FAQ
When should I start taking HRT?
You can start taking HRT as soon as you experience your first menopausal symptoms, for example, hot flushes.
How long can I take HRT for?
If you are taking HRT purely to control menopausal symptoms, you will probably only need short-term treatment (less than 5 years). It is worth having a trial period off treatment every year or so to see if symptoms are still present.
Some women take HRT to protect against osteoporosis when other treatments have proved to be unsuitable. In this case, longer term therapy may be necessary. However it is important for both doctors and patients to balance the risks of long-term HRT against the benefits. For example, HRT taken for more than 5 years after the age of 50 has been associated with a small increase in risk of breast cancer.
If you have a premature menopause (before age 40) it is usual to take HRT until you reach normal menopausal age (about 50). Longer term use under these circumstances is not thought to carry any additional risks.
What are the side effects of HRT?
You may experience some side effects when you first start taking HRT. These will often lessen or disappear after the first few months of treatment. The most common side effects are breast tenderness, irregular bleeding and feeling bloated. Headaches and nausea can also occur. Talk to your doctor about any side effects which trouble you or which do not improve over the first 3 months. He or she may suggest trying a different HRT product.
Will I put on weight if I take HRT?
In the first few months, you may notice some fluid retention which can cause you to feel bloated. However, studies have found no evidence that HRT causes women to gain weight. Most women tend to put on a few pounds after the menopause whether or not they take HRT. Some women find that because they feel better in themselves whilst taking HRT, they are more motivated to exercise and eat healthily. This can help to keep weight gain in check.
If you find that weight gain is a particular problem whilst taking HRT, talk to your doctor who may suggest reducing the dose or changing to a different type of HRT.
Is there anything I can do to reduce breast tenderness?
Breast tenderness is very common in the first few weeks after starting HRT and should improve by 3 months. Some women find Oil of Evening Primrose helpful, but it does not work for everybody. If your breasts are still very sore after 3 months, talk to your doctor. He or she may suggest trying a lower dose of estrogen or changing to a different type of progestogen. Sometimes giving HRT in a different way, for example, using HRT skin patches, can alleviate troublesome and persistent breast tenderness.
I have a strong family history of breast cancer. Can I still take HRT?
A close family history of breast cancer (eg mother, sister), especially if the cancer occurred at a young age, can increase a woman’s risk of developing breast cancer. Taking HRT for more than 5 years after the age of 50 has also been associated with a small increase in risk of breast cancer. All women in this position need to talk the matter over with their doctor and make an individual decision balancing the risks against the benefits of taking HRT.
I had breast cancer a few years ago but now I’m getting hot flushes and other menopausal symptoms. Is there anything I can take?
HRT cannot be recommended for any woman with a past history of breast cancer. Sometimes it is worthwhile considering whether lifestyle changes might help. For example:
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Stopping smoking
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Drinking less alcohol
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Reducing caffeine intake
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Eating healthily
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Exercising regularly
There are some non-hormonal medicines, for example, clonidine, which can improve hot flushes. Please talk to your doctor who will be able to give you more information.
My mother and grandmother both suffered from severe osteoporosis. I don’t have any menopausal symptoms but should I be taking HRT to protect my bones?
Although we know that HRT protects against postmenopausal osteoporosis and fractures, it is not recommended as a first-line treatment. If you have no signs of osteoporosis (eg pain, fractures), you may need to have a bone scan to assess whether or not you are at risk. If the scan shows that your bones are becoming thinner, there are several effective, non-hormonal osteoporosis treatments which your doctor will want to try first. If you are unable to take these other treatments but have a high risk of osteoporotic fractures, HRT may be considered.
Will my periods come back when I start HRT?
Cyclical or sequential HRT where a progestogen is given for 10-14 days each month will usually cause a monthly withdrawal bleed, similar to a normal period. However, if you have not had a period for at least a year, period-free HRT can be used (see Question 10). After some initial bleeding over the first 3-6 months, this should settle and you will not have monthly bleeds.
If you have had a period within the last year, you will probably start with a cyclical HRT product (which will give monthly bleeds) and then switch to period-free HRT at a later date.
Why am I still bleeding with my ‘period-free’ HRT?
If you have not had a period for at least one year, you will probably be prescribed a type of HRT known as ‘period-free’. You will take a small dose of estrogen and progestogen every day. Taking a progestogen every day makes the lining of the womb very thin and eventually prevents bleeding. However, the thinning process can take several weeks and during this time it is very common for women to experience some bleeding.
This bleeding is likely to be irregular and unpredictable. It can vary from occasional spotting to period-like bleeding on and off for the first 3 months of therapy. You can expect that the bleeding should be minimal by 3 months and will have stopped completely by 6 months. It is important to persist with treatment in the early months as, for most women, this will eventually result in period-free HRT. However, if the bleeding is heavier or more prolonged than you would expect or if it continues beyond 6 months, please talk to your doctor.
Do I need a mammogram before starting HRT?
You do not need to have a mammogram just because you have started HRT. The NHS breast screening programme invites women between the ages of 50 and 70 to attend for routine mammograms every 3 years. There is no need to have more frequent mammograms because you are taking HRT. Of course, if you develop any new breast symptoms, it is important to see your doctor. This applies to all women regardless of whether or not they are taking HRT.
Do I need a smear test before starting HRT?
There is no need to have a smear test before starting HRT. HRT is not thought to have any effect on the risk of cervical cancer. You should continue to have a cervical smear every 3-5 years until the age of 64, as recommended by the NHS cervical screening programme. There is no need to have more frequent smears or to continue after the age of 64 just because you are taking HRT.
My HRT is controlling my hot flushes but I am still troubled by vaginal dryness. Is there anything that might help?
Hot flushes will normally start to improve after about one month of HRT and by 3 months, your flushes should be well controlled. However, vaginal dryness and soreness can take much longer to improve. It may be as long as 6 months before you notice any real benefit. You may be happy to wait, but if not, you could consider trying local vaginal estrogen therapy.
Estrogens can be given locally to the vagina in the form of a low-dose cream, pessary, tablet or ring. They usually contain a low-dose of a natural estrogen such as estradiol or estriol. These products act locally on vaginal tissues and have little or no effect on the rest of the body. You should not need to take additional progestogen since local estrogens do not affect the endometrium when used in the short term. It may be possible to stop vaginal estrogens after a few months by which time your HRT will be having its full effect.
Do I have to stop HRT before a long flight?
There has been a lot of recent publicity about the risks of blood clots in veins (venous thrombosis) occurring during long haul flights. It has been known for a long time that oral contraceptives increase the risk of blood clots. It is now known that HRT can do the same, but to a lesser extent.
For healthy women who have no past history of thrombosis, the risk of getting a blood clot is very small. You should not need to stop your HRT before a long flight. You should, of course, take sensible precautions as recommended for all passengers. These include leg exercises (shown in in-flight magazines), drinking plenty of water, avoiding coffee and alcohol, walking up and down the plane occasionally and not sitting with legs or ankles crossed.
Some doctors advise taking a one-off, low-dose aspirin before flying to keep the blood thinner but it is best to discuss this with your own doctor as aspirin is not suitable for everyone. Elasticated flight stockings are another possible preventative measure but you must make sure that they fit correctly and are not too tight.
Do I have to stop HRT before surgery?
Major surgery, particularly gynaecological, orthopaedic or surgery on veins in the legs, does carry an increased risk of blood clots (thrombosis). It is known that HRT can slightly increase this risk. However, current guidelines suggest that unless a woman has an above average risk of thrombosis, there is no need to stop HRT before surgery. Risk factors include:
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Previous thrombosis
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Thrombosis in a close family member before the age of 45
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Obesity
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Trauma (eg road traffic accident)
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Long-term immobilisation (may be inevitable with some types of surgery)
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Varicose veins
If you have a major operation planned, talk to your doctor well in advance and see what he or she advises. If your doctor advises you to stop your HRT, you will normally need to do this 4 weeks before the operation. HRT will not be restarted until you are fully mobile.
Do I still need to use contraception whilst taking HRT?
Contraception around the time of the menopause can be a confusing issue. In general, if periods stop before the age of 50, contraception should be continued for a further 2 years. If periods stop after the age of 50, contraception should be continued for one year.
HRT does not have a contraceptive effect nor will it restore fertility in a woman who is postmenopausal. If you are still having periods when you start taking HRT, you should continue to use an alternative, non-hormonal form of contraception. Under these circumstances, it can be difficult to know when it is safe to stop using contraception. General advice is that it is safe for all women to stop at age 55, but many women will choose to stop earlier than this on the advice of their doctor.
Are there any dietary or natural alternatives I could try?
There are a number of plants, for example, cereals, soy, legumes which contain phytoestrogens. These are naturally occurring chemicals with estrogenic activity and can be taken as dietary supplements. There has been only a small amount of research into the effects of such products and it is not yet clear whether they offer any real benefits. For more information on natural remedies try: www.womenshealthlondon.org.uk.
