Should women take HRT before the menopause? Some experts now say it’s the best way to ease your symptoms – and avoid long-term health problems
- Recent survey found many menopausal women are struggling without HRT
- Some specialists say they should take preventative action in their 40s
Until now, most women – and doctors – have thought you should only seek help for the menopause if symptoms become unbearable.
Even then, concerns about possible side-effects have led many GPs to recommend that women try to manage without hormone replacement therapy.
In the meantime, the attitude has been to just get on with life.
But as a survey published last week found, many menopausal women are struggling to do that. Half those interviewed were depressed, and one in three suffered from anxiety.
More than a quarter found their symptoms – such as exhaustion, hot flushes, memory loss and depression – made it difficult to cope with everyday life. Significantly, many said their GP either failed to recognise their problems as resulting from the menopause, or refused to prescribe treatment such as HRT.
The survey highlighted how a generation of women is struggling to cope with their menopausal symptoms without treatment or support.
But now some specialists are calling for a radically different approach; they say women shouldn’t just have to cope, but should be encouraged to take preventative action in their 40s, when early menopausal changes occur. This preventative action – in the form of lifestyle changes and possibly hormone-balancing medication – could help women avoid potentially distressing menopausal symptoms in their 50s, and also reduce their risk of conditions related to the menopause, such as osteoporosis and heart disease in older age.
Many don’t realise the menopause is approaching
From the age of 40, most women’s levels of oestrogen and progesterone start to decline and they produce fewer eggs – this marks the start of the perimenopause.
In the early stages, normal menstrual cycles are interspersed with abnormal cycles; as hormone levels gradually decline, the number of abnormal cycles gradually increases and periods eventually stop. The ‘menopause’ is when a woman has her last period (the average age for this in the UK is 52).
For decades, menopause research has centred on this point, and on the post-menopausal years.
But focus is now shifting to the perimenopause – when hormone levels become increasingly erratic as they decline.
It is at this time that women can start to experience symptoms such as increased anxiety, mood changes and trouble sleeping. However, because early symptoms can be mild and women are still having periods, these symptoms are often not recognised as being hormone-related.
Mild or not, the unpredictable fluctuation in hormones can be enormously distressing, says Dr Marion Gluck, a London-based private GP who specialises in women’s hormonal health.
One month, for instance, a woman’s oestrogen levels might take a sharp dip, triggering flushes, sweats and disturbed sleep, along with depression, irritability and anxiety. The next month, an unexpected progesterone dip could trigger breast tenderness, foggy thinking and headaches.
‘Perimenopause is the single most difficult time in a woman’s life,’ says Dr Gluck. ‘It is arguably worse than menopause because your hormone levels can fluctuate wildly.’
Women are told it’s just depression
The added stress of these changing symptoms can exacerbate anxiety, fatigue and mood swings, which are all too often then misdiagnosed as depression.
Dr Gluck adds: ‘Doctors are much too quick to prescribe anti-depressants. They should be asking women about their menstrual cycle, how they sleep, whether they have a reduced libido, tiredness, anxiety or a general loss in confidence – all very common signs of perimenopause.’
It’s at this point, before the menopause and before strong symptoms kick in, that experts now advocate stepping in. Last Saturday, World Menopause Day, was marked by their call to see the perimenopause as a time of great medical opportunity, and not the uncomfortable and slightly embarrassing life stage which it’s so often regarded as.
The International Menopause Society, made up of endocrinologists and gynaecologists, now recommends intervention in the form of lifestyle changes, and earlier use of HRT – in low doses – to reduce the fluctuations and keep oestrogen levels boosted for longer.
They say these hormone-balancing therapies will not only halt the progression of symptoms, but will provide more years of protection against conditions such as osteoporosis and heart disease.
Women’s risk of developing these can rise dramatically when the protective effect of oestrogen is lost.
For these reasons, all women should ask for a perimenopausal health check on their 50th birthday to discuss any symptoms, suggests Dr Heather Currie, a gynaecologist at Dumfries and Galloway Royal Infirmary in Scotland, and honorary secretary of the British Menopause Society.
‘If women are targeted early enough with information about lifestyle changes they can make, and possible hormonal adjustments through forms of HRT, they can not only reduce the severity of symptoms – perimenopausal and menopausal – they can get an early start on protecting their health.’
Cut back your daily coffee intake
The lifestyle recommendations are straightforward – studies consistently show that smoking, caffeine, alcohol and refined carbohydrates exacerbate the detrimental health effects from dropping oestrogen, and can also make perimenopausal symptoms worse (see box, right).
If these lifestyle changes seem fairly unremarkable, the use of HRT for the menopause – let alone the perimenopause – divides opinion.
In the Nineties HRT was widely regarded as a wonder treatment and women would take it well into their 70s. But a major study published in 2002, the Women’s Health Initiative trial, found that it increased the risks of heart disease, stroke, blood clots and breast cancer. Subsequent studies and re-analysis of the data have suggested these dangers might have been exaggerated.
‘However that study is in the undergraduate text books,’ says John Studd, formerly professor of gynaecology at Imperial College London. ‘It remains in the minds of many GPs and it will take a generation to get rid of it.’
In fact, research over the past 12 years shows that starting HRT in the perimenopause provides more benefits than risks, controlling symptoms and reducing risk of heart disease and fractures, suggests Dr Currie.
Much of her work for the British Menopause Society involves educating GPs about these kinds of research developments.
GPs, however, fight shy of offering HRT unless symptoms are debilitating. As vice-chair of the Royal College of GPs, Dr Tim Ballard speaks for many of them. He says that HRT should only be given for a short period (up to two years), so women are likely to be advised to wait until symptoms are severe before they are prescribed it.
Women need more support from GPs
Yet those advocating early intervention controversially suggest women can actually take HRT for much longer than this – even into their 60s; the important thing is getting the timing right. Dr Currie, who at 55, has herself has been taking HRT for three years, says studies show the risks of HRT are more likely to occur when it is started too late.
‘It is perfectly fine to start HRT even if you are still having periods and certainly for the first few years after your periods stop. But the key is not to wait to start taking it until more than ten years after the menopause,’ she says. ‘If HRT is taken for more than five years after the age of 50, there may be a small increased risk of breast cancer being diagnosed. HRT doesn’t appear to cause breast cancer, but in a very small number of cases it could promote growth of cancer cells which are already present.
‘But right up to the age of 60, regardless of when HRT was started, and for many women even after age 60, the benefits outweigh the risk.’
Some women will simply not want to take hormones.
And the jury is still out on the long-term safety of different forms of HRT. Studies suggest hormones taken orally can increase the risk of blood clots because they have to pass through the liver – which hormones delivered via patches, creams and implants do not.
Others prefer to prescribe ‘bio-identical’ hormones made from plant extracts (rather than animal origin), claiming they more ‘closely mimic’ natural hormones and have fewer side-effects. They are not, however, regulated.
John Studd, who now works privately in London, has been prescribing bio-identical hormones for the past 20 years. ‘And I am convinced they are very safe,’ he says. ‘Every woman should be able to get them from their GP.’
Which brings us back to last week’s survey and the finding that nearly a quarter of women who’d seen their GP about their symptoms said the menopause was never discussed.
Women need more support, says Dr Gluck. ‘Some lucky women glide through this time in their lives unbothered by symptoms, but for others, perimenopausal symptoms can border on psychosis. You shouldn’t wait until you are desperate to see a specialist -it should be enough to be able to say ‘I just don’t feel like my old self any more’.’
A spokesperson from the Royal College of Obstetricians and Gynaecologists said: ‘The symptoms of the menopause can have a drastic effect on the quality of life for some women, so it is important for GPs and practice nurses to pick these up.
‘Not all women experience the same symptoms and some require specialist treatment. In the case of HRT, care should be individualised according to the woman’s needs.
‘Arbitrary limits should not be placed on the duration of usage of HRT; if symptoms persist, the benefits of hormone therapy usually outweigh the risks.
‘If HRT is to be used in women over 60 years of age, lower doses should be started, preferably with a transdermal route of administration [a patch].’
Simple steps to ease the impact
The following lifestyle changes can reduce your symptoms and protect your long-term health:
Cut back on refined carbohydrates. Women who consume lots of high sugar food and drinks (including wine) are more likely to produce poor-quality eggs, which in turn pump out less oestrogen, potentially making perimenopausal symptoms worse.
Quit smoking – it triggers the liver to produce oestrogen-destroying enzymes, making menopausal symptoms worse.
Lose weight – being overweight exacerbates menopausal symptoms. It’s thought larger people have a higher body temperature, making flushes and sweats more likely or worse. Being overweight can also raise your risk of heart problems and breast cancer.
Cut back on alcohol – this can lower the incidence of menopausal hot flushes. Drinking is thought to raise oestrogen levels temporarily, making the drop back to normal levels more extreme and sudden once the alcohol has been metabolised.
Cut back on caffeine – it’s bad for bone health (it leaches calcium from bones), and studies show any more than 3-4 caffeinated drinks a day can make hot flushes worse.
Exercise regularly – studies show that women who exercise have fewer and milder flushes, night sweats and sleep disturbances. Exercise is also great for heart and bone health.
How the specialists coped with their own fluctuating hormones
Dr Heather Currie, 55, a gynaecologist at Dumfries and Galloway Royal Infirmary, Scotland
I was very convinced about the heart and bone health benefits of HRT, but thought I should wait until I experienced perimenopausal symptoms.
However, I got to 50 without any and wondered if I should make a few up to give my GP justification for the prescription.
But things changed very suddenly when I was 52 – I went through a period of very disturbed sleep, with night sweats, and became extremely tired. My skin also went extremely dry and blotchy. So I was given an oestrogen tablet and things returned to normal within a few days – though it can take longer for many women.
I also cut back on alcohol and caffeine, started exercising more regularly, and cut down on carbohydrates. I’m still taking the pills, and I’ve had a very good menopause so far.
Dr Marion Gluck, 64, a private GP who specialises in women’s hormonal health
I started getting heart palpitations in my late 40s which can be a common perimenopausal symptom, so I use a cream that combines bio-identical [plant-based] forms of hormones. Over the years I have adapted my dosage according to my symptoms. I sleep well and have no mood swings, and am still on the hormones.
Gabrielle Downey, 53, a consultant gynaecologist at City Hospital Birmingham and BMI Priory Hospital
I’m active, I eat very healthily and I don’t smoke, so thought I’d sail through the menopause – I certainly wasn’t planning to take HRT. But then it hit like a thunderclap on my 52nd birthday.
It was night sweats first, then I was waking at 3, 4 or 5am and spending my days with a foggy head.
The crunch came when I found myself in surgery unable to find the word I needed for an instrument. I was taken completely by surprise by this foggy-brained old woman I’d suddenly become.
I assumed it was lack of sleep and over-work, but I asked a GP friend to put me on a short trial of HRT to see if it could make any difference. Within ten days of having a combined oestrogen and progestogen patch, I was completely back to my normal self.
My plan is to stay on HRT for as long as I’m working as a consultant (and need full focus), then I’ll do a short trial without to see if my symptoms recur.
Parveen Abedin, 46, consultant gynaecologist at Birmingham Women’s Hospital and BMI Edgbaston in Birmingham
In a couple of years I will be entering the full throes of the perimenopause – with a strong family history of heart disease and stroke, and osteoporosis, I would definitely consider going on HRT even without having menopausal symptoms.
I will probably start on a combination of a low dose oestrogen and progesterone, preferably as a patch applied to the skin which has less risk of a blood clot.
Zita West, 58, fertility specialist
I noticed intermittent hot flushes when I was around 47, then when I reached 50 my periods suddenly stopped.
I went to five different menopause specialists, had lots of tests and got completely different responses from each.
I started HRT, but came off it after a few months because I was worried about side-effects. But within a few months the hot flushes were becoming more bothersome, affecting my sleep, and I was feeling exhausted.
So I went to see a private GP to ask about bio-identical hormones.
For the past 18 months I’ve been taking oestrogen gel (one dab a day), progesterone pessaries, occasional vaginal oestrogen, and a hormone supplement, DHEA (which is thought to boost oestrogen levels). I finally feel I’m on top of things again.
My energy levels have returned and no more flushes.
I’m planning to stay on the hormones for as long as I need (with regular check ups) both for the protection they offer to my bones and heart health, but also for the feelgood factor. www.zitawest.com