HRT reduces the likelihood of some debilitating diseases such as osteoporosis, colorectal (bowel) cancer, and heart disease if properly taken.
Menopause marks the end of menstruation in a woman’s life. It occurs because a woman stops ovulating (releasing a mature egg once monthly), and her ovaries no longer produce estrogen (one of the female sex hormones).
Menopause means ‘the last period’. It is a natural event that marks the end of the reproductive years, just as the first menstrual period during puberty marks the start.
Estrogen/Progesterone Therapy for Women
Many women, although not all, experience uncomfortable symptoms before and after menopause, including hot flushes, night sweats, sleep disturbance, and vaginal dryness. These symptoms and physical changes can be managed in various ways, including lifestyle changes such as healthier eating and increased exercise, and hormone replacement therapy (HRT).
Hormone Replacement Therapy (HRT): What is it?
HRT, also known as hormone therapy (HT) or menopausal hormone therapy (MHT), is a medication containing the hormones that a woman’s body stops producing after menopause. HRT is used to treat menopausal symptoms.
While HRT reduces the likelihood of some debilitating diseases such as osteoporosis, colorectal (bowel) cancer, and heart disease, it may increase the chances of developing a blood clot (when given in tablet form) or breast cancer (when some types are used long-term).
‘Premature menopause’ is when the final menstrual period occurs before a woman is 40. ‘Early menopause’ is when the final menstrual period occurs before a woman is 45. For women who experience premature or early menopause, HRT is strongly recommended until the average age of menopause (around 51 years), unless there is a particular reason for a woman not to take it.
Menopause symptoms and HRT
Menopause symptoms that may be relieved by HRT include:
- hot flushes and night sweats;
- vaginal dryness;
- thinning of vaginal walls;
- vaginal and bladder infections;
- mild urinary incontinence;
- aches and pains;
- insomnia and sleep disturbance;
- cognitive changes, such as memory loss;
- reduced sex drive;
- mood disturbance;
- abnormal sensations, such as ‘prickling’ or ‘crawling’ under the skin;
- palpitations;
- hair loss or abnormal hair growth;
- dry and itchy eyes.
Other therapies, including vaginal estrogen products, antidepressants, or other medications, may be used depending on the symptoms and risk factors. Seek advice from a doctor.
Added benefits of HRT
HRT reduces the risk of various chronic conditions that can affect postmenopausal women, including:
- diabetes – taking HRT around the time of menopause reduces a woman’s risk of developing diabetes;
- osteoporosis – HRT prevents further bone density loss, preserving bone integrity and reducing the risk of fractures, but it is not usually recommended as the first choice of treatment for osteoporosis, except in younger postmenopausal women (under the age of 60);
- bowel cancer – HRT slightly reduces the risk of colorectal cancer (bowel cancer);
- cardiovascular disease – HRT has been shown to reduce cardiovascular disease markers when used around the time of menopause.
Side effects of HRT
HRT needs to be prescribed for each woman individually. Some women experience side effects during the early stages of treatment, depending on the type and dose of HRT. These side effects will usually settle within the first few months of treatment and may include:
- breakthrough bleeding;
- breast tenderness;
- bloating;
- nausea.
HRT does not cause weight gain
Weight gain at menopause is related to age and lifestyle factors. An increase in body fat, especially around the abdomen, can occur during menopause because of hormonal changes, although exactly why this happens is not clear. Normal age-related decrease in muscle tissue, and a decrease in exercise levels, can also contribute to weight gain.
Most studies do not show a link between weight gain and HRT use. If a woman is prone to weight gain during her middle years, she will put on weight whether or not she uses HRT.
Some women may experience symptoms at the start of treatment, including bloating, fluid retention, and breast fullness, which may be misinterpreted as weight gain. These symptoms usually disappear once the therapy doses are changed to suit the individual.
Contraception and HRT
HRT is not a form of contraception. The treatment does not contain high enough levels of hormones to suppress ovulation, so pregnancy is still possible in women in perimenopause (the time of hormonal instability leading up to menopause).
Periods can be erratic in perimenopause, and egg production will be less frequent, but can still occur until menopause. For women younger than 50, contraception is recommended for at least two years after the final period. For women aged 50 and above, contraception is recommended for at least one year after their final period.
Long-term use of HRT
It is currently believed that, overall, the risks of long-term (more than five years) use of HRT outweigh the benefits. HRT should not be recommended for disease prevention, except for women under 60 years of age with a substantially increased risk of bone fractures, or in the setting of premature menopause.
No alternative therapy has yet been clinically proven to reduce a menopausal woman’s risk of osteoporosis, including the use of soy products, phytoestrogens (plant estrogens), and herbal medicines.
Women with liver disease, migraine headaches, epilepsy, diabetes, gall bladder disease, fibroids, endometriosis, or hypertension (high blood pressure) need special consideration before being prescribed HRT. In these situations, HRT is often given through the skin (transdermally).
Despite the risks of long-term use, in women with severe and persistent menopausal symptoms, HRT is the only effective therapy.
Women with premature or early menopause are prescribed HRT long-term because of their increased risks of earlier onset of heart disease, osteoporosis, and some neurological conditions compared to women undergoing menopause around the age of 50 years. Seek specialist advice; regular check-ups are recommended.
Testosterone Therapy for Women
Testosterone blood levels in women tend to peak during their 20s. This is followed by a gradual decline with age. By the time a woman reaches menopause, blood testosterone levels are about one-quarter of what they were at their peak. However, after the age of 65-70 years, women have testosterone blood levels similar to those seen in young women.
A sudden fall in testosterone blood levels occurs when women have both of their ovaries removed (surgical menopause). Other causes of low testosterone in women include:
- The use of the oral contraceptive pill – switches off testosterone production by the ovaries and produces a liver protein (SHBG) which may reduce the effects of testosterone;
- Oral steroid therapy – suppression of testosterone production by the adrenals;
- Anti-androgen therapy for acne, hirsutism, or scalp hair loss – drugs that block the actions of testosterone in body cells; and
- Complete loss of pituitary function (panhypopituitarism).
To exclude other potential causes, we recommend you talk to a healthcare professional.
What are the consequences of low testosterone in women?
The effects of low testosterone in women have been greatly debated for many years. Firstly, and most importantly there is no blood level that can be used as a cut-off to “diagnose” low testosterone in women.
Some studies have indicated that there may be an association between low sexual desire and low testosterone, but this has not been a consistent finding in all studies.
Is there any benefit of testosterone therapy?
A complete review of all the published studies published in 2019 has shown that postmenopausal women who experience a reduction in sexual desire, that causes them personal concern or distress, may benefit from testosterone therapy. This review also revealed that there is not enough evidence yet to show that premenopausal women will benefit from testosterone therapy.
Low sexual desire with associated distress has been also termed Hypoactive Sexual Desire Disorder (HSDD). As there are many reasons why women might experience HSDD if you are experiencing what you think is HSDD you should talk to a doctor and explore the full range of possible causes. It is only after doing so that testosterone therapy should be considered.
Some women are being treated with testosterone for reasons other than HSDD. IMS brought together a team of leading experts to review the evidence base of testosterone therapy and published our recommendations in a global Consensus Statement (2019).
The review found no clear evidence that testosterone improves wellbeing or mood and should not be used only for this purpose. The Statement concluded that there is not enough evidence one way or another to support the use of testosterone for any symptoms or medical condition other than HSDD.
How is testosterone given?
Testosterone can be taken as a tablet/ capsule, but this is not recommended for women or men as oral forms have unwanted effects on blood cholesterol levels.
If testosterone is used it should be in a non-oral form such as a skin gel, cream, patch, or implant under the skin. The dose of testosterone should reproduce blood levels that are seen in young women. Levels higher than this are likely to cause side effects such as excess body hair, scalp hair loss, and acne, and are considered unsafe.
There is limited availability of testosterone in a dose formulated for women. The global Position Statement (2019) recommendation is that if a formulation for women is not available, a small amount of an approved male formulation (as recommended by a doctor) can be used, with regular blood monitoring to check blood levels do not exceed those of young women. The international expert panel recommended against the use of compounded testosterone formulations.
Feel free to contact our team of medical experts for an additional free consultation.