HRT

Hormone Replacement Therapy

‘The Dilemma’

The Journey

From puberty till menopause, ovaries secret three main hormones e.g., Oestrogen, Progesterone and Androgen. It is the oestrogen deficiency that is responsible for most of the menopause symptoms.

What is HRT?

HRT stands for Hormone Replacement Therapy. It refers to the process of replenishing the diminishing ovarian hormones at or around the commencement of menopause. Women sometimes require the use of HRT earlier in life in cases where early or surgical menopause occurs. Early menopause is the cessation of periods (ovarian function) before the age of 40. Surgical menopause occurs when both ovaries are removed before the usual age of the menopause.  

HRT Benefits

HRT is more crucial than ever as we see women's life expectancy increasing year after year with research showing that women are commencing the use of HRT within 10 years of menopause. HRT is considered by many experts as the most effective way of managing the symptoms of menopause. Many women experience long-term health benefits which includes a reduction in the risk of osteoporosis, fractures, and heart disease.

Which Hormones do women need?

Oestrogen given alone, can restore the premenopausal balance and reduces your menopause symptoms. However oestrogen alone will increase the risk of uterine cancer. Unless the woman has had her uterus removed (by hysterectomy), progesterone needs to be given with oestrogen to reduce the risk of uterine cancer. Progesterone can be given in the form of oral tablets, patches or in the form of intrauterine device e.g., Mirena coil.

Androgen (Testosterone) can be added if there is a loss of libido.

HRT For Women with a womb

This group of women can be given HRT in two ways:

1.    Combined HRT (oestrogen and progesterone). This can be given in two ways:

a.    Sequential HRT. A usual 28 tablets packet contains 14 tablets of Oestrogen followed by 14 tablets of Oestrogen & Progesterone. HRT taken ithis way results in a monthly bleed. This kind of HRT is more appealing for women who still have their periods but suffer from menopause symptoms.

 b.     Continuous. A usual packet contains 28 tablets of both Oestrogen & Progesterone , taken daily without a break. Both hormones can be taken also as skin patches. This approach results in no bleeding. Continuous combined HRT is usually more suitable for women who are postmenopausal and have had no period for a year or more.

2.    Oestrogen-only HRT. This HRT contains oestrogen alone. This is more suitable for women who had hysterectomy or have a Mirena coil inserted.

HRT For Women after hysterectomy

These women can be divided into two groups:

  1. Women who had Total hysterectomy (Uterus and cervix removed):

    This group can safely take Oestrogen-only HRT, as there is no risk of developing uterine cancer.

  2. Women who have had a subtotal hysterectomy (the cervix was not removed):

    This procedure might not remove all the endometrium (Cells lining the womb). These cells can develop uterine cancer if stimulated by oestrogen only HRT. This group of women should ideally be treated as they are still having their womb and use continuous combined HRT as explained above.

Testosterone

The male hormone testosterone plays an important physiological role in female reproductive tissues, mood, cognition, breasts, bones, muscles, vasculature, and some other systems in women. Currently, the only evidenced-based indication for testosterone therapy in women is for treating low sex drive in women.

If needed, transdermal preparations (Cream, gel or Patches) are preferred. Continuation of treatment should be based on clinical response rather than blood tests, as hormone levels do not usually correlate with symptoms.    

Post-menopausal bleeding (PMB)

Post-menopausal bleeding (PMB)

Post-menopausal bleeding (PMB) is defined as unscheduled vaginal bleeding that occurs a year after the last natural menstrual period or any breakthrough bleeding on cyclical HRT or breakthrough bleeding after 6 months on continuous combined therapy when there has been established amenorrhoea. Women using sequential/cyclical HRT are expected to have regular bleed.

Bleeding with HRT

Abnormal bleeding while on HRT is a relatively common problem.  Literature reveals that 38% of women using sequential HRT and 41% of women on continuous combined HRT (CCT) report abnormal bleeding. The risk of cancer is usually less when using the continuous combined therapy HRT than when using sequential therapy or not using HRT.

What should I do if I have PMB

PMB is most frequently caused by benign gynaecological conditions, such as vaginal or endometrial atrophy secondary to oestrogen deficiency, endometrial or cervical polyps, uterine prolapse, use of vaginal rings and endometritis. Risk of endometrial cancer increases with diabetes, obesity, oestrogen only HRT, tamoxifen use for breast cancer treatment, nulliparity and some familial cancers. The possibility of a woman with PMB to have cancer is only 9%.

Women with PMB needs an urgent assessment. Other gynaecological cancers should be considered in the differential diagnosis such as vulval, vaginal and cervical cancers. Other non-gynaecological diseases such as urinary or gastrointestinal can also give rise similar bleeding that might be interpreted as vaginal.

 Assessment for PMB starts with a detailed history and physical general and pelvic examination. Timely evaluation of the lower genital tract and endometrium, with ultrasound, endometrial sampling and possibly hysteroscopy are all needed to establish a diagnoses and start treatment.