Hormone replacement therapy - choices and finding the path that's right for you

Menopause is a natural phase of life that every woman experiences, and with it comes a variety of changes in the body due to fluctuating hormones. While these changes are a normal part of aging, they can lead to symptoms that impact your daily life - hot flashes, night sweats, mood swings, and even joint pain. Hormone Replacement Therapy (HRT) offers one option to help manage these symptoms, but it’s not a one-size-fits-all solution.

So, how do you know if HRT is right for you? And what other choices do you have? Here’s a breakdown to help you navigate your options.

What Is HRT?

Hormone Replacement Therapy involves taking medications to supplement the body’s reduced levels of oestrogen and progesterone during menopause. There are two main types of HRT:

• Oestrogen-only HRT: Usually prescribed to women who have had a hysterectomy.
• Combined HRT (oestrogen and progestin): Recommended for women who still have their uterus, as it helps prevent the risk of uterine cancer.

These hormones can be administered in different forms - pills, patches, gels, or vaginal creams - depending on your needs and preferences.

The benefits of HRT

HRT can offer significant relief from many common menopause symptoms:

• Hot flashes and night sweats: One of the most common complaints, and HRT is highly effective in reducing their frequency and intensity.
• Vaginal dryness and discomfort: Oestrogen can help restore vaginal moisture and elasticity, easing discomfort during intimacy.
• Bone health: Oestrogen plays a key role in maintaining bone density, and HRT can help prevent osteoporosis and reduce the risk of fractures.
• Mood and sleep: For some women, HRT helps regulate mood swings, anxiety, and can even improve sleep quality.

Weighing the risks

While HRT offers significant benefits, it’s crucial to understand the potential risks, which can vary based on your health profile, the type of HRT, and how long you use it. Here’s a closer look at the most discussed risks, supported by research.

• Breast cancer: Studies have shown a slight increase in breast cancer risk for women who use combined oestrogen-progestin therapy over a long period. According to a large study from the Women’s Health Initiative (WHI), women using combined HRT had an increased risk of developing breast cancer by about 24% compared to non-users. For every 1,000 women on HRT for more than five years, there would be 8 more cases of breast cancer than in non-users . However, the risk decreases when women stop HRT.

• Blood clots (Venous Thromboembolism): Oral HRT, particularly estrogen pills, can increase the risk of blood clots. According to a BMJ study, women using oral oestrogen-only HRT have a 2-3 times higher risk of developing blood clots, while those on combined oestrogen-progestin therapy have a slightly higher risk. The risk is still small in general—about 1 in 500 women using HRT for one year will develop a blood clot .

• Stroke: The risk of stroke is slightly increased for women taking HRT, particularly at higher doses. The WHI found that women on HRT were about 40% more likely to have a stroke than those not on HRT. This risk, however, remains small. For every 1,000 women on HRT, there might be an additional 2 cases of stroke .

• Heart Disease: HRT has a complex relationship with heart health. For women younger than 60 or within 10 years of menopause, HRT might actually provide heart protection. However, for older women or those more than 10 years past menopause, the WHI found that combined HRT slightly increases the risk of heart disease by about 29%. The overall increase amounts to about 7 additional cases of heart disease per 1,000 women .

These risks can vary based on whether you take HRT as a pill, patch, or gel, and whether you are using oestrogen alone or in combination with progestin. In addition, certain factors like smoking, obesity, and preexisting health conditions may further affect your risk profile.

Alternatives to HRT

For some women, the risks outweigh the benefits, or they may prefer to take a different approach. Fortunately, there are alternatives to managing menopause symptoms:

• Non-hormonal medications: Medications like selective serotonin re-uptake inhibitors (SSRIs) and gabapentin can help reduce hot flashes and mood swings without the need for hormones.
• Natural remedies: Many women turn to supplements like black cohosh, red clover, or soy isoflavones, which are thought to mimic oestrogen’s effects in the body.
• Lifestyle changes: Regular exercise, a balanced diet rich in calcium and vitamin D, and techniques like yoga and mindfulness meditation can help manage symptoms like hot flashes, sleep disturbances, and anxiety.

How to decide if HRT is right for you

Choosing whether to pursue HRT is a deeply personal decision, and there’s no right or wrong answer. The key is to assess your health, symptoms, and what feels right for you. Here are a few questions to consider:

• Are your menopause symptoms affecting your quality of life?
• Do you have risk factors like a family history of breast cancer, heart disease, or blood clots that make HRT a less attractive option?
• Would you prefer to explore natural or non-hormonal remedies first?

Discussing these questions with your healthcare provider can help you weigh the risks and benefits. Your treatment should be tailored to your individual needs, and what works for one woman may not work for another.

The Bottom Line

HRT is one of many paths available to navigate menopause, and choosing the right one depends on a variety of factors. Whether you decide to pursue HRT, try natural remedies, or focus on lifestyle changes, the important thing is that you feel empowered in your decision. Remember, menopause is a natural transition, and finding the right path to manage your symptoms will help you embrace this new phase with confidence.