When it comes to menopause, awareness of symptoms and ways to mitigate their impact are changing. Chief among treatments that have undergone an image change is hormone replacement therapy (HRT).
While many women have been wary of such medication because of concerns over an increase in the risk of breast cancer, it has recently become a focal point for high-profile campaigners such as Davina McCall, who have stressed its benefits for managing symptoms from low mood to hot flushes.
So what is HRT? What benefits can it bring? And is it the right option for you?
What is HRT?
Menopause is often defined as beginning 12 months after a woman’s last period, with perimenopause referring to the transitional phase before this, which can last several years.
During perimenopause, levels of a hormone known as oestrogen fall, causing many of the symptoms associated with menopause including hot flushes, mood swings and vaginal dryness. Levels of another hormone – progesterone – also decline.
HRT boosts levels of such hormones, and in doing so mitigates against a host of symptoms. It can also help to maintain muscle strength and prevent osteoporosis – a weakening of the bones that can arise as oestrogen levels fall. By taking HRT, and hence increasing oestrogen levels, bone loss can be prevented, reducing the risk of fractures.
How many women use HRT?
According to the Department of Health and Social Care, around 15% of women aged 45-64 in England are currently prescribed HRT, with figures on an upward trajectory.
Not everyone likes the term HRT, with some including Dr Ruth Brauer, lecturer in pharmacoepidemiology and medication safety at University College London, preferring the term menopausal hormone treatment (MHT).
“The ‘replacement’ bit suggests that you’re lacking in something when you hit menopause, which is, of course, not true. Menopause is a natural transition in the life of every woman with a uterus. So if you lose your oestrogen that’s a natural part of life, and it does not need to be replaced,” says Brauer.
However, for the sake of clarity, this article will use the term HRT instead of MHT.
What types of HRT are there?
As Dr Channa Jayasena, an expert in reproductive endocrinology at Imperial College London, points out, in the UK and Europe all forms of HRT should contain the main oestrogen found in women, estradiol. This can be given in a variety of ways, from pills to patches, sprays and gels, as well as via vaginal application.
But while oestrogen-only HRT can be given to women who have had a hysterectomy, women with a womb are also given another hormone to prevent its lining from thickening. “The problem with just giving estradiol alone is that you thicken up the womb, and that can, over time, cause problems and potentially increase risks of endometrial cancer,” says Jayasena.
This second hormone is a progestogen, which can either be progesterone – the version found in the body – or a non-natural progestogen which is similar in structure and action.
This extra hormone can be given continuously – as in the case of the Mirena intrauterine system – which can prevent bleeding altogether, or it can be given intermittently, for example in tablet form, if women prefer to have a bleed.
“The oestrogen does the good and the progesterone is given because you need to give it for safety,” says Jayasena.
Combined HRT offers both hormones in a single product, and comes in various forms including tablets and patches. “The combined pill [used for contraception] basically has the same components as HRT, so oestrogen and progesterone, but at much higher doses,” Jayasena says.
One concern, however, is that HRT tablets have been associated with a small increased risk of blood clots and stroke – although this risk depends on dose and other factors, and is lower for patches, gels or sprays. For stroke, the risk also depends on age.
Another concern is that progestogen-containing HRT has been linked to a slightly raised risk of breast cancer in those that use it, with risk linked to duration of use.
However, as the British Menopause Society (BMS) notes, for most women – who have a low underlying risk of breast cancer – the benefits of using HRT for up to five years will exceed potential harm due to the relief it provides from symptoms of menopause.
What about testosterone?
According to Jayasena there is debate around whether an additional hormone, testosterone, should be offered to women who are taking HRT, but who still have problems with low libido, to improve their sex drive. “[Testosterone] is a male hormone, but women have [it] in lower doses,” he says.
Testosterone is currently unlicensed in the UK for women so can only be prescribed ‘‘off-label’’. However, a recent investigation by the Pharmaceutical Journal revealed there has been a 10-fold increase in testosterone prescriptions among women in recent years, with the number of women aged 50 years and over receiving testosterone gel using an NHS prescription rising from 429 women in November 2015 to 4,675 in November 2022.
As well as helping with sex drive, some women have reported taking testosterone improves their mood, concentration, motivation, and energy levels. However, not everyone is convinced that testosterone needs to be widely prescribed.
“Lack of sex drive is very complex,” says Dr Paula Briggs, a consultant in sexual and reproductive health and chair of the BMS. “The natural thing, as you get older, is that your sex drive diminishes a bit,” she says, adding that in some cases women simply no longer fancy their partner.
“I think now the patient expectation, because of what [information] they’re being fed, is that every woman needs testosterone, it’s the missing piece of the jigsaw – and it just isn’t right,” says Briggs.
The BMS also says that while some individuals have reported myriad benefits from taking testosterone, further research is needed. “Randomised clinical trials of testosterone to date have not demonstrated the beneficial effects of testosterone therapy for cognition, mood, energy and musculoskeletal health,” the society noted in 2022, adding that taking testosterone can also come with side-effects, including acne. It can also result in thicker body hair, and Jayasena cautioned that taking testosterone can cause male-pattern hair loss in some women.
However, further studies may be some way off: as the BMS itself notes, there is a reluctance within the pharmaceutical industry to finance such research.
What are bioidentical and body-identical HRT?
Bioidentical hormones have the same chemical structure as those that occur naturally in the human body, but are made in the laboratory to ensure they are pure.
“HRT used to be equine urine-derived, and it had a much higher risk of blood clots,” says Jayasena.
Bioidentical hormones are already available on the NHS in some forms of HRT, and have been through rigorous testing and are regulated. There is also some evidence that they might bring benefits; for example, early research suggests HRT that contains bioidentical progesterone is associated with a slightly lower risk of breast cancer than HRT containing non-natural progestogens.
Some experts have called for HRT involving bioidentical hormones to be dubbed “body-identical” HRT. That is because in recent years the term “bioidentical HRT” has been confused with formulations produced by specialist pharmacies that are marketed as bespoke to individuals. These formulations – called compounded bioidentical HRT – often include oestrogen, progesterone and testosterone.
Experts have warned that while compounded bioidentical HRT might sound good, such medications have not gone through the rigorous drug development and regulatory pathways that conventionally prescribed HRT has passed.
In addition, despite claims about its superiority, compounded bioidentical HRT has not been subjected to randomised control trials to compare its effectiveness or safety against placebo or conventional HRT. “They might help but you don’t know what the risks are, both short-term and long-term,” says Brauer.
Briggs adds that another concern is variation in the makeup of the prescription. “You just wouldn’t know what you’re getting from one prescription to the next,” she says. “And they market it as bespoke HRT – they are testing hormone levels in blood and saliva and saying ‘this is your unique product’, but you can’t do that, because hormone levels will change continuously.”
Who should be taking HRT?
This is a controversial point. Many campaigners argue that scare stories have led to the medication being underused, and that far more women would benefit from taking HRT than currently have prescriptions for it. However, some experts are concerned the message now being sent is that every woman who is going through perimenopause needs HRT.
“In reality, there are some women who will have little or no symptoms [of menopause], and there are other women who will have extremely severe and debilitating symptoms,” says Jayasena. “The advice is that you should take HRT if it will help you. Clearly if you have no benefits because you feel perfectly fine, the advice is that you shouldn’t take it.”
Briggs agrees: “You’ve got the extreme end who say women are being overmedicalised. And then the other end [saying] that everyone should have HRT because it’s a deficiency state. And neither of those are right.
“It should be there for women who are symptomatic, who have no contraindications and who want to take it,” Briggs says. “[But] being made to feel that you need to be taking something when you might not want to, that’s not right either.”
It is also important to note that some women cannot take HRT because it is not compatible with other aspects of their health, or may simply not want the medication. One concern about the drive to increase uptake is that while the risks from HRT – such as a small, increased risk of breast cancer associated with progestogen-containing forms – are low, they do exist.
According to the NHS, there are around five extra cases of breast cancer in every 1,000 women who take combined HRT for five years. This is a small uptick in risk but, if all women took such HRT, Jayasena says the number of women affected by uncommon complications would be large.
“The more people who take this without any tangible benefits, the more breast cancer cases you will create unnecessarily,” he says, adding that there is a concern that increased awareness of HRT might now be catapulting women from being undertreated to being overtreated.
But that isn’t to say HRT is reaching all those who might benefit from it.
Brauer says research has suggested prescribing rates are higher among women who are more affluent, while there are also differences based on ethnicity, revealing there could be access issues at play among some groups. She also notes there have been calls for greater access to HRT for women who experience mental health problems, and a proportion of women experiencing anxiety and low mood as a result of hormonal changes could benefit from having HRT rather than antidepressants.
Are new drugs in the offing?
Yes, there have been some exciting developments in recent years. Among them, Jayasena and colleagues have been working on a drug called Veoza, also known as fezolinetant, that prevents hot flushes.
“It’s brand new,” says Jayasena. “It’s not what we would call HRT, because it doesn’t have the holistic effects. In other words, it’s not going to help your bone density, it’s not going to help your mood. It’s not going to help libido. But what it does do is target the reason why people get flushes when they have low oestrogen.”
While Veoza has been approved by both the FDA in the US and the UK’s Medicines and Healthcare Products Regulatory Agency (MHRA), it is not yet available on the NHS – although a review by the National Institute for Health and Care Excellence (Nice) is expected to begin this year which could change that.
Jayasena says the active ingredient is a neurohormone, meaning it is suitable for some women who may not be able to take conventional HRT. “In someone who cannot have HRT because they have breast cancer, and they have horrendous flushes, then this is a brilliant treatment to make their life much, much better,” he says.
