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As recently as 2005 biological women have had a positive attitude towards hormone replacement
therapy but based on the empirical data these attitudes may be overly optimistic. There is still much to
learn about how HRT affects people. In the combined hormone trial, the WHI tested only one estrogen
(Premarin) and one progestin (Provera), in a single pill (Prempro), at a single dose (0.625 mg Premarin
and 2.5 mg Provera). Therefore the results are not reliable nor representative.

What is hormone replacement therapy?

Hormone replacement therapy (HRT) is given to some women whose estrogen and progesterone levels
drop significantly because of the menopause. Estrogen and progesterone are hormones. HRT tops up a
woman's levels of essential hormones. HRT may also refer to male hormonal treatment, as well as for
individuals who undergo a sex change.
When estrogen and progesterone levels drop, as they do when the menopause approaches, some
women may benefit from artificially boosting their hormone levels to reduce certain menopausal
The hormone estrogen stimulates the release of eggs. As soon as a woman's supply of eggs has
ended, estrogen levels start to go down.

What are the signs and symptoms of a drop in estrogen levels?

Estrogen helps maintain good bone density, skin temperature and regulating moisture of the vagina. A
drop in estrogen levels can cause:

Vaginal dryness

Urinary problems

Thinning hair

Sleep problems

Night sweats


Lower fertility

Irregular periods

Hot flashes (UK: hot flushes)

Concentration and memory difficulties

Breasts get smaller

Accumulation of fat in the abdomen

These sometimes unpleasant symptoms usually go away within two to five years, except for vaginal
Symptoms may sometimes occur before the menopause starts (peri-menopause). In this case the
woman's supply of eggs has not finished, they have just dropped significantly, which can trigger a fall
in hormone levels. So, the patient may still have regular periods as well as menopausal symptoms.
HRT estrogen comes from pregnant horse urine or plants. Progesterone's main function is to prepare
the woman's womb for possible pregnancies. This hormone also helps protect the endometrium (the
lining of the uterus). Lower progesterone levels do not really cause the woman any immediate
discomfort. Experts say her risk of developing endometrial cancer may be higher.

What are the benefits of HRT?

HRT is approved for the relief of menopausal symptoms and the prevention or treatment of
osteoporosis. Below are some other benefits linked to HRT:

HRT improves muscles function - Dr. Lars Larsson, from Uppsala University Hospital
Sweden, reported in The Journal of Physiology that HRT improved muscle function in women, even
down to the muscle fiber.
Dr. Larsson said "We found that even though individual muscle fibers did not change in size, the
muscles of HRT users showed greater strength by generating a higher maximum force compared to
non-HRT users. It is thought that using HRT, at least in part, reduces modifications of muscle
contractile proteins that are linked to aging."

HRT reduces heart failure and heart attack risk - females who receive HRT soon after the
menopause have a dramatically lower risk of heart attack and heart failure, a team of Danish
researchers reported in the BMJ.

HRT lowers mortality in younger postmenopausal women - an article published in The

American Journal of Medicine informed that HRT "almost undoubtedly" decreased mortality in
women whose menopause arrived early.

HRT protects against brain aneurysms - a team from Rush University Medical Center found
that HRT and oral contraceptives reduce the risk of the formation and rupture of
brain aneurysms in women.

New HRT Guidelines released

With a sigh of relief, British doctors received new guidelines regarding HRT from the British Menopause
Society and Women's Health Concern in May 2013. The guidelines - "The 2013 British Menopause
Society & Women's Health Concern recommendations on hormone replacement therapy" - were also
published in Menopause International and are likely to be replicated around the world. The new
guidelines are the result of extensive consultations and meetings among
endocrinologists, gynecologists and other health care professionals - collectively known as the "Panel
of Experts". They carefully researched and re-assessed the WHI and MWS studies, as well as several
other human trials and studies. The Panel believes the new guidelines offer doctors "a detailed review
of the available evidence to help them make the best possible clinical decisions, as well as providing
women with more balanced, impartial and accurate HRT treatments for menopausal females. " Lead
author of new recommendations, Nick Panay, Chair of The British Menopause Society, said: "Our aim is
to provide helpful and pragmatic guidelines for health professionals involved in prescribing HRT and for
women considering or currently using HRT. With these updated recommendations, it is hoped that HRT
will once again be used appropriately and provide benefits for many women in their menopause."
The new guidelines include the following key points:

An individual decision - each patient must receive proper and comprehensive information
from her doctor so that she can make a fully-informed choice. Whether or not to use HRT is an
individual decision.

HRT dosage - should be calculated on an individual basis, as should overall regimen and

Annual evaluation - every woman on hormone replacement therapy must have her
treatment evaluated once a year for pros and cons.

No arbitrary limits on duration - the duration of HRT usage should not be restricted by
arbitrary limits. "If symptoms persist, the benefits of hormone therapy usually outweigh the

HRT more favorable for younger patients - when deciding on HRT usage, the patient as
well as the doctor must remember that there is a more favorable benefit/risk profile for patients
who start therapy before they are 60 years old.

Premature ovarian insufficiency - patients should be on HRT at least until the average age
of the menopause.

Older patients - patients over 60 who are prescribed HRT should initially be on lower doses
and ideally with a transdermal route of administration.

R&D must focus on risks and benefits - as people continue having longer lifespans,
research and development needs to concentrate on maximizing benefits and minimizing risks
and side effects. "This will optimize quality of life and facilitate the primary prevention of longterm conditions which create a personal, social and economic burden."

Menopause test is not usually required

In most cases women do not need to be tested for menopause, unless they are very young or have
abnormal bleeding patterns during menstruation. In such cases, the patient needs to be tested for
other conditions with similar symptoms, such as a thyroid problem or cervical.
HRT may not be suitable for women who:

are pregnant

have uncontrolled hypertension (high blood pressure). The hypertension needs to be treated

have severe migraines

have a history of thrombosis or blood clots

have a history of stroke

have a history of heart disease

have a history of endometrial, ovarian or breast cancer

Females may become pregnant even after their periods have stopped; those under 50 might remain
fertile for up to a couple of years. In such cases, doctors recommend that sexually active women use a
condom, diaphragm or some non-hormonal contraceptive.

Three main types of HRT

HRT with only estrogen - women who have had a hysterectomy where their uterus (womb)
and ovaries have been removed do not need progesterone, because there is no risk of endometrial
Cyclical HRT (sequential HRT) - for patients who are still menstruating but have
menopausal-like symptoms. The cycles may be monthly, an estrogen plus progestogen dose at the end
of the menstrual cycle for 14 days, or a daily dose of estrogen and progestogen for 14 days every 13
Continuous HRT - used for post-menopausal patients. They take a continuous combination of
estrogen and progestogen.
The doctor may recommend Tibolone, a synthetic hormone that uses both estrogen and progestogen
(combined HRT). Tibolone mimics the effects of both hormones.

How does the patient take HRT?

The doctor will try to control menopausal symptoms with the lowest possible dosage - it may
occasionally take some time to get it right.
HRT may be taken in the following forms:

Cream/Gel - it is placed either on the skin or in the vagina if the woman has vaginal dryness


Skin patch
Patients usually come off HRT gradually - they are weaned off slowly.

Does HRT affect memory and cognitive abilities?

Some women may be concerned that HRT might affect their memory and thinking skills (cognitive
abilities). Researchers from Wake Forest School of Medicine, Winston-Salem, N.C., USA, reported
in JAMA Internal Medicine (June 2013 issue) that women aged 50 to 55 on HRT have no risk of memory
problems or cognitive declines. Their study demonstrated that HRT for post-menopausal females with
CEEs (conjugated equine estrogens) is not associated with overall sustained benefit or risk to cognitive
function. The researchers added that we do not know whether this might be the case with younger
patients. Lead researcher, Mark A. Espeland, Ph.D., said "Global cognitive function scores from women
who had been assigned to CEE-based therapies were similar to those from women assigned to placebo.
Similarly, no overall differences were found for any individual cognitive domain. Our findings provide
reassurance that CEE-based therapies when administered to women earlier in the postmenopausal
period do not seem to convey long-term adverse consequences for cognitive function."

Some measures the woman can do herself

The following measures may help ease symptoms:

Consume less caffeine
Consume less alcohol
Consume less spicy food
Don't smoke
Do exercise regularly
Wear loose clothing
Sleep in a well-ventilated, cool rom
Some SSRI type antidepressants can help treat hot flashes. The antihypertensive drug, clonidine, may
help reduce the symptoms of hot flashes. Anecdotal accounts say that consuming ginseng, block
cohosh, red clover, soya beans and Kava help with menopausal symptoms. Experts say scientific
studies are needed to confirm this.

Hormone replacement therapy has been shown to have other beneficial effects. In a study women
taking estrogen through HRT showed that the estrogen positively affects the prefrontal cortex by
boosting the working memory. This suggests that estrogen may play a key role in certain frontal lobe
functions in women. Women using HRT after menopause have no additional weight gain compared to
women who do not use HRT. Also women who use HRT with an estrogen component show positive

effects in their sex life (mainly increasing their sex drive and sexual sensitivity) but the effects are
inconsistent across women. These sexual improvements may dissipate after receiving some forms of
HRT for extended periods of time.


Shuster, Lynne T.; Rhodes, Deborah J.; Gostout, Bobbie S.; Grossardt, Brandon R.; Rocca,
Walter A. (2010). "Premature menopause or early menopause: Long-term health
consequences". Maturitas 65 (2): 161166.
Sveinsdttir, Herds; lafsson, Ragnar F. (June 2006). "Women's attitudes to hormone
replacement therapy in the aftermath of the Women's Health Initiative study". Journal of
Advanced Nursing (Wiley) 54 (5): 572584.