HRT is used to replace those hormones which decline during the menopause. Essentially the ovaries produce two hormones namely progesterone and oestrogen, although a small amount of male hormones (testosterone) are also produced.
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In women who have had a hysterectomy, only oestrogen replacement is used. In women who still have a uterus, progesterone needs to be added to counteract the stimulating effect of oestrogen on the endometrium (inner lining of the uterus) which can lead to uterine cancer.
Benefits of HRT
HRT was originally developed to relieve the symptoms of the menopause ( hot flushes, night sweats, mood swings etc). It is now known that HRT also prevents the serious long-term complications of oestrogen deficiency (e.g. osteoporosis).
Osteoporotic fractures of the spine, hip and wrist are decreased by 50-70%.
Oestrogen has a beneficial effect on blood vessels and blood cholesterol.
HRT appears to improve cognitive function and may delay the onset of Alzheimer's disease although further research is required. It significantly decreases the incidence of colon cancer.
Potential risks of HRT
(Long-term use)
Cancer
Uterine Cancer
Endometrial cancer is increased in women who take only oestrogen therapy and still have their uterus intact. Progesterone should therefore be taken in conjunction with oestrogen. Combined HRT does not increase the risk of uterine cancer.
Breast Cancer
Long-term oestrogen therapy (more than 5 years) increases the risk of breast cancer. The risk seems to be insignificant in the short-term (less than5 years). Before initiating HRT, a baseline breast examination and mammogram should therefore be done.
Other cancers
The risk of other cancers is not increased.
Vascular problems
HRT is known to increase the incidence of deep vein thrombosis (DVT). HRT should be temporarily discontinued during periods of relative immobilisation (e.g. bed rest, long flights). Recent evidence has suggested that there may be an increased risk of cardiovascular disease during the first year of HRT. Known coronary artery disease and a recent myocardial infarction (heart attack) should be regarded as a contra-indication for HRT.
Short term side-effects
Vaginal bleeding
This usually occurs when HRT is given cyclically (10-14 days per month) and a monthly bleed follows. HRT can also be given continuously. Bleeding may occur for the first 6 months and should stop. If it continues, this needs to be investigated.
Breast discomfort
Breast discomfort and enlargement can be quite bothersome. It usually decreases with time and can be overcome by changing the hormone preparation or reducing its dose.
Fluid retention
This is more frequent in women who have been without oestrogen for many years and are started on too high a dose of HRT. These symptoms usually disappear after a while. Reduce salt intake and exercise. A different hormone preparation and the addition of a diuretic can also relieve symptoms.
HRT remains the only true effective way of treating the symptoms of menopause and is still one of the most cost-effective ways to prevent post-menopausal osteoporosis- it reduces fractures of the spine and hip by 50%.
It does, however, have side-effects and is not suitable for every woman. Decisions whether to start with HRT should be based on a thorough knowledge of the subject and open and honest discussion between the patient and her doctor. Every patient should be treated as an individual with specific needs.
Safe and effective alternatives to HRT exist to prevent osteoporosis.
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