Hormone replacement therapy: To take or not to take?

There is a big discussion about the use of hormones in women during menopause. Some 10 years ago, results of big clinical trials confused almost all the patients and even many doctors. We know today that much of the information has to be seen from different perspectives, case by case and the treatment options have to be individual. There is no one-size-fits-all therapy.

Menopause is the stage in a woman’s life when menstruation stops. This normally is a process lasting several months or even years, and while some women may not feel big changes, others may experience symptoms that really reduce their quality of life.

Hormone replacement therapy (HRT, HT, ET, ERT) can be taken during menopause for different reasons.

One reason is to ease menopausal symptoms such as hot flashes, mood swings, sleep disturbance and vaginal dryness.

Other reasons are to prevent future problems like osteoporosis, arteriosclerosis, heart diseases, Alzheimer’s disease, metabolic syndrome, among others.

Therapy has to be individualised, which means that there is no one-size-fits-all therapy but several treatment options for each patient. The treatment plan requires an individual procedure, including for example evaluation of lifestyle, age, pre-existing health problems, mammogram, blood tests and, most importantly, what the patient wants and what is possible.

Normally, women are particularly worried about the higher risk for breast cancer. Once again, this has to be evaluated individually as some patients on HRT may even present a lower risk for breast cancer, depending on pre-existing risk factors, age and health-related problems. For example, obesity, regular alcohol intake, smoking and lack of physical activity put women at higher risk for breast cancer than HRT.

Also, here the individualised therapy with the correct substance is very important. In general, we will use the lowest effective dosage for the lowest individual therapy interval necessary.

Just to give you concrete examples, a woman experiencing strong menopausal symptoms at 40 years of age will benefit much more than a woman who has a regular menstruation without symptoms until 55 years of age. Lower estrogen levels during menopause can lead to progressive bone loss, which is especially rapid in the first five years after menopause. Thus, to prevent osteoporosis (bone loss), HRT should be started early. To start it at the age of 65 or older can have more negative side-effects than benefits.

Prescription of HRT can also be individualised by the way of administration, in the form of tablets (oral therapy), patches and creams for transdermal or intravaginal application.

Conclusion and take-home message:
The younger you are when you start menopause, the more you will probably benefit.

The more you suffer from menopausal problems, the better your quality of life will be after taking HRT.

If you want to prevent health problems like osteoporosis, heart disease or others, you should start early (hormones in this situation are for prevention, not for therapy).

To help you make up your mind about HRT, you should read articles in newspapers, books, television, internet and maybe listen to a friend’s opinion. But, in the end, you should see a specialist to make an evaluation of your individual situation. The final decision is yours.

Take into consideration that opinions and guidelines vary quite a lot, even from study to study, or from country to country. And they can change (and they do) over the years!

By Dr. Holger Duesmann
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Dr. Holger Duesmann, Gynaecologist and Obstetrician since 1993. Studied and worked in Brazil and Germany. Specialised in Gynaecological Endoscopic Surgery in Germany. He works and has lived with his family in the Algarve for more than 10 years. He now works at Hospital Particular do Algarve.