Facing up to menopause: To HRT or not
Hormone Replacement Therapy (HRT) was a no-go for me and I was fortunate to have a fairly easy transition through the main couple of years of hormonal change, around 51 years old. However it may be very helpful relief for other women who suffer the unpleasant symptoms more and for longer. Whatever your personal situation, be sure to understand the pros and cons, and ensure that your advising doctor screens you for health risks and prioritises your best interests.
Read more as I share some research I did into HRT while at college (references available), which reassured me that I could live well without HRT.
How did HRT start?
HRT was first available in the early 1940’s as Oestrogen Replacement Therapy after the US FDA approved use of injections of synthetic oestrogen, derived from the urine of pregnant female horses, to treat hot flushes and related menopausal symptoms (1).
During the 1950’s, concerns about increasing rates of uterine cancer in women on ORT prompted the release of synthetic progesterone, progestin, which could be used in combination therapy(2), now known as HRT. Its use was widely promoted to prevent heart disease, delay aging and maintain strong bones. Robert Wilson’s book “Feminine Forever”, published in 1966 and claiming that synthetic oestrogen could completely prevent menopause to maintain youth and femininity, drove demand for HRT(3).
However use of HRT declined sharply during the 1970’s after various studies reported significantly increased risks of endometrial cancer, breast cancer, strokes, and blood clots. During the 1980s and 1990s, reports of HRT’s protective effects against osteoporosis, and possibly heart disease, restored some interest, before results of two major trials, the Heart and Estrogen/Progestin Replacement Study (HERS) published in 1998 and the Women’s Health Initiative (WHI) published in 2002, reported poor outcomes and increased risks of breast cancer, stroke, heart attack and blood clots in women with heart disease as well as in healthy women.
Research continues to examine the WHI data to identify specific risk factors that predispose women to these health risks, and opportunities to use HRT more safely for its deemed benefits.
Bottom line: it’s not suitable for all women.
What’s happening to us women in menopause?
Menopause is the permanent cessation of menstruation due to loss of ovarian follicular activity(4). Some ovarian oestrogen production continues at reduced levels, but ovarian progesterone production ceases without ovulation(3) . Our adrenal glands become the main source of these hormones. These changes in production and activities of hormones affect all parts of the body: the condition of our skin (epithelial cells); cholesterol levels (changes in lipid profile) and bone integrity (due to demineralisation of bone)(5).
Oestrogen is a potent antioxidant, and its decline is directly associated with aging of skin and atrophy of the urogenital system, from oxidative damage in epithelial cells, reduced blood flow and reduced secretions causing localised dryness and loss of acidity(4) . We become more vulnerable to vaginal infections. Chronic cystitis anyone?
Cortisol levels rise without the suppressing effect of oestrogen, leading to increased levels of circulating blood glucose, higher blood pressure, reduced stomach acid and impaired digestion that can cause bloating, diarrhoea and constipation. Excess blood glucose is converted to triglycerides and deposited as abdominal fat, with associated weight gain. These effects contribute to the characteristic changes in lipid profile of increasing cholesterol, triglycerides and LDL (the so called “bad” cholesterol) and lower HDL (“good” cholesterol)(5).
Bone demineralisation increases without adequate oestrogen to suppress bone resorption(5) or progesterone to stimulate bone building(6). Reportedly we postmenopause women can lose 1-2% of bone density per year(7). This is cause for concern about potential osteoporosis.
So how can we maintain normal bone density during aging?
We can help ourselves maintain normal bone mineral density (BMD) as we age with
adequate dietary intake of all the bone building minerals and cofactors
adequate vitamin D for gastrointestinal absorption of calcium
healthy gut microflora that endogenously produce vitamin K involved in bone mineralisation
a balanced healthy diet and lifestyle that avoids stimulating excessive bone resorption
weight-bearing exercise that promotes muscle- and bone strength.
The recommended daily intake (RDI) of calcium for women older than 50 is 1300 mg/day, and with a serum blood vitamin D level in excess of 50 nmol/L. Healthy bones also require adequate absorption of other nutrients including magnesium, silicon, boron, vitamin K, vitamin C, inositol and L-arginine(8). We also need adequate magnesium for healthy function of our parathyroid gland, which controls how our body regulates calcium. Vitamin K2 can be produced by beneficial bacteria in the distal small intestine and colon, and contributes to reducing bone turnover and improving bone strength(8)
Thus bone health is much more complicated than the simplistic claims that we need calcium from eating dairy products. We need a nutrient rich diet, which avoids high salt foods and excessive animal protein that increase calcium loss through the kidneys, as well as highly refined carbohydrates that elevate blood glucose and increase metabolism of calcium in the synthesis of insulin. Stress management and avoiding corticosteroid medications also help to suppress cortisol stimulation of blood glucose.
We are also advised to do modest impact activity for 20 minutes three times weekly to improve our BMD(9)
Can HRT benefit some of us?
This is what MacLennan(7) advocates:
HRT as the only scientifically validated effective therapy for oestrogen deficiency symptoms and loss of bone density leading to osteoporosis, evidenced by quality randomised controlled trials of HRT. He recommends use of small maintenance doses of oestrogen with progesterone and testosterone where necessary, for the following benefits:
alleviation of hot flushes, night sweats, sleeplessness, low libido, joint pains and vaginal dryness that causes discomfort during intercourse
reduced loss of bone mineral density and spine and hip fracture risk
reduced risk of developing colorectal cancer and diabetes
reduced genitourinary problems in old age, including urinary and vaginal infections, incontinence and vaginal dryness.
He(8) suggests that the health concerns identified in the WHI study related primarily to older women with other pre-existing adverse health conditions and to use of oral HRT, and should not be assumed to be applicable to women who begin taking HRT in midlife, rather than years later. There may be beneficial reduction in the risk of heart disease, strokes and developing Alzheimer’s disease when HRT is started from this earlier age.
He also advises that side effects that include irregular bleeding, breast tenderness, pre-menstrual like symptoms, and increased risks of gallstones, uterine fibroids and thromboembolism can be avoided with non-oral HRT and different dosages.
He acknowledges the evidence of increased risk of breast cancer, but argues that this is compensated by evidence of reduced risk of bowel and uterine cancer, and that there is not enough evidence of increased risks of other cancers to justify not using HRT if it can improve a woman’s quality of life.
He believes that with the exception of women with pre-existing heart disease, risk factors for heart disease or oestrogen dependent cancers, HRT can be managed to achieve health benefits that outweigh the risks.
He also suggests that no health condition should be an absolute contraindication to HRT if the potential risks are understood, if HRT is effective in symptom control and if quality of remaining life is a high priority.
What about downsides of HRT?
Nelson etal(10) presents an alternative risk assessment of HRT based on a systematic review of nine randomised, placebo-controlled trials that studied the effect of HRT on prevention of cardiovascular disease (CVD), cognitive decline, osteoporosis and cancer. This assessment included four trials that were part of the WHI, and five other studies.
The review confirmed the following benefits when using oestrogen only therapy:
reduction in incidence of- and mortality from breast cancer and
reduction in fractures
and with combined therapy:
reduction in diabetes
reduction in fractures and
some evidence of a protective effect against colorectal cancer.
It also confirmed statistically significant high risk when using oestrogen only therapy or combined therapy of
deep vein thrombosis
gallbladder disease and
and when using combined therapy, further high risk of
lung cancer mortality
Nelson acknowledges that most of these study participants were generally older women using oral-HRT, and hence should not be assumed to be applicable to a younger age group and use of non-oral HRT. Interpretation of the results was also complicated by low adherence to the HRT protocols and high attrition (drop out) of participants.
Consequently, there is arguably neither enough validated evidence of increased adverse health outcomes for a younger cohort starting HRT earlier and with non-oral HRT, nor enough scientific evidence of acceptable safety in using HRT.
On the basis of Nelson’s review, the US Preventive Services Task Force (USPSTF) continues to recommend against the use of combined therapy for the prevention of chronic conditions in postmenopausal women, and likewise against the use of oestrogen only in postmenopausal women who have had a hysterectomy(11). But this advice does not apply to use of hormone therapy to treat menopausal symptoms, such as hot flashes or vaginal dryness.
Other opponents to HRT argue that it interferes with our body’s own capacity to adjust to changing hormone levels, and itself creates other imbalances with ill-effect. Instead it should be possible to support a healthy body naturally to gradually adjust to these hormonal changes with minimal discomfort(12).
What does a natural alternative to HRT look like?
A natural alternative to HRT is to manage diet and lifestyle to maximise nutritional support for the body’s physiological needs, maintain a good metabolism and minimise stressors that deplete the body nutritionally or stimulate adverse hormonal responses, particularly from the adrenal glands.
A good diet will be nutrient rich and comprise a diversity of food types, predominantly vegetables and fruit to provide essential micronutrients, antioxidants and phytochemicals that help counter oxidative damage.
Digestive enzymes can be used if necessary to support a well-functioning digestive system so nutrients are properly digested and absorbed.
Fermented foods and probiotics can be used if necessary to maintain a healthy balance of gastrointestinal microflora, that help maintain healthy bowel function and detoxification, as well as producing vitamin K2 that is needed in bone mineralisation.
Incorporating phytoestrogen-rich food in the diet can help alleviate moderate to severe menopausal symptoms(12) . A meta-analysis of studies of red clover isoflavones has shown their efficacy in significantly reducing vasomotor symptoms of hot flushing, and a potential long term benefit on reduced bone turnover(13) .
Reducing stress helps avoid disorders associated with hormonal disturbances arising from adrenal fatigue or adrenal exhaustion.
Regular exercise helps with stress management and maintenance of muscle mass and bone strength.
This approach helps the body adjust naturally to a new hormonal balance and supports healthy physiological function without the risks of HRT.
It was my choice to adopt a natural approach to transitioning through menopause. I encourage and support my 40-something year old female patients to prepare for a smoother, happier menopause experience by changing to healthier habits sooner rather than later.