This article looks at a number of different case scenarios where patients may benefit from being prescribed HRT
Professor John Studd, London PMS and Menopause Clinic
Dr Louise Newson, Shirley Medical Centre, Solihull
The negative publicity that followed the Women’s Health Initiative (WHI) study over a decade ago has led to many women – and also many doctors – being concerned and anxious about the potential risks of hormone replacement therapy (HRT).1
A large number of women are still being refused to be prescribed HRT for their menopausal symptoms and are suffering with symptoms which could be easily treated with HRT. It has been estimated that only around one in four women in the UK who would benefit from HRT actually take it.
Mrs F is a 51-year-old banker who presented to her GP with irregular periods, hot flushes and feeling more tired than usual. She noticed that she had less energy and lower libido than she had in past years. She was otherwise well with no past significant medical history. Her GP arranged to have some blood tests, including TFTs, LH and FSH which were all normal.
Despite this, the diagnosis of menopause was made. She was given topical oestrogen in the form of estrogel (two measures daily) and also micronised progesterone tablets 100mg to take on days 1-7 of her cycle. She was also given testosterone gel to use daily to help her libido (one 5g tube to last for two weeks).
The improvement in her symptoms was dramatic.
In a review appointment three months later she had already noticed a vast improvement in the quality of her life and no longer had any hot flushes. Her energy had returned to normal and her libido had also improved.
It is unhelpful to test FSH in women who are still having periods, as it may fluctuate considerably through the cycle. Menopause should be diagnosed clinically.
It is considered safest to administer oestrogens transdermally, to minimize thromboembolic and cardiovascular risk.2 This route is also advantageous for women with diabetes, hypertension and other cardiovascular risk factors. The gel is easy to use and the dose can be titrated according to the improvement of symptoms.
Micronised progesterones are natural, ‘bodyidentical’ progesterones, devoid of any androgenic as well as glucocorticoid activities, but being slightly hypotensive due to their antimineralocorticoid activity. These appear to be the optimal progesterone in terms of cardiovascular effects, blood pressure, VTE, probably stroke and even breast cancer.3 Utrogestan is the only one currently available to prescribe in the UK.
Testosterone has been shown in many studies to improve mood, energy and also libido in menopausal women.4 It is presently unlicensed in the UK, but it can be very effective when given to women who are receiving HRT.
Mrs T is a 48-year-old lady who presented with a six-month history of recurrent cystitis and dyspareunia. Urine culture was negative.
She had undergone a total abdominal hysterectomy (with conservation of her ovaries) eight years earlier for uterine fibroids.
She had been given topical oestrogens in the form of vagifem vaginal tablets to use daily for two weeks then twice a week. She had found that they had not really improved her symptoms. She had also noticed that her hair was thinner than it used to be and she also had less energy.
Her GP had referred her for my opinion. I prescribed her topical oestrogen in the form of estrogel. This was started as two measures daily and then increased to three measures daily. Six months later, her energy levels had returned, her sex life was normal again and she no longer had any urinary symptoms.
As women go through their menopause, they do not display all the classical symptoms of menopause. Oestrogen deficiency commonly leads to thinning of the pelvic tissues leading to vaginal dryness. Although localised, oestrogen treatment can be beneficial for some women, often they need to have systemic HRT to improve their symptoms.
After the menopause, women lose around 25% of their body collagen leading to inelastic skin, brittle nails, loss of hair and also loss of the collagenous bone matrix.5 As oestrogen treatment also has a beneficial effect upon collagen, many women taking HRT notice an improvement in the texture of their skin and nails.
Miss R is a 53-year-old teacher who was referred from her GP for a DEXA bone scan.
She was concerned as her mother and maternal grandmother had osteoporosis in their early 50s and her maternal aunt had recently sustained a fractured neck of femur from a fall.
Her last period was two years previously, but she decided she did not want to take hormone replacement therapy as she was worried about the risks presented in the media and from talking to colleagues at work. She was otherwise fit and well with no past medical history of note. She takes vitamin D supplements daily.
A DEXA scan revealed a low bone mineral density; her hip T-score was -2.7.
After a full discussion about the risks and benefits of taking HRT she was given hormone replacement therapy – topical oestrogen in the form of oestrogel (initially two measures daily, increased to four measures daily after six months) and micronised progesterone tablets 100mg to take on days 1-7 each month.
A repeat DEXA bone scan one year later showed already an improvement in her bone density; her score was -2.3. She continues to take HRT and has noticed other health improvements from taking it.
Oestrogens are the most effective way of increasing bone mineral density and also of preventing osteoporotic fractures in women.6 They are safer and more effective than bisphosphonates. In women under 60 years old, even those without menopausal symptoms, oestrogens should be given as first line treatment for the management of osteoporosis. There is a dose-related increase in bone density with oestrogens given to women under 60. It should also be noted that HRT is of most benefit for the prophylaxis of postmenopausal osteoporosis if started early in menopause.7
Mrs T is a 35-year-old lady who was referred by her GP with a long history of premenstrual syndrome (PMS) that had worsened over the past five years, since the birth of her first child. She had 28-day cycles with 12 bad days each month, the worse ones being one or two days before the start of her period. Symptoms included irritability, poor sleep and low libido. During her two pregnancies she had no symptoms of depression, but suffered with severe postnatal depression three years ago after the birth of her second son. She also had many of the symptoms of postnatal depression after the birth of her first son, but received no treatment for this.
She explained that for at least two weeks of her cycle she felt low in mood and had little interest in anything. She felt her sleep was poor and she would wake early during this fortnight. She also had very poor libido. However, at other times of the month she felt much better and had more energy.
She was prescribed a 200mcg oestradiol patch twice weekly and felt much better after only one month of treatment. She was given cyclical progesterone Utrogestan 100mg for 10 days each month. This led to the return of many of her PMS symptoms. She subsequently had a total hysterectomy and bilateral salphinooopherectomy and continued on the oestradiol patch. She has remained symptom free and is delighted to be free of all symptoms of depression and free of all cyclical symptoms.
It is common for women with severe PMS to have a history of teenage premenstrual mood swings that improve during any pregnancies. Many also have a history of postnatal depression and then have cyclical PMS when their periods return.8 This is typical of reproductive depression. Many of these women are incorrectly given antidepressants or even mood-stabilising drugs if misdiagnosed as bipolar disorder.9
Hormone responsive depression should be diagnosed from the history and not through measurement of hormones, which is unhelpful.
An article looking at new HRT guidelines will be published in the British Journal of Family Medicine early next year.
1. Rossouw JE, Anderson GL, Prentice RL, et al; JAMA. 2002 Jul 17;288(3):321-33.
2. Canonico M. Maturitas. 2015 Jul 26. pii: S0378-5122(15)30006-2
3. Panay N. Post Reprod Health. 2014 May 22;20(2):69-72
4. Pluchino N, Carmignani A, Cubeddu A, Santoro A, Cela V, Errasti T. Arch Gynecol Obstet. 2013 Oct;288(4):731-7
5. Studd J. Menopause Int. 2010 Mar;16(1):44-6
6. Marjoribanks J1, Farquhar C, Roberts H, Lethaby A. Cochrane Database Syst Rev. 2012 Jul 11;7:CD00414
7. Studd J. Climacteric. 2009 Jun;12(3):206-9
8. Studd J. Menopause Int. 2012 Jun;18(2):82-6
9. Studd J. Climacteric. 2015 Feb;18(1):3-5