no reason to limit therapy to 5 or 10 years. In patients with a uterus they will require endometrial protection with a progestogen which can be for the orthodox 14 days or continuously or, with patients with progestogen intolerance for 7 days each month.
Young women with premature ovarian failure need oestrogen therapy to protect their bones and their cardiovascular system as well as prevent symptoms until at least the age of 50 – the time of the normal menopause. If there is a suggested limit for the duration of HRT then the counting starts from the age of 50, the age of the normal menopause. It is important to check the bone density of these patients before treatment and every 3 years.
After hysterectomy and bilateral salpingo-oophorectomy, women need oestrogens, sometimes in the higher dose than for more mild symptoms. If they have lost their ovarian androgens, they benefit from the addition of testosterone. These women often suffer symptoms of the female androgen deficiency syndrome, (FADS) which is loss of energy, loss of libido and loss of self confidence, depression and headache. The ideal way to treat these patients is by implantation of oestradiol 25 mgs and testosterone 75 mgs every 6 months.
Patients with perimenopausal depression which is often linked with cyclical premenstrual depression are better treated with transdermal oestrogens in the form of oestradiol patches 100 mcgs or even 200 mcgs. This not only wipes out the cycles producing the cyclical symptoms of PMS but has a mental tonic effect for the perimenopausal women. These women of course require cyclical progestogen tablets but as these women with hormone responsive depression, (perhaps better called reproductive depression) are progestogen intolerant, a Mirena IUS should be considered.
Osteoporosis can usually be prevented by oestradiol therapy and the bone density can be increased in established osteoporosis by the use of oestrogens which produce plasma oestradiol levels of at least 300 pmol/L. This is a most effective therapy, more effective than bisphosphonates or SERMS but of course will not correct any deformity that may have occurred in established osteoporosis.
Many patients have loss of energy and loss of libido and these respond well to a higher dose of oestradiol with or without testosterone. Patients should have a clear explanation of the advantages and the putative dangers of HRT and their need for HRT assessed every year. The lowest effective dose should be used for the appropriate symptom or indication remembering that a higher dose is required for depression or correction of osteoporosis than for vasomotor symptoms.
Older post menopausal women who need oestrogens for pelvic atrophy or established osteopenia or osteoporosis should initially have a very low dose possibly with unopposed oestrogens because the major side effects of the WHI study occur in older women receiving combined oestrogen and progestogen therapy.
The strange syndrome of chronic fatigue syndrome/PMS is associated with low plasma oestradiol levels, low bone density and an excellent response to transdermal oestrogens with or without testosterone. This infrequently recognised condition needs further study.
There may be an increased risk of breast cancer after 5 or 10 years but these data are disputed and on a practical level it is very difficult to persuade women who feel well on HRT to discontinue. Until this issue is clarified, I believe patients should be advised to have a mammogram every 18 months.
Endocrine Society Statement.
Hormone Replacement Therapy or Menopausal Hormone Therapy offers significant benefits to women around the menopause suffering from moderate to severe menopausal symptoms.
The Australasian Menopause Society welcomes the publication of a complete analytic review of the evidence on the use and safety of menopausal hormone therapy. The US-based Endocrine Society has published a scientific statement “designed as a comprehensive, rigorously documented, objective, scientific analysis of existing data evaluating the benefits and risks of hormone therapy for menopausal women.”
The Review Committee consisted of a group of experts with clinical experience from across the world including three from Australia. The report outlines the risks and benefits according to their level of evidence, level A being the highest level of evidence.
The major level A conclusions were that Menopausal hormone therapy improves the symptoms of the menopause, including vaginal and bladder symptoms, prevents early postmenopausal bone loss and prevents hip and vertebral fractures. Combined oestrogen and progesterone therapy reduces colon cancer risk and oestrogen and oestrogen plus progestogen therapy increases mammographic density. The risks include a 2 fold risk of venous thrombosis with oral Menopausal Hormone Therapy, which is further increased when other factors such as weight and age are taken into account. Cancer of the uterus is a risk in women taking oestrogen alone but not with oestrogen and progestogen, but either therapy increases the risk of gallbladder disease. Stroke risk is not reduced in older women on hormone therapy. Testosterone as a patch developed for women improves sexual function whereas DHEA does not.
Other conclusions are of weaker levels of evidence.
The President of the Australasian Menopause Society, Dr Elizabeth Farrell, believes this is a very important scientific review outlining for women and health professionals information about the use of hormone replacement therapy. Many women suffer the symptoms of the menopause and should be given rational and up to date information about the safety and risks of the therapy. These women should be able to be prescribed without fear that has been relayed in the past using inaccurate levels of evidence.
The full report from the Endocrine Society can be downloaded from this site:
The statement is published in the July 2010 issue of the The Journal of Clinical Endocrinology and Metabolism.
Menopausal Hot Flushes – new report shows women don’t have to suffer, says International Menopause Society
International Menopause Society – press release
Embargoed until: 00.01, 18th October, 2011
Up to a quarter of women suffer a poorer quality of life because of hot flushes and night sweats associated with the menopause. Now the International Menopause Society (IMS) is marking World Menopause Day (18th October) with a new report* highlighting the problems associated with the menopause, and by calling for women and doctors to be more aware of the treatment possibilities for troubling menopausal symptoms.
The majority of women suffer from hot flushes or night sweats (also known as vasomotor symptoms or VMS) during the menopause. The exact numbers vary by culture, ethnic group, and individual health background, but on average 25% of women experience debilitating or distressing symptoms. These symptoms include depression, discomfort and embarrassment, causing real problems for women, their partners and their families. On average these symptoms may last 4 years, although some women are less troubled whereas some women have significant symptoms which are longer-lasting.
The IMS commissioned a multi-disciplinary comprehensive review of the evidence behind hot flushes and night sweats (published in the peer-reviewed journal Climacteric). As a result of the review, the IMS concludes that women should be less accepting of the problems caused by menopausal symptoms, and calls for women to be more proactive in asking for treatment.
women should be less accepting of the problems caused by menopausal symptoms, and calls for women to be more proactive in asking for treatment.
Hot flushes are caused by dilation of the blood vessels and increased flow of blood to the trunk, head and neck. This can cause reddening of the skin, and sweating. Night sweats are hot flushes which take place during sleep, so disrupting sleep and causing fatigue and stress.
These symptoms can lead to physical discomfort, embarrassment, fatigue, and loss of confidence, often leading women to avoid social situations. The impact of hot flushes on quality of life varies with a variety of factors, including the frequency and duration of the flushes, a woman’s lifestyle and how she views her symptoms. A woman may enter a ‘vicious cycle’, where the symptoms lead to problems in coping with her everyday life, which in turn leads to problems in coping with the symptoms.
The review concludes that Hormone Replacement Therapy (HRT) shows the best results in treating VMS, with up to 90% of symptoms being abolished within 3 months of starting the treatment. However, not all women can take HRT, and for them there may be alternatives such as SSRIs and other non hormonal medications as well as psychological methods of treatment (e.g. using cognitive behavioural therapy).
The IMS review cautions against the use of untested or unproven methods of counteracting VMS, Some techniques such as acupuncture have shown mixed results