What type of MHT can I have?
If you have had the whole of your uterus (womb) removed, you usually only need oestrogen MHT although there are some exceptions to this e.g. severe endometriosis or endometrial cancer.
If you still have your uterus you need both oestrogen and a progestogen (combined MHT) to stop the lining of the uterus building up and in rare cases developing endometrial cancer. This is divided into continuous combined or sequential combined MHT. Which one you start with will depend on your age and when your last period was.
MHT can be delivered by patches, gels, spray or tablets and we can discuss the most suitable option for you. We prefer to prescribe oestrogen through the skin as this doesn’t increase the risk of blood clots and is safer in women with other medical issues. However, oral MHT may suit those without any risk factors for thrombosis.
What are the side-effects and risks of MHT?
There are so many myths about MHT that are still being perpetuated and many doctors are still very cautious about prescribing it despite the proven benefits. Typical misconceptions are that it makes you put on weight, that you can’t have it if you get migraine or have a family history of breast cancer, that it just delays your menopause and that you should only be on it for the shortest possible time.
The biggest worry for most women is the reported risk of breast cancer with MHT but the benefits for symptom control as well as cardiovascular and bone health also need to be considered. The risk is small and is related to the type of MHT used and the duration of use. The Women’s Health Concern website has excellent information on this, including an infographic looking at the lifestyle risk factors for breast cancer. Our biggest risks for breast cancer are being female and getting older plus a small proportion of women have a genetic mutation that increases their risk.
There is a small increased risk of blood clots and ischaemic strokes with the tablet forms of oestrogen but not in healthy women using the patch, gel and spray forms of oestrogen. The choice of progestogen is also important.
What are the long term benefits of HRT?
If you start HRT before the age of 60 or within 10 years (but ideally sooner) of your last period, you may have a significantly reduced risk of developing cardiovascular disease in the future. Long-term HRT can also protect against osteoporosis. Women on continuous combined HRT have a lower risk of endometrial cancer than those on no HRT at all.
What about testosterone?
Women produce testosterone in our ovaries and via our adrenal glands. Our ovaries continue to produce it postmenopause. Our levels peak in our 20s, reduce in our late 20s/early 30s and then plateau in midlife, sometime increasing in our 70s. Our levels reduce more dramatically if our ovaries are removed or are effected by chemotherapy, radiotherapy etc.
A trial of testosterone may be indicated to see if it will help with low libido in women who are already on MHT (with transdermal oestrogen). However, there are many other factors that can contribute to low sexual desire. Some women do report that it helps with their mood, cognition, muscle strength and energy levels but research so far has not shown these effects. New studies are ongoing. You would normally have a trial of an adequate dose of oestrogen (with progestogen if you still have a uterus) for at least 6 months before considering whether testosterone is needed to help with low libido.
Does MHT also act as contraception?
No. If contraception is still needed, the Mirena (52mg LNG-IUD) is a good option. This can act as the progestogen part of MHT, contraception and reduce heavy bleeding so many doctors recommend it. Other women may decide to take the progestogen only pill as well as their HRT.
How can I improve my vaginal symptoms?
As we lose oestrogen we all develop thinning of the tissues of the vagina, vulva and bladder. This is not something that settles after the menopause but steadily gets worse without treatment, often leading to vaginal burning and itching, painful sex, urinary frequency and recurrent urinary tract infections. Some women find that having a smear becomes more uncomfortable as they get older because of this. All these symptoms can be helped by the regular, long term use of local (vaginal) oestrogen which is very safe and effective. It does not increase the risk of breast cancer and those still with their uterus do not need to have a progestogen as well. Women on an aromatase inhibitor need to discuss their options with their oncologist.
Most women on MHT find their vaginal symptoms are greatly improved but at least 25% find they need to add in long term vaginal oestrogen.