Menopause and HRT: Myths and facts

In the latest of our series exploring some common misconceptions about conditions seen in general practice, GP Dr Toni Hazell debunks some myths about the menopause and HIV – and explains some perhaps less well known facts

Myths

1. The menopause always presents with hot flushes and night sweats

The menopause occurs at the average age of 51 in the UK, but symptoms often begin during the perimenopause, the period of time during which oestrogen levels fluctuate and periods become less regular. The perimenopause may last for several years, and a woman is only said to be post-menopausal when she has not had a period for 12 months. Around 70 – 80% of women will have vasomotor symptoms (hot flushes and night sweats), but the rest may present with other symptoms. These can include insomnia, fatigue, low mood, anxiety, joint pain, ‘brain fog’ and urinary symptoms. It is worth considering the menopause as a cause of these symptoms in women in their 40s, even if they do not have vasomotor symptoms.

2. HRT acts as a reliable method of contraception

HRT is not contraceptive, unless the 52mg levonorgestrel intrauterine device (LNG-IUD) is used as part of the HRT regime, in which case it can do double duty as contraception and HRT. A woman can stop using contraception when she is one year past her last period, if that occurred over the age of 50, or two years if the last period was before 50. For those who use a progestogen only method which causes amenorrhoea, it is harder to know when they can stop, as the last period cannot be used as a guide. They can either continue until the age of 55 (after which conception is ‘exceptionally rare’), or they can have a test of follicle-stimulating hormone (FSH) at age 50. If this is in the menopausal range then they can stop contraception one year after the blood test.

Women with no risk factors other than age may want to continue using combined hormonal contraception (CHC) up to the age of 50, even if they are going through the menopause – this can suppress symptoms in the same way that HRT does, and also acts as a contraceptive. It should be stopped at the age of 50, at which point women who do not want a LNG-IUD as part of their HRT regime can combine the HRT of their choice with either the progestogen only pill or the implant. The depot injection is generally not recommended over the age of 50. Women can also use this combination at a younger age, if they would rather move from CHC to HRT before 50, or if they have to do this due to a combination of risk factors such as age, weight, smoking status or cardiovascular risk.

3. Taking HRT increases a woman’s risk of dying of breast cancer

The use of HRT has varied significantly over the last few decades, often increasing and decreasing in response to media scares about its association with breast cancer. Many of the trials in the early 2000s which caused anxiety were done on a population that was very different from those using HRT in the UK (in particular, much older when starting HRT), and using progestogens which are higher risk for breast cancer than those that we use now.

Women who want to discuss HRT and breast cancer can be advised of the following:

• Unopposed systemic oestrogen and vaginal oestrogen carry little or no increased risk.
• The absolute excess risk with combined HRT is small, around 10 extra cases per 1000 women aged 50 – 59, over 14 years of use.
• This increase should be weighed against the significant decrease in endometrial cancer which comes with using long-term continuous HRT.
• Having obesity, or drinking ≥ 6 units of alcohol per day both carry the same risk (or a higher risk) of breast cancer than comes from using HRT.
• HRT does not increase mortality from breast cancer.
• There is no strong evidence that HRT increases the risk of breast cancer more in women who have a strong family history of the disease – risks will depend on the individual history and a genetics referral should be considered if the woman meets NICE criteria for this.

4. Women who have had a hysterectomy can always use oestrogen only HRT

There are two hormones in combined HRT – oestrogen, to treat symptoms by replacing the oestrogen lost at the menopause, and a progestogen, to prevent the oestrogen causing endometrial hyperplasia and cancer. Most women who have had a hysterectomy can use oestrogen only HRT, but there are two important exceptions to this.

Women who have had a sub-total hysterectomy may have some endometrium left in the cervical stump, which is at risk of hyperplasia if oestrogen only HRT is used. A pragmatic solution is to use sequential combined HRT for three months – if there is no withdrawal bleeding in that time, then it can be assumed that there is no endometrium present and the woman can change to oestrogen only HRT.

Women who have had a hysterectomy for endometriosis may also have some patches of endometrium left behind, in the pelvis or elsewhere, and these can be at risk of hyperplasia and malignancy from unopposed oestrogen. There is limited evidence to guide practice here, but it is generally recommended that continuous combined HRT be used until the age of natural menopause (51), as oestrogen only HRT may increase the risk of recurrence of pain. At the age of 51, a personalised, shared decision making approach would need to be taken towards a possible switch to oestrogen only HRT. This would be aided by an enquiry to the gynaecologist who did the hysterectomy, as they may be able to advise on the likely amount of endometrium left behind.

5. Testosterone is licensed in the UK for post-menopausal women with a low libido

Premenopausal women produce testosterone – levels decline with age and drop sharply when menopause is induced iatrogenically, by surgery or medication such as chemotherapy. Many women do not have any symptoms from a drop in testosterone and there is no need to routinely measure levels, however the use of testosterone to treat low libido has been discussed much more widely in the past few years than it was before.

Despite some media reports, there is no evidence for the use of testosterone therapy to benefit mood, cognition, energy or musculoskeletal symptoms – it is not a panacea for eternal youth! However, it may help women who have a persistently low libido, despite being well oestrogenised (from HRT use), and when a biopsychosocial approach has considered and excluded other causes, such as stress, medication and relationship issues. There is currently no preparation licensed in the UK for this reason and so use is always unlicensed – medicolegal safety can be improved by following BMS guidelines in the area, but the patient must be made aware that they are being prescribed an unlicensed drug.

Facts

1. Any 52mg levonorgestrel intrauterine device can be used as part of an HRT regime

There are three 52mg levonorgestrel intrauterine devices (LNG-IUDs) available in the UK – Mirena®, Benilexa® and Levosert®. Only Mirena® has a licence for use as the progestogen component of HRT, and this licence is for four years only, compared to its eight year licence for contraception. The Faculty of Sexual and Reproductive Healthcare (FSRH), widely seen as the gold-standard provider of guidelines in this area, advises that all three of these devices can be used for the progestogen component of HRT, and that they can be used for this indication for five years. The choice of device available to an individual clinician may depend on the decisions made by medicines management in their area. Women who use a 52mg LNG-IUD for both HRT and contraception must have it changed every five years – the lower dose LNG-IUDs, Kyleena® and Jaydess®, cannot be used as part of HRT for any length of time.

2. Women with a past history of venous thromboembolism can use HRT

The use of oral HRT increases the risk of venous thromboembolism (VTE), with a relative risk of 2-4 – VTE is most likely in the first year after initiation. Other risk factors for VTE are well understood and include age, obesity, smoking, family or personal history and known thrombophilias. Transdermal preparations of HRT (gels, patches and sprays) are not associated with any increase in VTE risk and therefore should be used first line for all women at increased risk. This would include those with a body mass index (BMI) ≥ 30, or who have a strong family history or personal history of VTE. Consideration should also be given to using micronised progesterone for these women, as this has a lesser chance of increasing the risk of VTE, compared to other progesterones. Dydrogesterone is also lower risk for VTE, but at the moment is only available in the UK in a combination oral form of HRT, which would therefore not be advised for women at high risk of VTE.

The British Menopause Society (BMS) advises that ‘discussion with a haematologist should be considered in postmenopausal women at particularly high risk for VTE who are being assessed for HRT’, but it does not define ‘particularly high risk’. As always, a shared decision making approach should be used and the need to involve a haematologist will depend on the perceived risk and the confidence of the clinician in the use of HRT in this population. Thrombophilia testing is unlikely to affect management.

3. There is no absolute age at which HRT needs to be stopped

There is no fixed age at which HRT should be stopped – many GPs, including the author of this article, will have a patient or two who continue to take it into their 80s or older, because of recurrence of symptoms every time they try and stop, and after a lengthy, well-documented discussion and full acceptance of the possible risks. A shared decision making approach should be used to support women in their decision as to when to stop HRT. Older women may need lower doses than those who are younger, and need to understand that their breast cancer risk will increase with age and continued use of HRT, although there is a lack of clear evidence as to the exact risks over the age of 60. Continued participation in the breast screening programme would be sensible – women over 70 are not routinely invited, but can proactively request a mammogram every three years.

4. Bioidentical HRT is available on the NHS

Bioidentical hormones are those which are an exact duplicate of the hormones naturally made in the human body. Regulated bioidentical HRT (rBHRT) is used in the NHS – preparations include micronised progesterone. In recent years there has been expansion in the proliferation of private clinics offering customised bioidentical HRT (cBHRT). These are often produced in small amounts for individual patients, using specialised pharmacies. They are unlicensed and have a lack of evidence for safety, both in terms of the oestrogen dose used and whether or not there is enough progesterone to protect the endometrium.

There is an international consensus that the safety of cBHRT is unclear – this comes from the BMS, NICE and the International Menopause Society. In the UK, the Advertising Standards Authority has also ruled in this area, saying that it should not be claimed that cBHRT is safer than non-bioidentical HRT, or that HRT can be tailored to a woman’s specific needs.

We cannot prevent our patients from accessing any types of HRT (or other medication) from the private sector, but if we become aware of cBHRT use then it would be sensible to advise on the risks and to decline to get involved in any prescribing to do with such a regime.

5. Vaginal oestrogen can be used in combination with systemic HRT

Genitourinary syndrome of the menopause (GSM) – also known as urogenital atrophy or atrophic vaginitis/vulvitis – is common in women of menopausal age. Symptoms include vaginal dryness, itching and burning, with pain on urination and on sexual intercourse, the latter of which may lead to a reduction in libido. Lifestyle change can help, with smoking and a sedentary lifestyle being associated with GSM, but the mainstay of treatment is HRT. Women who have GSM despite the use of systemic HRT can also use vaginal HRT in combination with systemic HRT. For women who use vaginal oestrogen alone, there is no need for an accompanying progestogen as the absorbed dose is too low to give any risk of endometrial hyperplasia.

Women who have had breast cancer often have a particularly troublesome menopause, with professionals being understandably cautious about the risks of HRT in terms of cancer recurrence, and medications such as tamoxifen causing menopausal symptoms. Lubricants are a first-line treatment in this cohort, but where these are not sufficient, the BMS recommends considering the use of vaginal oestrogen, after ‘seeking advice from a healthcare professional with expertise in menopause/breast specialist’. A recent cohort study suggests that there is no evidence of increased breast-cancer specific mortality in patients who use vaginal oestrogen after having had breast cancer, and some NHS trusts have made statements to the effect that such use is reasonable. Others have expressed concern that vaginal oestrogen may reduce the effectiveness of anastrozole; a discussion with the patient’s oncologist would be a good place to start, if considering prescribing for a woman who has had breast cancer. It is important to weigh up risks against quality of life, and the likelihood of non-adherence to medication such as tamoxifen or anastrozole due to adverse effect.

Dr Toni Hazell is a GP in London. She has a long interest in women’s health and has previously been worked in contraception and sexual health clinics. She is on the board of the Primary Care Women’s Health Forum

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