More than half the world's population will experience menopause in their lifetime. So the number of misconceptions which still surround the topic is disappointing at best.
On average, women will hit menopause at the age of 51, while perimenopause can start as early as the late 30s. More than 75% of women will get symptoms, according to the National Library of Medicine. Hot flushes, brittle bones, anxiety, depression, brain fog, low libido, UTIs, insomnia, joint pain and heavy vaginal bleeding are just a few debilitating side effects that women can experience.
Usually multiple symptoms are experienced at once, which can have a devastating impact on someone's life. WalesOnline previously spoke to Tracey Bowen and Lisa Nicholls whose symptoms were so serious that it led to the end of their careers.
Read more: World Menopause Day: Quarter of men admit that don't understand what menopause is
Hormone Replacement Therapy (HRT) is a group of treatments used to combat the physical and mental effects of the menopause. For many, HRT is a lifeline as they struggle to go about their normal lives without it. However, others recoil in horror at the thought of taking it - even menopause sufferers who are very unwell.
Most of the fear associated with HRT stems from a flawed and now discredited study by the Women's Health Initiative in 2002. The study suggested that HRT raised a woman's risk of cancer and heart disease. Recent studies have debunked much of the data reported in the study. Instead modern studies suggest that if HRT is taken correctly and at the right point in someone's menopause, it can protect the heart and will have little - if any - impact on the likelihood of a woman to develop breast cancer in most cases. New types of body identical HRT reduce the risk even further. In the vast majority of cases, the benefits far outweigh the risks. You can get more health news and other story updates straight to your inbox by subscribing to our newsletters here.
In the last year or so, more people have started talking openly about the menopause - most notably Davina McCall with her documentary - Sex, Myths and the Menopause. It has increased the confidence of people asking for HRT as well as the GPs prescribing it. According to a report by NHS Business Authority, almost half a million more UK women were prescribed at least one Hormone Replacement Therapy medicine in 2021/22 - up 35 per cent on the year before. In Wales prescriptions for HRT have increased by more than 90% in the last five years and more than 40% since 2020/21, according to the Welsh Government.
Although awareness and education has helped thousands more women to reap the benefits, there are still complications which prevent many from accessing it. For example, twice as many women living in the least deprived areas were prescribed HRT compared to those living in the most deprived areas.
And what's more, several HRT shortages over the last two years have seen women travel far and wide to access it - often to no avail. The effects are so devastating for some women that they have even tried to import it into the UK themselves. In light of Menopause Awareness Day on Tuesday, October 18, we have asked two menopause specialists in Wales to debunk the major myths associated with taking HRT.
Dr Michelle Olver is an accredited menopause specialist and trainer for the BMS and the Faculty of Sexual and Reproductive Healthcare (FSRH). She plays an active role in education in both undergraduate, postgraduate, primary and secondary care settings and has worked with the FSRH to devise the new educational products offered by them to teach health care professionals about the menopause.
Dr Jayne Forrester-Paton is a British Menopause Society (BMS) accredited menopause specialist and GP. She established and is the clinical lead for the Cardiff East NHS Menopause clinic. She works as a menopause specialist within Aneurin Bevan’s menopause service as well as a GP and women’s health lead for Llan Healthcare, a large GP practice based in East Cardiff. She is also a proud member of the Wales Menopause Network. Here's what they had to say on HRT:
What is HRT?
Dr Forrester-Paton said: "HRT is hormone replacement therapy. Essentially what you are doing is if you’ve gone through the menopause naturally or surgically, you’ve lost oestrogen and some of your other hormones and then we are just giving them back. There are different types of HRT and the risk associated with the different types is different - this is often where the misconception comes in."
According to the NHS website, there are many different types of HRT and finding the right one for you can be difficult. There are different HRT hormones, methods and plans, including:
- HRT hormones – most women take a combination of the hormones oestrogen and progestogen, although women who do not have a womb can take oestrogen on its own (oestrogen only HRT can increase your risk of endometrial cancer if you have a womb)
- Ways of taking HRT – including tablets, skin patches, gels and vaginal creams, pessaries or rings
- HRT treatment plans – HRT medicine may be taken without stopping, or used in cycles where you take oestrogen without stopping but only take progestogen every few weeks
Some women are also prescribed testosterone alongside HRT, which can improve libido, mood, fatigue and cognitive function. It's not currently licenced for use in women on the NHS, although it can be prescribed by a specialist doctor if they think it will help.
Why has the 2002 WHI study been discredited?
Dr Forrester-Paton said: "The study meant lots of women and doctors were frightened of HRT and it wasn’t prescribed so much.
"The study has since largely been discredited in that the participants were much older than the age we’d normally start women on HRT. They used old types of HRT compared to what we use now, they didn't use body identical types. Therefore, lots of the findings cant be generalised
"Even if you look at the study, the suggested increased risk of breast cancer is very small. More recent studies have looked at women who use body identical HRT and there doesn't look to be any increase in the risk of breast cancer in the first five years of use. After that, yes, there is evidence that suggests more women will get diagnosed with breast cancer on HRT than not. However, that risk is very small: four or five per thousand."
Can I take HRT if I'm at risk of breast cancer?
Dr Olver said: "The three leading causes of death in women now are stroke, heart disease and dementia and HRT can potentially help with two out of three of those things. Lots of people automatically think breast cancer is the leading cause of death in women and then they decide they don't want to take HRT.
"I have breast cancer referrals all the time which say: 'this lady can’t have HRT'. It’s all about helping them understand what we know about the risks, talking to them and then signposting them to evidence so they can make a decision for themselves.
"We have women who could have [complications] associated with HRT but they accept the risk. I wouldn’t tell somebody not to do a bungee jump because there’s a chance they’d die. It’s up to them to make that decision on whether that risk is worth it for them, for quality of life, and we support women through those decisions."
She said that, although some women would be willing to take that small risk to ensure they had a better quality of life, other women with the same small risk might not want to take the chance. It should be up to the individual with the support of education.
Dr Forrester-Paton said Utrogestan was a body identical progesterone that did not appear to cause an increase in breast cancer for the first five years of taking it. After this, the risk remained low.
"But women’s biggest risk of breast cancer comes from their own baseline risk," she said. "What’s my family history? How much do I weigh? How much do I exercise? Do I smoke? All these lifestyle risk factors contribute way more to a woman's likelihood to develop breast cancer than being on HRT
"A conversation I have with a lot of my patients is that a lot of them get to a point where they feel horrendous. They gain weight due to the hormonal changes, they feel low and anxious and they don’t go out as much. They stop exercising, they might start drinking because of the insomnia or mood. Actually, when they get on HRT, they feel healthier and they feel better about exercising again. They cut down their alcohol and they feel more able to tackle these other issues which have a bigger impact on their risk of breast cancer than actually taking the HRT. It's about being able to have that discussion with women.
What are the health risks associated with menopause if I don't take HRT?
As Dr Olver stated, heart disease is one of the top three killers of women, along with strokes and dementia. Although the 2002 study suggested that HRT increased a woman's chance of having a heart attack, recent studies challenge this theory and suggest - particularly with modern types of HRT - the opposite is true.
Dr Forrester-Paton said: "Around the menopause we know the risk of certain health conditions increases. Because of the loss of oestrogen, our risk of osteoporosis increases. This means as soon as we start going through the menopause, our bones start to thin.
"Our risk of heart disease goes up dramatically. Before menopause, our oestrogen protects us and we have a far lower risk than men of the same age. Then, as soon as we go through the menopause, that risk ratchets up. Heart disease is one of the biggest killers of women - which is something women should balance when thinking of the breast cancer risk associated with HRT. Women are much more likely to die of heart disease than they are of breast cancer - even though breast cancer is what women say they fear most.
"Being on HRT can cut your risk of heart disease by 50%. Studies show that women live longer on HRT as it decreases overall mortality - but that doesn’t mean it is for everyone and not everyone has to take it. It's important to consider there's a flip side to the risks associated with HRT, there are benefits."
Is there anyone who can't take HRT?
Dr Olver said: "There isn’t anyone I wouldn’t give HRT to if they were aware of all the risks. The biggest thing I can think of is breast cancer, especially women who have oestrogen sensitivity cancers. But even the NICE guidelines say women who are having really severe symptoms and are having a really poor quality of life and have breast cancer, we can trial them with HRT as long as they are informed."
Are there any alternatives?
Dr Olver said: "There are other options, you don’t have to give patients HRT. There are non-hormonal and non-invasive options. Cognitive behavioural therapy (CBT) is one which we have in house (at the clinic) and there are other medications which will help with their symptoms. HRT might not be my first line choice for someone, but if a woman says she’s tried these methods and wants to go on HRT then I would support them. We have breast cancer patients on our books who take HRT."
Dr Forrester-Paton said: "There are different types of HRT and the risk associated with the different types is different - and this is often where the misconception comes in. There are a lot of women out there who can’t take contraceptive pills because of migraines, weight and blood clots. Women are told 'if you can’t take the pill you can’t take HRT either', but they are quite different.
"If you take it through the skin - transdermal HRT - it takes away any clot risk and it makes it much, much safer. That and using things like body identical Utrogestan progesterone are so much safer that the majority of women can take them and it’s safe for them to have."
Why are / were some GPs hesitant to prescribe HRT?
Dr Forrester-Paton said: "Even the computer system I use flashes up with a million different warnings when you go to prescribe someone HRT, and as someone trained in menopause, I know none of them are relevant and that I’m prescribing HRT safely. If you imagine a GP with no menopause training, you can imagine them going to prescribe something and several red warnings come up: risk of breast cancer, risk of blood clot, risk of stroke. Lots of doctors are going to go: 'Oh my God, I don’t want to harm anyone'."
What HRT clinical studies are happening right now?
Dr Olver said: "The study I’m most interested in is called the UK HRT trial. It's basically giving HRT to breast cancer sufferers. It's based in London and it's in active follow-up now. The results will be massive. All the studies done on breast cancer patients have been done with synthetic HRT whereas this will be using the body identical stuff. The other study which is currently recruiting is for young women who go through the menopause. There is also research looking for other non-hormonal treatments for breast cancer sufferers."
What is going on with the HRT shortage?
Dr Forrester-Paton said: "There have been some horrendous issues with shortages. It has been an issue since around April time. First it was Oestrogel. Now no issues there, but so many women switched to Sandrena, Lenzetto and patches and it then created many more shortages.
"I still feel like Lenzetto is hard to get hold of and sandrena can be hit and miss. Patches really depend on strength and brand. The BMS produces an updated list of stock shortages on its website, but it doesn’t always reflect what is happening locally. For example, when oestrogel was reported to be back in stock it took a few more weeks before I saw improvement. It also really depends on the pharmacy chain.
"We have been advising women to shop around, sometimes this can lead them to going to several pharmacies to find what they need. There have been government statements on HRT shortages as there was an outcry from women - quite rightly - about this recurring issue. It also wastes a lot of clinical time as we field call after call from women who need to be switched to something in stock. I feel things are better than over the summer, but still issues are ongoing."
A Welsh Government spokeswoman said: “We are concerned that some women are experiencing difficulty in obtaining hormone replacement therapy. The UK Government is responsible for maintaining medical supplies to the UK and they have committed to improving the supply of HRT.
"We have provided advice to all prescribers about which products are in short supply and which suitable alternatives are available to ensure women can have ready access to HRT products if their prescribed medication is unavailable. Community pharmacies are also able to supply alternative HRT treatments without referring women back to the GP in some circumstances. Anyone who is having difficulty obtaining treatment should contact their doctor or pharmacist to discuss what alternatives might be available.”
READ NEXT:
- World Menopause Day: Quarter of men admit that don't understand what menopause is
- Women discuss the positives of menopause - including no more periods or PMS
- Woman says clueless doctors misdiagnosed menopause symptoms causing 10 years of torment
- Lives of mothers and babies at risk due to severe shortage’ of midwives, say RCM
- Worried ITV presenter Ruth Dodsworth says she is 'looking over her shoulder' as her ex gets out of jail
