Frequently Asked Questions

Q. When should  I start taking HRT?

A. It depends  on the reasons for wanting to take HRT. If it is for the relief of menopausal  symptoms, then it can be started as soon as you wish, even if the periods have  not yet stopped. For the prevention of osteoporosis, it should ideally be started  as near to the menopause (last period) a possible, when the bone density loss  is at its greatest.

Q. How long  should I take HRT for?

A. Again this  really depends on the reason for taking it in the first place. For symptom  relief it can be taken for 3 to 5 years and then stopped after the dose has  been reduced as gradually as possible.

For the prevention of osteoporosis it will need to be taken for much longer,  preferably for at least 10 years. It needs to be borne in mind that bone density  will be lost rapidly again after HRT is stopped, so consideration should be  given to continuing HRT for as long as possible, or to changing to a non-hormonal  treatment to protect the bones.

Women who have had a premature menopause should be advised to take HRT until  at least the average of menopause (51 years) after which the same risks and  benefits apply as for those women undergoing menopause at an average age. HRT,  even if taken for many years under the age of 50, is not associated with an  increased risk of breast cancer. It is only the years of HRT use after the  age of 50 that is associated with breast cancer, by extending the length of  time that a woman is exposed to oestrogens.

Q. How long  is it safe to take HRT for?

A. There is  no short answer to this question as it depends entirely on the woman herself  and her reasons for taking the HRT.

The major risk associated with long-term HRT is an increase in the risk of  developing breast cancer. A significantly increased risk of developing breast  cancer begins after 5 years and continues to increase slightly for each year  of use. It is commonly felt that women should stop taking HRT after 10 years  because of this risk, but this should not be a firm rule, merely a guide. As  can be seen in the section on HRT and breast cancer the increased risk after  10 years is still a relatively small risk and may well be a risk worth taking  for some women whose quality of life is felt to be so much better on HRT than  off it.

In other words the decision as to when to stop HRT must be an informed decision  made by each women, inpidually after weighing up the pros and cons of continuing  treatment. (See HRT - risk assessment)

Q. If I take  HRT to control my hot flushes, am I just putting them off until I stop taking  HRT?

A. No. If  your symptoms have not settled naturally when you stop your HRT you will need  to restart it for a further period of time and then try stopping it again.  Occasionally stopping the HRT may cause some symptoms to recur but this can  be minimised by weaning the dose down gradually rather than stopping it abruptly.

Q. Is there  an upper age limit for taking HRT?

A. No. HRT  is one of the best options for women at risk of osteoporosis and can be started  in women of any age who are fully informed of the risks and benefits. In fact,  the lower the bone density, the greater the potential gain after HRT is started.  In fact, there is an argument for starting HRT nearer to the time of likely  fractures, the late 60s and 70s, to gain the most benefit and minimise the  risks of long term treatment. In addition, older women may need lower doses  of oestrogen to protect the skeleton

Q. I am having  hot flushes and night sweats but still having regular periods - could my symptoms  still be menopausal?

A. Yes. Menopausal  symptoms such as hot flushes and night sweats are caused by falling oestrogen  levels and this can begin a number of years before the periods stop, even whilst  they are still regular.

Q. My doctor  has told me that I am not in the menopause because my blood tests are normal  so what could be causing my hot flushes and night sweats?

A. Blood hormone  tests are unlikely to be of help in deciding whether or not symptoms are menopausal,  as normal results do not exclude the menopause as a cause of symptoms, but  a 3 month 'therapeutic trial' of HRT should make the diagnosis.

Q. Will HRT  make me put on weight?

A. The short  answer is NO - as confirmed in a number of different studies. Unfortunately,  however, the menopause itself is associated with weight gain (on average about  half a stone), whether or not HRT is taken. It is also true that body fat is  redistributed, so that fat from the hips and thighs tends to settle around  the middle and can therefore give the appearance of weight gain even when there  is none. It is never more important than during the peri-menopausal years,  to concentrate on following a healthy, low fat diet and to be taking regular  aerobic exercise, to keep weight under control.

Q. If I take  HRT will it mean I have to continue with regular periods?

A. Again,  the short answer is NO. Postmenopausal women (that is women who are 1 year  past their last period) can now take HRT that is designed not to produce a  regular bleed , for more details see HRT - types - continuous-combined. Women  who start HRT whilst still having regular or infrequent periods, will need  to have a regular bleed initially but will be able to change to a 'no period'  type of HRT after a few years, maybe as soon as 2 or 3 years after commencing  a cyclical HRT or at the age of 54, whichever is earliest. This can be discussed  with your GP. In any event it may be advisable to change to a 'no-period' HRT  after 5 years on a cyclical HRT because of the greater protection to the endometrium.

Q. I did try  HRT once for nearly 3 months but it didn't suit me - what else can I try for  the hot flushes?

A. It is quite  possible that you might experience side effects when first starting HRT. Just  as you are getting menopausal symptoms because of falling oestrogen levels,  so you might experience some side effects when increasing your oestrogen levels  again after starting HRT. Side effects might include nausea, indigestion, breast  tenderness, headaches and leg cramps, but they should all be settling by 3  months as the body adjusts to having higher hormone levels again. You should  always try a preparation for at least 3 months before abandoning it to give  the side effects time to settle down as they almost always do. If the side  effects do persist, go back and discuss them with your doctor who will be able  to suggest a different HRT which might suit you better. Usually the first type  of HRT suits most women but sometimes it may take a little while to sort out  the best preparation for maximum acceptability.

Q. I had problems  on the oral contraceptive pill (OCP) does that mean I am more likely to have  problems on HRT?

A. Not necessarily.  One of the most misunderstood issues surrounding HRT is its relationship to  'the pill'. OCPs contain high doses of synthetic hormones to ensure that they  are contraceptive, unlike HRT which uses only low doses of natural hormones  to simply replace the hormones that the ovaries are no longer able to produce.  Therefore many of the problems associated with 'the pill' do not apply to HRT  and by the same token, HRT is not contraceptive. If you have concerns you should  discuss them with your GP or practice nurse.

Q. I have  a family history of breast cancer - can I still take HRT?

A. Yes, providing  you are fully aware of the risks associated with HRT and are able to make an  informed decision to do so. The risk of breast cancer associated with HRT is  discussed fully in 'HRT - Risks'. Essentially, women with a family history  of breast cancer have a higher risk of developing breast cancer themselves,  the level of risk depending on the numbers and ages of breast cancers within  the family. HRT taken for more than 5 years is also associated with a slight  increase in the risk, which continues to increase for each year of use. But  there is no evidence that the increased risk, from HRT, is any greater in women  with a family history of breast cancer than those without. In many cases the  advantages of taking HRT are likely to outweigh the disadvantages.

Q. As a cigarette  smoker, can I take HRT?

A. Yes. All  cigarette smokers should give serious consideration to stopping smoking because  of its massive contribution to the risk of developing and dying from heart  disease. HRT, however, may help to reduce the risk of heart disease in women  who have not yet developed it, and there appears to be no increased risk in  smokers, unlike the oral contraceptive pill.

Q. I have  already had a heart attack - will HRT help to reduce my risk of further heart  attacks?

A. This is  an area which is still unclear. At present it seems that HRT use in women with  heart disease may increase the risk of further heart attacks in the first few  years of use, although there may be some protection after 4 or 5 years. The  advice at present is not to take HRT to prevent further heart disease in women  who already have angina or have suffered a heart attack.

Q. I have  had a stroke - will HRT help to prevent further strokes?

A. The same  arguments apply as in the previous question. At present HRT should not be taken  to reduce the risk of further strokes.

Q. I have  high blood pressure - can I take HRT?

A. Yes, if  your blood pressure has been controlled on treatment. HRT only rarely causes  an increase in blood pressure, but it should be controlled before treatment  starts and checked again after 3 months on treatment. Usually blood pressure  remains the same or even falls slightly on HRT. Having high blood pressure  is a major risk factor in the development of heart disease, therefore you may  benefit from being on HRT as it may help to reduce your risk of developing  heart disease. The prevention of heart disease however should not be the only  reason for taking HRT as this benefit has not yet been confirmed.

Q. I have  varicose veins - can I take HRT?

A. Varicose  veins are not in themselves a reason for not being able to take HRT. If they  are very severe, they may increase your risk of having a thrombosis and HRT  may increase that risk further. If in doubt, consult your GP, but generally  varicose veins should not be a problem.

Menopause - Contraception

Although fertility is significantly reduced over the age of 40, contraception  remains an important issue and should not be ignored until the risk of pregnancy  is over.

The current recommendations are that women whose last period is under the  age of 50 should continue with some form of reliable contraception for 2 years  after the last period and women who are over 50 when the periods stop should  continue contraception for 1 year. HRT is not contraceptive and with advancing  age the choice of contraceptive method often changes. Suitable methods for  perimenopausal women are as follows.

1. Combined Oral Contraceptive Pills

'The pill' remains a suitable method of contraception for older women. Healthy,  non-smoking women can take the pill until the menopause but smokers should  change to an alternative method at the age of 35.

The pill will control menopausal symptoms such as hot flushes and will therefore  mask the menopause. It is therefore difficult to assess when contraception  can be stopped in women on the pill and consideration should be given to changing  to alternative methods at the age of 50 to reduce any risks associated with  combined pills in older women. Risks can also be reduced by using lower dose  pills such as the 20 microg pills.

2. Progestogen-only Pills (POPs)

The progestogen-only pills ('mini pills') are very suitable for older women,  including smokers. As they do not contain oestrogen they will not control or  mask menopausal symptoms. Women wishing to take HRT should consider changing  to a non-hormonal method of contraception as the effects of HRT and POPs used  together have not yet been fully assessed.

3. Barrier Methods

Barrier methods of contraception including condoms and diaphragms, have a  lower failure rate as fertility declines and they have the additional advantage  of protecting against sexually transmitted diseases. They can be used alongside  HRT in perimenopausal women.

4. Intra-uterine Devices (IUD)

'Coils' offer effective contraception for peri-menopausal women and if fitted  over the age 40 can be left until contraception is no longer needed. The menopause  will not be masked but periods can be heavy in the perimenopause and the IUD  may contribute to this.

5. Levonorgestrel Intra-uterine System (IUS)

The IUS releases levonorgestrel (a synthetic progestogen) in the uterus (womb),  providing extremely effective contraception and lighter periods. It can be  left in place for up to 5 years and provides contraception as reliable as female  sterilisation. Although there may be irregular bleeding in the first few months,  in many cases periods stop altogether. It will not mask the menopause but oestrogen  can be added to provide 'no-period' HRT in peri-menopausal women. The IUS is  not currently licensed for use in HRT but can be used on a named patient basis.  This can be arranged through your GP or local family planning clinic.

6. Injectables

Three-monthly progestogen injections provide effective contraception by preventing  ovulation. As they contain only progestogens they do not mask the menopause  or control menopausal symptoms. Periods tend to be lighter but can be irregular  initially.

7. Implants

Implants containing progestogen, to suppress ovulation, are inserted under  the skin of the upper arm. As with all progestogen only methods bleeding can  be irregular and the menopause is not masked. They can be left in place for  up to 3 years.

8. Sterilisation

Sterilisation is a popular choice for the older woman reducing the risk of  pregnancy almost completely. It will not mask the menopause but will not interfere  with HRT in perimenopausal women.

9. Spermicides

Spermicides, available over the counter, may be used alone by women over  50 when fertility has reduced significantly.

10. Emergency contraception

Emergency contraception, using hormonal methods or the copper IUD, can be  used by women of any age.