Menopause is big news at the moment, and where menopause goes, so does hormone replacement therapy (HRT). From television to skincare products, it sometimes feels hard to escape the m-word. However, this isn’t always reflected in real life. Many women mention their worries about menopause in passing rather than making it the focus of a conversation, almost as if menopause symptoms aren’t worthy of attention (they are!). For those who do seek help specifically for menopause, many are already in a state of crisis. Jobs, relationships, and mental health often suffer. In Spain, over 65% of women report workplace problems due to menopause symptoms, with similar patterns seen internationally.
HRT is seen either as an unfailing cure-all or a last resort when, in reality, it’s neither. It is a useful and effective treatment for some menopause symptoms, and can be life-changing for others. However, it comes with risks and a history of controversy.
What is menopause?
Menopause refers to the point when a woman’s periods stop. This is most commonly in the early 50s, although it can happen earlier or later. However, perimenopause – the hormonal changes that eventually leads to the end of periods – can last for years prior to this. For this reason, menopause symptoms can last for a decade or more: because the hormonal changes leading to that final period aren’t done and dusted in a few months.
The only exception to this is if your menopause happens because you’ve had surgery to remove the ovaries. In this case you don’t have an extended perimenopause period although menopause symptoms can still affect you. Common menopause symptoms include hot flushes, night sweats, sleep disturbance, mood changes, aches and pains, genital changes (including dryness, pain, itch and recurrent urine infections) and brain fog.
What is HRT?
HRT is a medical treatment used to replace the hormones which your body no longer produces due to menopause. HRT contains oestrogen, as low and unstable oestrogen levels cause the majority of menopause symptoms. Progesterone and testosterone may also be recommended depending on your individual needs. Oestrogen can be given as patches, gels, sprays, pills, or vaginal preparations - each with its own benefits and risks. Your doctor can advise on the best option for you. Historically, Spain has seen less demand for HRT compared to other Western countries, but access appears to be improving.
Who is HRT for?
HRT is recommended for women who are either struggling with menopause symptoms, or those who need to take it for long-term health. For example, if you have been through menopause before the age of 40, your doctor will recommend taking HRT so that you don’t miss out on the protective effects of oestrogen on cardiovascular health and bone health.
The benefits of HRT
HRT is a proven treatment for:
- Hot flushes (with some studies reporting a 90% reduction)
- Night sweats
- Genital changes (GSM)
HRT is also known to reduce cardiovascular risk in some cases, as well as to improve bone density.
This is unlikely to be the whole picture when it comes to the benefits of HRT. We are still learning about treatment and many questions remain when it comes to the effects of hormone replacement on other menopause symptoms.
Addressing the risks: what does the evidence say?
HRT has been the subject of significant debate since studies in the early 2000s suggested increased cancer risks. Subsequent research has shown that risks are much lower than initially thought—but HRT isn’t risk-free.
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Blood clots: Some forms of HRT increase the risk of serious clots like deep vein thrombosis or pulmonary embolism. Transdermal methods (patches, gels, sprays) significantly reduce this risk compared to tablets due to differences in how oestrogen is processed by the body.
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Breast cancer: Combined HRT slightly increases breast cancer risk (4 extra cases per 1,000 women over five years). However, this risk is lower than other factors like obesity (23 extra cases per 1,000 women) or regular alcohol consumption (5 extra cases per 1,000 women). Women with certain medical conditions - such as breast cancer or other oestrogen-sensitive cancers - are generally advised against taking HRT. It’s therefore essential to discuss your medical history with your doctor before starting treatment.
What if I can’t have HRT?
Even if you can’t have HRT, other treatments are still available. These range from targeted talking therapies delivered by a psychologist, to antidepressants (which can help to reduce hot flushes in some cases) and the relative newcomer fezolinetant (also proven to reduce hot flushes).
How to get started
If you have menopause symptoms that are not improving or that are impacting your daily life, check in with your doctor. They will be able to help you understand the cause of your symptoms and decide whether HRT or a non-hormonal alternative could help.
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