A health watchdog has stressed that hormone replacement therapy (HRT) should be the first treatment offered to women with symptoms of the menopause.
The National Institute for Health and Care Excellence (Nice) said “HRT is the the preferred, recommended approach” for managing symptoms such as hot flushes, insomnia and low mood, and should be offered by GPs in discussion with patients about the risks and benefits.
This announcement follows drafted guidance from the health body last November which suggested that cognitive behavioural therapy (CBT) could be offered as an alternative or alongside HRT – but NICE has now emphasised that CBT is an add-on therapy.
Contrasting information about HRT has gained significant media attention over the last few years, so we have asked the experts to unpick the following statements to establish which are the facts, and which are myths.
1. HRT causes breast cancer
“The risk of breast cancer when taking HRT is very small in most cases, and depends on many factors including the type taken and how long you take it for,” explains Dr Samantha Wild, women’s health lead at Bupa Health Clinics. “When HRT is stopped then the risk falls and there is no increased risk of dying from breast cancer.”
Wild stresses that lifestyle factors play a more influential role in this risk.
“It is also very important to put the risks of taking HRT into perspective against lifestyle risks for developing breast cancer,” highlights Wild. “Most women don’t realise that the risk is greater from drinking more than 14 units of alcohol a week, and is doubled if their body mass index is over 30.”
2. HRT causes heart problems
“The idea that HRT causes heart problems is outdated for most women, especially those under 60 or within 10 years of menopause,” says Dr Shirin Lakhani, women’s intimate health and menopause expert. “In fact, some studies suggest that starting HRT early can have protective effects on heart health by helping to maintain lower cholesterol levels and improved cardiovascular health.”
The form of HRT (oestrogen-only or combined with progestogen) and the method of delivery could also make a difference.
“For instance, transdermal oestrogen (applied through the skin) is often preferred for women at higher risk of heart problems,” notes Lakhani.
3. HRT causes blood clots
“When HRT is taken transdermally in the form of patch, gel or spray, it is not associated with an increased risk of blood clots, but when it is taken orally there is a very small increase in risk of venous blood clots,” clarifies Mrs Pradnya Pisal, consultant gynaecologist at London Gynaecology.
Lakhani explains, “Transdermal HRT forms bypass the liver, leading to fewer changes in blood clotting factors.”
Some women have a higher risk of blood clots than others.
“The risk increases with age, and also with things like obesity, smoking, a history of clots, or genetic clotting disorders (such as Factor V Leiden),” explains Lakhani. “Women with these risk factors may still be able to use HRT but are usually advised to opt for transdermal rather than oral forms.”
4. Natural treatments are more effective and safer than HRT
“Natural (herbal) treatments are not more effective than HRT, however in some women they can relieve menopausal symptoms adequately,” explains Pisal.
Lakhani adds: “Many ‘natural’ treatments, including herbal supplements, are marketed as safe alternatives to HRT. However, these products are often not regulated as strictly as prescription medications, meaning their quality, dosage, and efficacy can vary significantly.
“Also, most natural treatments lack rigorous scientific evidence regarding their safety and efficacy.”
5. You should not start on HRT too young
“You can start taking HRT as soon as you experience menopausal symptoms and do not have to wait for periods to have stopped,” says Wild. “Women who experience premature menopause or primary ovarian insufficiency (reaching the menopause when they are under 40) must absolutely consider taking HRT to prevent some of the long-term health consequences of oestrogen deficiency.”
6. HRT causes weight gain
“There is no evidence which suggests this,” clarifies Wild. “Women may gain some weight during the menopause, as a natural part of ageing, but this can happen whether you are taking HRT or not.
“Making lifestyle changes, such as exercising regularly and eating a balanced diet should help to manage weight gain.”
7. You should wait until your symptoms are unbearable before you start taking HRT
“If you’re experiencing menopause symptoms you can take HRT to help reduce these symptoms, it doesn’t matter if these are mental health related, hot flushes, vaginal dryness – HRT can help all of these,” confirms Wild. “They don’t need to be unbearable, and I know many women tend to just ‘put up’ with them but that doesn’t need to be the case.
“If someone is experiencing significant symptoms with the menopause or if they have had an early menopause, it’s really important to discuss that with their doctor so they can give individualised advice.”
8. You need blood tests and examinations before your doctor will prescribe HRT
“Perimenopause is a clinical diagnosis based on symptoms and does not require blood tests for diagnosis,” confirms Lakhani.
However, there is a role for testing when appropriate.
“Blood tests may be recommended for women who experience menopause at an unusually young age (before age 45) or for those with irregular symptoms where the diagnosis is unclear,” highlights Lakhani. “In cases of premature ovarian insufficiency (POI) or early menopause, hormone level testing can help confirm the diagnosis and guide treatment.”
