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Menopause - HRT or Nature?

I am a 52-year-old woman and I’m peri-menopausal (which means I still have my periods but they aren’t as regular as they used to be). Too much information? No? Then, let me continue. Nowadays, I find I don’t sleep particularly well. I tend to wake up at about 4 am needing a pee and I often have trouble getting back to sleep. I gave up wine about a year ago, after realising that even one glass would sabotage my temperature control and I’d then spend the night in a cycle of removing and replacing my bed covers. Those of you who know me well will have noticed my increased word finding difficulties—this tends to occur when I need food. In searching for the correct word, my brain offers me seemingly random suggestions. An elbow becomes a knee and banana seems as good a word as any to describe my phone. A couple of years ago I began to suffer dreadful anxiety. It’s better now, which is why I can mention it, but at the time it was crippling. I found my confidence was shattered and I struggled to do the things I used to find easy.

Apparently all this is completely normal! I’m told it’s a natural part of aging, and whilst I know that natural is good I must be completely honest and tell you that this does not feel good. I realise that it isn’t feminine to make a fuss and, in the same way that women don’t pass wind or defecate, they should not suffer from symptoms of menopause either. Well, I’m clearly not a proper woman!

The novelist Florence King wrote that menopause allowed a woman to be ‘free of the shackles of that defect of body and mind known as femininity’, but I am still struggling to feel this. Whilst I realise I am lucky to be growing old and want to do it gracefully, I don’t really want to grow old at all.

Managing menopause is an emotive subject for social and political reasons. Many women believe that to deny nature is both sexist and ageist. It is a natural part of life and as such should be kept out of the paternal hands of the medical profession and pharmaceutical companies. They believe that natural approaches, such as good nutrition, exercise and alternative therapies, are the best ways to keep any short-term symptoms at bay. Others feel they have a right to be in charge of their own health and if menopause symptoms are making their life intolerable then hormone replacement therapy (HRT) is the obvious solution.

With regard to my own menopause, I feel I could perhaps struggle on with my present symptoms, but what seriously worries me are the long-term effects of oestrogen deficiency.According to the current life expectancy for women in the UK I may live one third of my life without the protection of oestrogen. This means that as I grow older, I am at serious risk of suffering from osteoporosis - leading to bone fractures, cardiovascular disease, vaginal atrophy and cognitive decline.

At this stage I hear a number of women shouting: ‘But what about the increased risk of breast cancer associated with HRT?’ To which I reply: read on, as I hope to demonstrate that for many women this risk is negligible and is outweighed by the quality-of-life improvement associated with HRT. As Mariella Frostrup stated in the recent television program The Truth About The Menopause, the increased risk of breast cancer from taking HRT is similar to the increased risk from drinking one glass of wine each evening.

MENOPAUSE

Menopause is defined as the cessation of menstruation. It occurs at around the age of fifty. In medical terms a woman reaches her menopause when she hasn’t had a period for one year. This means that her egg supplies are depleted and therefore ovulation cannot take place—pregnancy is impossible and periods no longer occur. Peri-menopause is the time before this, when egg supplies are low. This is when menopausal symptoms begin. Most women find that this occurs during their forties. Their cycle changes and becomes less regular, and hormones can become imbalanced. Because of the wide-ranging effect these hormones have on the body a woman can feel quite unlike her usual self for a long time—menopause symptoms can last for up to ten years.

MENOPAUSE SYMPTOMS

  • Hot flushes and night sweats
  • Insomnia
  • Headaches
  • Cognitive decline (verbal memory)
  • Joint and muscles pains
  • Vaginal wall thinning
  • Cystitis. Recurrent bladder infections
  • Heart palpitations
  • Dizziness. Vertigo

Long Term

  • Osteoporosis
  • Cardiovascular disease
  • Cognitive decline

HRT AND BREAST CANCER

Up until 2002 women commonly took HRT for the treatment of menopausal symptoms. Until that year the majority of studies examining the relationship between HRT and breast cancer (around 88%) found there was no increased risk. Suddenly in 2002 everything changed because a major clinical trial, known as the Women’s Health Initiative (WHI), which was set out to assess the risks and benefits of combined oestrogen and progestin in healthy menopausal women, was stopped early. The reason given for its premature ending was the discovery of an increased risk of invasive breast cancer in the HRT group. This huge study, which we now know was flawed and incorrectly reported by the press, caused a 70% drop in HRT prescriptions overnight. Over 15 years later, many websites still cite this study to discourage HRT use, and therefore women are confused and anxious about its potential risks. Whilst around 80% of women experienced symptoms during menopause in 2015, only 10% were taking HRT.

Leading experts, including some involved in the WHI, have now spoken out on the flaws of the study. The women were not healthy, as reported­—many of them were obese, and had high blood pressure, and half were either smokers or ex-smokers. The average age of women entering the study was 63 years old, which is far older than the age that women usually begin HRT—in fact only 30% of the women were under the age of sixty. The form of HRT being tested, known as Premarin and made from the urine of mares and a synthetic progestogen, is no longer used. What the study actually found was that if you give women who have passed the menopause an out-dated form of HRT then there is a small increase in the risk of breast cancer.

In their recent book Oestrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives - Without Raising the Risk of Breast Cancer, oncologist Avum Bluming and social psychologist Carol Tavris wrote: “we do think it is time to relegate the ‘common knowledge’ that ERT and HRT cause breast cancer to the dustbin of discredited ideas—along with the theories that radical mastectomy is the best treatment for primary breast cancer, that anger causes peptic ulcers, and that stress causes tuberculosis.” For those of you interested in learning more about oestrogen I strongly recommend you reading this enlightening book.

OESTROGEN

Most women are taught about the hormone oestrogen when they are young, as it is widely associated with menstruation and birth control. It actually affects very many cells in the body, which is why menopause symptoms can be so varied. The cardiovascular, immune, central nervous, and skeletal systems all need oestrogen to function optimally. 

FUNCTIONS OF OESTROGEN

  • Body temperature regulation
  • Maintenance of bone density and muscle mass
  • Promotes healthy sleep
  • Increases libido
  • Maintains arterial elasticity and increases blood flow
  • Lowers cardiovascular risk
  • Maintains collagen
  • Maintains cognitive function
  • Helps memory and concentration
  • Maintains eye structure
  • Prevents nerve-degeneration

There are three main types of oestrogen used by the body. Oestriol is only made in pregnancy and is an indicator of foetal health. Oestradiol is the major oestrogen and it is this oestrogen that is responsible for the health of so many of our cells. It is produced by the ovaries during the menstrual cycle and is the predominant oestrogen during reproductive years. As our egg supplies dwindle, oestradiol levels reduce. Oestrone is the only oestrogen found in any significant amount in menopausal women—owing to the depletion of oestradiol.

Modern HRT medication contains 17 beta oestradiol made from yams. This is almost identical to the oestradiol made by the ovaries and is often described as bio-identical. It can be given in a number of different ways. The favoured way is through the skin as a patch or gel. Taking HRT in pill form has slightly higher risks associated with it—the main one being gall bladder problems. 

PROGESTERONE

Progesterone belongs to a group of hormones called progestogens. Progestogens play an important role in maintaining the early stages of pregnancy. The name is derived from pro-gestation (for-pregnancy). After ovulation the egg sac secretes progesterone in preparation for pregnancy. A drop in progesterone levels during pregnancy can result in miscarriage. During peri-menopause, when ovulation does not occur every month, progesterone levels can be low—causing heavy, irregular periods. Once menopause occurs progesterone is no longer produced.

Progestogens must be taken with HRT oestrogen unless a woman has had a hysterectomy. They play an important role in preventing the lining of the womb from thickening and there is an increased risk of endometrial cancer associated with oestrogen-only HRT that is negated with progestogens.

In the 1990s progesterone with the same molecular structure as the body’s progesterone was synthesised using yams. This is now known as bio-identical or micronized progesterone (Utrogestan). Because of its similarity to the body’s progesterone it seems to cause fewer side effects. Recent studies have indicated that the small increased risk of breast cancer from HRT is actually associated with synthetic progestogens, rather than oestrogens—micronized progesterone appears to reduce this risk.

Your GP can prescribe progestogens in a number of different ways, including the Mirena coil, synthesised progestogens and micronized progesterone. The Mirena coil, which is the cheapest option, contains synthesised progestogens. For many women micronized progesterone is preferable due to the reduction in side effects; but all women are not the same. It can take some time to find the correct drug, dose and method of application. Peri-menopausal women who have had a period in the last year should note that micronized progesterone cannot be used as a form of birth control.

Easy prescription.pngTaken from The Menopause Doctors Easy Prescribing Guide (4)

COMPOUND HRT

For women with a uterus, who require both oestrogen and progesterone, bio-identical HRT is not available in one pill, gel or patch on the NHS. These women therefore need to remember to taker two different medications. Many private clinics have found a way to make taking HRT more simple by recommending compound HRT. This is a mixture of hormones in one pill that are made to order at a pharmacy according to the patient’s needs. Dr Louise Newson, GP and menopause specialist, states that although these drugs are licenced, they are not regulated or subject to quality controls. Dr Amalia Annaradnam of The London Hormone Clinic often prescribes compound HRT as she feels it allows her to adjust the dose where necessary, whilst keeping things simple for her patient. She is adamant that hospitals use pharmacies all the time to make up drugs and sees no issue with this. She does, however, agree with Dr Newson that the pharmacy must be reputable and hormones should never be bought off the Internet.

NATURE

For many women taking HRT is not an option. This may be because taking regular medication does not sit well with them or because they feel that for them the risks out-weigh the benefits. This view is perfectly valid and there are natural ways to reduce some menopausal symptoms, but at present there is no evidence-based natural alternative that is equal to oestrogen. Osteoporosis, cardiovascular disease and vaginal atrophy are three of the biggest problems associated with long-term oestrogen deficiency. Not all women will suffer from these problems as they age—this will be determined by their genetic make-up, their luck and their lifestyle. Women who choose not to take HRT are advised to use exercise and diet to keep themselves healthy. Weight-bearing activities will encourage the health of bones (see our previous article on Osteoporosis & Exercise), and aerobic training will aid the heart. A diet full of natural food and unsaturated fats is also recommended for healthy aging. General advice for reducing menopause symptoms includes quitting smoking, reducing alcohol and caffeine intake, and finding ways through exercise and mindfulness to reduce stress.

For some women cognitive behavioural therapy has been shown to have a mild effect on reducing symptoms and others find acupuncture, magnet therapy, herbal teas and aromatherapy oils can help. There is a wealth of herbal products available that are advertised as being effective in easing the symptoms of menopause. Some of these herbs can be beneficial, but they should be taken under the guidance of a herbal specialist because many have side effects and could interact with other medications. For example, ginseng may reduce hot flushes, increase sexual arousal and improve cardiovascular health, but its side effects include headaches and jitteriness, and it interacts with a number of medications. Black cohosh root is often taken instead of HRT, but this herb has been linked with liver toxicity and blood pressure problems. Red clover is considered safe and has been used to reduce hot flushes, boost immunity, improve bones strength, and reduce blood pressure. Green tea has been associated with improving bone strength and has no serious detrimental side effects.

CONCLUSION

I have read that the problem with research medicine is that it is predominantly biased. Most people have an opinion on a subject and commonly they will interpret the data to back up their opinion. This certainly seems to be the case with HRT. The NICE guidelines on the treatment of menopause are quite clear that every woman is an individual and should be treated as such. For some, HRT might be the right answer, but for others changing their lifestyle to reflect their time of life may be more appropriate. It is the case that there is a window of opportunity to start HRT that lasts less than a decade after menopause begins. There is also pretty consistent data suggesting that for women on HRT there is a reduction in the risk of developing heart disease, which kills more than twice as many women as breast cancer. With that in mind I have planned a visit to a hormone specialist to discuss my future. I haven’t made up my mind yet, but I do understand the subject more clearly now. If I choose to take HRT then I must take a drug each day. This drug may or may not help me age healthily. If I choose the natural approach, then I’m aware of the problems associated with oestrogen deficiency.

REFERENCES

1. The Truth about… The Menopause. (2018), BBC 1, 26th November 2018.

2. Cumming GP, Currie H, Morris E, et al. (2015) The need to do better — are we still letting our patients down and at what cost? Post Reprod Health 21(2):56–62. 11

3. Bluming, A & Tavris, C. Oestrogen Matters: Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives - Without Raising the Risk of Breast Cancer . Little Brown Book Group, (2018).

4.  https://pcwhf.co.uk/resources/easy-hrt-prescribing-guide/

5. Newson, L. My Menopause Doctor. Online Newson Health Ltd, 2019, (accessed 10 th February 2019), https://www.menopausedoctor.co.uk.

6. Annaradnam, A (2019), Bio-identical Hormones and Women’s Health. Slides, Molineri Institute of Health, delivered 20th January 2019.

7. National Institute for Health and Care Excellence (2015) Menopause: diagnosis and management NICE guidelines [NG23], (accessed 12th February 2019), https://www.nice.org.uk/Guidance/NG2

UPDATE (08/03/19)

Here are a few of the doctors who have been recommended to me since writing the blog.

Bath Dr Claire Quiggin NHS https://heartofbath.com/
Bristol Dr Caroline Overton Private Practice http://www.caroline-overton.co.uk/
London Dr Amalia Annaradnam Private Practice http://londonhormoneclinic.com/the-team/
London Dr Marion Gluck Private Practice https://www.mariongluckclinic.com/
Dorset Dr Mike Dooley Private Practice https://www.mdooley.co.uk/?p=243
Bath Mrs Ayesha Qureshi Both https://thebms.org.uk/find-a-menopause-specialist/

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