What are estrogen and progesterone?
After sexual development, the menstrual cycle in women is regulated by the activity of two major hormones; oestrogen and progesterone.
Estrogen is produced by the ovary and rises in the first half of the cycle before the egg is released
Progesterone is released in the second half of the cycle; if there is no egg release, then there is no progesterone (see PolyCystic Ovarian Syndrome)
What do these hormones do?
These hormones have a wide variety of effects on the body including, but not limited to,
- bone health
- heart and brain health
- regulating how breast duct tissues grow
- the menstrual cycle
- Ovulation, the release of an egg
- Mood
- Blood vessels
What is menopause?
Menopause is when the period stops. It generally occurs around age 50; however there is a relative window of hormonal changes before menopause. Each stage is defined by a different pattern of hormones and symptoms to match.
10 years before menopause (40-50)
Leading up to menopause, the first hormone to fall is progesterone
This can cause symptoms like difficulty sleeping, bloating, low energy or mood
Perimenopause
1-2 years before the last period
This typically causes mood swings and hot flushes
This can be very uncomfortable
The estrogen will go up and down unexpectedly leading to hot flushes and discomfort
Post menopause
This is associated with lower bone density
Many other problems such as bladder/vagina issues can ensue There is an impact on many cells and functions
What is Hormone Replacement Therapy ?
Hormone Replacement Therapy involves giving the major female hormones, estrogen and progesterone, to balance a woman’s hormones. This may mean replacing hormones which have declined over age, or around menopause; or balancing the amount of estrogen and progesterone before menopause.
How is Menopausal Hormone Therapy taken?
Hormone Replacement Therapy can be taken via the skin or as a tablet every day.
For women before menopause, progesterone alone is often used
For women experiencing symptoms before menopause; usually estrogen daily with progesterone at night days 14-25 is taken (a period occurs)
For women after menopause, continuous estrogen and progesterone is usually given
What are the risks of HRT?
Hormone Replacement Therapy has been associated with harm, especially in the past when larger doses of estrogen were used. Extensive research has been carried out in recent years.
Overall, Menopausal Hormone Therapy is considered safe in women who are otherwise well and <10 years from menopause or younger than 60
It should be used with caution if you have a risk of:
- heart disease,
- breast cancer,
- ovarian cancer,
- uterus cancer,
- stroke,
- blood clots or
- a family history of this
This is because estrogen might worsen some of these conditions or act as a risk factor for them.
HRT is associated with a small increase in blood clots, the chance of having a heart attack, or strokes and breast cancers however these are far less when HRT is used in women <60
What this means is that the estrogen might make it more likely for the blood to turn from a liquid to a hard solid clot in some places in the body. This may cause a deep vein thrombosis (a blockage in blood vessels in the leg draining blood back to the heart and lungs) or even in the brain, leading to a stroke.
Breast cancer is a type of cancer where estrogen fuels the growth of cancer cells. This is why it is very important not to take estrogen if you have had breast cancer. It is necessary to speak to your specialist first as taking estrogen can promote cancer growth.
HRT has a beneficial effect on hot flushes, vaginal symptoms and bone density but is not recommended solely for these reasons. It should be used on a personal and individual basis
Any woman with a uterus, who has not had a hysterectomy to remove the womb, should have progesterone if taking estrogen. If we just give estrogen, the uterus will build up endlessly. This may lead to uterus cancer. The progesterone counteracts the effect of estrogen in this way to protect the womb against uterine cancer.
What measures should I do before starting HRT?
There are some routine tests that all women shoulder undergo prior to beginning HRT.
General blood tests
Make sure underlying health is optimised e.g cholesterol, sugar
Pelvic Ultrasound
Check that there is no endometrial abnormalities in the uterus prior to starting HRT
This is because it can become difficult to know if any unexpected bleeding is secondary to HRT
All unexpected bleeding in a post menopausal women requires referral to a Gynaecologist to assess for endometrial cancer
Bone Mineral Density or DEXA Scan
Assess the baseline bone density for comparison
Mammogram
Ensure no breast cancer or lump is present as estrogen therapy can fuel this to grow
Pap smear
Pap tests are recommended every 3 years up until the age of 65-70 Family History: discuss breast cancer and blood clots risk
Discuss any genetic or environmental predispositions; is there a big family risk of blood clots, stroke, breast cancer etc. that make it unwise to use estrogens.
What should I watch out for when HRT is started?
Achieving the right level of hormones takes some time as each woman is different. There are some common patterns:
Some women may experience some vaginal bleeding; this is variable and may warrant investigations to rule out other causes. Typically, more progesterone is needed
Some women may experience breast tenderness, mood changes and fluid retention; this may mean the estrogen is too high
If there are hot flushes, vaginal dryness and no relief of symptoms, then more estrogen may be required.
What are the alternatives to HRT?
HRT is traditionally given for the alleviation of menopausal symptoms. Antidepressants can have a role in treating these symptoms, as can natural medicine remedies. Furthermore, some of the associated symptoms can be
treated individually, for example, sleep difficulties. You should have a general discussion with your doctor about the advantages and disadvantages.
What is bioidentical HRT?
Bioidentical is just a term used to describe giving hormones as close as possible to what the body would produce. In women after menopause, this might mean giving one or two kinds of estrogen in a special balance. Progesterone will be needed.
How is HRT given?
HRT usually involves both estrogen and progesterone. Some women who are experience symptoms before menopause may just have progesterone.
Both estrogen and progesterone can be given in a pill or tablet or can be in a cream. The cream is often preferred however there are a variety of practices.
Progesterone is often used at night whilst estrogen is used in the morning; progesterone may cause some sleepiness in some women.
It is important to test the hormones from time to time the day after using the creams; this is to check that there is enough.
REFERENCES
Academic Committee of the Korean Society of Menopause, Lee SR, Cho MK, et al. The 2020 Menopausal Hormone Therapy Guidelines. J Menopausal Med. 2020;26(2):69-98. doi:10.6118/jmm.20000
Fait T. Menopause hormone therapy: latest developments and clinical practice. Drugs Context. 2019;8:212551. Published 2019 Jan 2. doi:10.7573/dic.212551
https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with hormone-therapy
