Knowledge Is Power: HT Risks and Benefits | Stella
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HT risks and benefits

byDr. Lucy Wilkinson

Hormone therapy (HT) is the most effective proven treatment for many menopause symptoms. Yet there is an almost overwhelming amount of information out there – some of it conflicting. Inevitably, there are many myths and misunderstandings around HT. It can even be difficult for medical professionals to make sense of the ever-changing recommendations. Read on for more on the facts and evidence about the risks and benefits of HT, helping you to be better informed.

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What is HT?

Hormone therapy (HT) is a treatment for menopause symptoms. It comes in the form of pills, patches, creams, and gels among others. It has been consistently proven to be the most effective treatment for a range of menopause symptoms such as mood changes, hot flashes, painful sex, and bladder symptoms.

It’s important that you discuss any symptoms with your healthcare provider to be sure of your diagnosis before you consider HT treatment. Other medical issues can mimic menopause symptoms. 

Likewise, HT may not be suitable for you because of your medical history or you may just prefer not to take it. That’s ok, HT isn’t for everyone – there are alternative, non-hormonal medications, and lifestyle change can help too. Your healthcare provider will help you make an informed decision.

HT, HRT, and MHT – what’s the difference?

Research and self-education can improve your menopause experience and speed up the process of finding the right treatment for you. Confusing terminology can get in the way of this! We want to clear things up if you have come across the terms HRT, HT, or MHT and you’re not sure what they mean. The truth is, there is little difference between these abbreviations.

  • HRT stands for hormone replacement therapy. Many symptoms of menopause are caused by a dramatic reduction in levels of certain hormones such as estrogen. This name suggests that the medication works by replacing the hormones that are no longer produced by your body during menopause
  • HT, or hormone therapy, is a term that is growing in popularity as the way to describe this type of treatment, as HT does not technically ‘replace’ hormones. It is more accurate to say that the hormones in HT safely and effectively treat symptoms caused by changes in your body during menopause
  • MHT, or menopausal hormone therapy, is a more precise phrase than HT. Hormones are used in lots of different medical treatments, so MHT is used to specifically describe HT for menopause and is often preferred by research scientists for this reason. You may see this phrase used in scientific research papers

Understanding your menopause journey

Menopause is best understood as a journey rather than a destination. For most women, this journey lasts about 10 years, although it’s different for everyone.

It is common to start noticing symptoms between the ages of 40 to 45. These frequently include hot flashes, disrupted sleep, tiredness, brain fog, and mood changes. You may also notice that your periods become irregular or less frequent, and they can become even heavier.

Menopause can be very different from one person to the next. Some women have minimal symptoms, whereas others may find them very disruptive.

Your symptoms will change over those 10 years as your body adjusts to the hormonal changes. You may find that your symptoms wax and wane, or that new symptoms arise just when you least expect them – and that’s normal (although annoying!).

Menopause is best understood as a journey rather than a destination.”

Dr. Lucy Wilkinson

It is very difficult to predict when you will go through menopause, although a few factors including family history, illness, and medication can have an impact. Going through menopause before the age of 45 is considered early menopause. 

Learn more about the stages of menopause.

How do you know if you need HT?

Ultimately this is a personal choice and depends on how your symptoms are affecting you. Many women manage their menopause without any form of treatment, while others find HT helpful.

This is often a tricky decision to make. Menopause symptoms can be vague and develop over years, making it difficult to describe exactly how they are affecting you. If this is the case, keeping a diary or using a menopause symptom tracker, may help you to get an objective overview.  

If your menopause symptoms are having a significant impact on your quality of life, are disrupting your daily activities, or are not responding to lifestyle changes, it is a good idea to at least think about HT. 

There is also a wide range of non-hormonal treatments and lifestyle changes that you may find useful, from dietary changes to exercise plans. The Stella app offers a personalized plan to help guide you through lifestyle changes to help manage symptoms. 

Do menopause symptoms require long-term treatment?

You will be pleased to hear that most symptoms eventually improve as your body adjusts to the new, lower level of hormones. If this is the case, you can consider stopping your HT. For many women, this happens after a few years of treatment.

The only group of menopause symptoms which tend to need longer-term treatment is known as genitourinary syndrome of menopause (GSM). These changes include vaginal discomfort, dryness, painful sex, and urinary symptoms, and are caused by persistently low estrogen levels. 

GSM can be treated very effectively using estrogen creams, gels or pessaries applied directly to the affected areas of the vagina, vulva, and urethra, also known as topical HT. It is common to need ongoing treatment for many years after your other menopause symptoms have disappeared. Thanks to the low-risk nature of this sort of HT, this is safe and effective in practice. 

 How long does HT take to work?

Don’t be disappointed if it doesn’t work straight away. It can take a few weeks for your symptoms to start improving and it’s common to have some side effects initially.

It can take anywhere from 6 weeks to 3 months to see how your body will react to the HT. After this amount of time, you should have a good idea as to how much your symptoms will improve and whether any of those pesky side effects will stick around.

Your healthcare provider should review your progress after three months. They will want to know how your symptoms are responding to the HT, whether you have any side effects, and whether your health has otherwise changed since you started the prescription (e.g. new medical conditions or medications).

If things aren’t going so well at this point, you may want to discuss changing your HT. This can include changes to the dose or type of HT you take. Your healthcare provider will be able to advise on the best choices for you. 

Can you have HT?

While using HT is a personal choice, there are certain circumstances in which your healthcare provider may advise against it. These are mostly due to pre-existing conditions that increase your risk of serious side effects or that might accelerate the development of another medical problem. 

Healthcare providers are currently advised not to prescribe HT if you have any of the following:

  • Any breast cancer, whether past, present, or suspected
  • Any other known or suspected estrogen-dependent cancers (meaning those which grow in response to the presence of estrogen, most commonly found in cancers of the ovary, uterus, or endometrium)
  • Vaginal bleeding of unknown cause (including bleeding in between periods, bleeding after sex, or unexplained heavy bleeding)
  • Untreated atypical endometrial hyperplasia (abnormal thickening of the lining of the uterus)
  • Certain types of venous thromboembolism (blood clots) including pulmonary embolism (PE) and deep vein thrombosis (DVT), unless you are already on medications to thin the blood (anticoagulants)
  • Certain types of arterial disease including angina or myocardial infarction (heart attack), whether past or present
  • Liver disease with evidence of abnormal liver function
  • Pregnancy 
  • Thrombophilic disorders (conditions which increase your blood’s tendency to clot)

They are also advised to prescribe only with caution in several conditions, including:

  • Porphyria cutanea tarda – a rare metabolic disease
  • Personal history of breast cancer, a strong family history of breast cancer, or evidence of a high-risk genetic predisposition
  • Diabetes mellitus
  • Significant risk factors for venous thromboembolism – blood clots including DVT or PE. These include being aged over 60, smoking, having medical complications related to being overweight, or having a history of cancer 
  • Having a history of endometrial hyperplasia – abnormal thickening of the lining of the uterus
  • Migraine

If you have one or more of these risk factors, your healthcare provider needs to discuss your overall health and specific risk factors versus the benefits of taking HT with you. Your healthcare provider may want to monitor you more closely or choose a type of HT specifically to minimize your risks. They may also advise that HT is too risky in your circumstances. If this is the case, take a look at the many treatment options that are available to you besides HT. Good nutrition, exercise, and stress management can all have a positive effect on menopause symptoms and can be personalized through your plan on the Stella app.  

Also, it may be helpful to know that vaginal estrogen has fewer limitations compared to oral or transdermal hormone therapy because very little is absorbed into the blood. 

HT risks and benefits  

Why is HT controversial?

While an effective treatment for menopause symptoms, HT is not without controversy. 

In the early 2000s, a large-scale, randomized clinical trial into the long-term safety and efficacy of HT concluded that oral HT came with more risks than benefits. Specifically, the earliest data published seemed to demonstrate an increased risk of breast cancer and coronary heart disease. This trial was the Women’s Health Initiative study, with the first results published in 2002. 

This understandably caused a wave of concern throughout the media and the medical community alike. Many patients stopped taking HT, and many healthcare providers stopped prescribing it.

However, a closer look at the study results showed that the reality was not as clear-cut as originally thought. This was in part due to the design of the study, which only included a very limited number of HT preparations. Further analysis also showed that the majority of the women included in the study were over a decade past their last period, so it was unclear whether the conclusions of this study could be applied to younger women who were less than 10 years from menopause – who are often the ones taking HT.

Recent studies

Over the following years, many studies have been done to investigate further. Thanks to this, we now have a much better understanding of the risks of HT, and the concerns identified in the early 2000s. As well as having more information about HT, we also have more access to different forms and routes of systemic HT compared with those included in the study 20 years ago. 

Transdermal HT – in the form of patches or hormone gels applied to the skin – is known to be lower risk for many women than the oral medications studied in the Women’s Health Initiative study, and is now widely used.  

The risks of HT are not being ignored, but they are now much better understood and can be weighed more individually against the benefits of this useful and popular treatment.

What are the benefits of HT?

The biggest benefit of HT is that it provides the most effective available treatment of menopause symptoms including:

Long-term health impact

Osteoporosis: Osteoporosis affects 1 in 3 women. The thinning of the bones associated with this condition makes fractures – even without a significant fall or injury – more likely. The evidence that HT protects your bone density, reduces the risk of so-called fragility fractures, and prevents osteoporosis, is consistent and widely accepted. This benefit continues throughout the time you take HT.

Heart disease: There is some evidence that HT may be beneficial for heart health. Those who start estrogen-only or combined HT before age 60 or within 10 years of their last period may have a reduced risk of both coronary heart disease and death from cardiovascular disease. One Danish study of over a thousand women found that the relative risk of coronary heart disease decreased by 50%. This protective effect only seems to happen for those who begin HT within the earlier years of their menopause, sometimes referred to as the estrogen window of opportunity theory. 

Despite these findings, the North American Menopause Society’s (NAMS) current stance is that evidence is not yet strong enough to confirm this effect. This means that while a reduced risk of heart disease may be a welcome side-effect of HT when used to control your menopausal symptoms, it is not recommended that you start HT solely for this reason.

Bowel cancer: Several studies – including this large 2017 study – have found taking combined HT is associated with reduced risk of bowel cancer. However, evidence is still emerging and there are some questions still to be answered (including about the doses and types of HT that produce this effect). Just as for heart disease, this is therefore a potentially beneficial side-effect rather than a primary reason to take HT.

Sarcopenia: Sarcopenia is just the fancy Greek word for the gradual reduction in muscle mass and strength that happens as we age. There is reason to believe that HT may slow down the loss of muscle as you age, but the effect is still unproven.

What are the risks of HT?

As with all medications, HT comes with certain risks. As mentioned earlier, the medical community is constantly learning about the extent of these risks, as well as the different ways we can protect against them. It’s important to have a thorough conversation with your healthcare provider so that they can assess your risk profile. This will help you make a fully informed decision about the HT that is right for you. Let’s take a look at the risks of HT today…

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Does HT cause breast cancer?

Estrogen-only HT does not appear to increase your risk of breast cancer. There is some evidence that suggests that estrogen-only HT may reduce your risk.  

Similarly, vaginal estrogens – used to treat the genitourinary syndrome of menopause – are not associated with an increased risk of breast cancer. 

While that is good news for those on estrogen-only HT, it doesn’t hold true for all forms of HT. It is thought that another commonly used type of HT – combined HT, containing both estrogen and progesterone – may be associated with an increased risk. But what does that mean exactly? 

Breast cancer statistics

One way of understanding the statistics is to take an imaginary population of 1,000 women.

We know that among women aged between 50 and 59, we would on average expect to see 23 new cases of breast cancer among those 1,000 women over five years. This is known as your baseline risk.

If we were to give combined HT to all 1,000 of those women, an extra four would develop breast cancer within the next five years (giving a total of 27 women per 1,000). 

While these risks should be taken seriously, it is important to take them in the context of cancer risk in the real world. For example, if those 1,000 women drank one more drink per day, we would expect to see an extra five cases of breast cancer within the next five years – a greater increase than that seen with taking combined HT.

Likewise, we would see an additional three cases per 1,000 if all 1,000 of the women were smokers and a worrying 24 extra cases per 1,000 if all of the women were either overweight or obese.

As you can see, the increased risks of HT are worth bearing in mind. However, this discussion should also be a starting point for thinking about a generally healthy lifestyle and reducing other risk factors where possible. 

If you would like to see more statistics on this topic, take a look at this leaflet from Women’s Health Concern.

Does HT cause blood clots?

It depends on the type of HT you are prescribed.

When we talk about blood clots in HT, we generally mean those that form in the deep veins of the body. The medical term for this is venous thromboembolism (VTE), and this group of conditions includes pulmonary embolism (PE) and deep vein thrombosis (DVT). 

Oral HT does come with an increased risk of blood clots. The exact amount of increased risk varies between the different types of hormone in the HT preparation. In one study, it was determined that the baseline risk of blood clots was low in women over 50 who took HT and had no extra risk factors – around two blood clots per 1,000 women per year. In that study, the highest risk preparation of oral HT was associated with a risk of around 4 blood clots per 1,000 women per year. The lowest risk preparation – only appropriate for women without a uterus – was associated with a risk of 2.2 blood clots per 1,000 women per year.

Transdermal HT – patches or gels – and vaginal HT – vaginal gels, creams, and suppositories – are not associated with an increased risk. This happens because of the way the hormones are absorbed through the skin and directly into the bloodstream. Your healthcare provider is likely to recommend a transdermal preparation as a first choice, especially if you have any other risk factors.

Vaginal HT does not affect your risk of blood clots.  

Does HT increase your risk of stroke?

Oral HT is known to substantially increase the risk of stroke when started in women over the age of 60. But, since most people start hormone therapy before age 60, the risk of stroke is less than 0.1% per year.

Transdermal and vaginal HT are not associated with this increased risk. If you have any risk factors for stroke, your healthcare provider may recommend a transdermal type of HT if suitable.

Which HT is best for me?

The best prescription is one that controls your symptoms with the lowest possible amount of risk. It can be tricky to find the right one, but your healthcare provider will be able to advise on the best preparation for your circumstances.

When recommending any type of HT, your healthcare provider will be asking themselves two questions:

  • Which hormones do you need? 
  • Which is the best way to supply them?

Which hormones do I need?

All forms of HT should supply you with some form of estrogen, as this is the hormone that will help ease your menopause symptoms – thanks, estrogen! Your healthcare provider will usually recommend trying a lower dose to begin with, although this can be increased if needed at follow-up appointments.

If you still have your uterus, you need to take progesterone too. This is because estrogen alone can cause abnormal thickening of the uterine lining which can sometimes lead to endometrial cancer. Progesterone has a protective effect that removes this risk. This is only a risk with oral or transdermal therapies. Vaginal estrogen treatments, except for the Femring, do not increase your risk of cancer of the uterine lining.  

You may also read about testosterone, which is sometimes prescribed as a gel and absorbed through the skin. This is used less frequently than standard HT but is sometimes recommended where the loss of libido is an issue. 

How should I take my HT?

In general, healthcare providers tend to recommend starting with the lowest-risk preparation. Here are some examples…

Vaginal estrogen

If you only need help with vaginal and urinary symptoms, vaginal estrogen will likely be recommended. This is a particularly low risk given the type of estrogen used and the fact that the hormone is not absorbed into your bloodstream (or only in very small amounts). Vaginal estrogens do not affect the womb lining and can therefore be prescribed without adding in progesterone.

Patches, gels or sprays

If you need HT to help with other symptoms of menopause, transdermal HT is usually the lowest-risk option. This comes in the form of patches, gels, or sprays. 

Oral HT

If you find the patches inconvenient or struggle with certain skin conditions, patches or gels may not be suitable and oral HT may be best for you.

As you can see, there are plenty of options! Your own healthcare provider will be able to advise on the best starting point for you. Read more about different types of HT.

How does HT make you feel?

Hopefully a lot better! The majority of women who take HT for menopause symptoms will start to see an improvement within a few weeks, although it can take several months to see the full benefit of treatment.

As with any medication, there are a few side effects to look out for.

What are the side effects of HT?

The estrogen in your HT can cause:

  • Bloating
  • Swelling
  • Breast tenderness or swelling and nipple sensitivity
  • Nausea
  • Leg cramps
  • Headaches
  • Indigestion
  • Vaginal bleeding

The progesterone in your HT can cause:

  • Tender breasts
  • Fluid retention
  • Headaches
  • Mood swings
  • Depression
  • Breakouts and acne
  • Abdominal pain
  • Backache 
  • Vaginal bleeding

Read more about side effects. Check-in with your healthcare provider if any of these are troublesome, severe, or unexpected. They will be able to rule out any other possible causes that could be confused with side effects and recommend any changes needed.

How long do HT side effects last?

Side effects usually settle within a few months. You might need to go back to your healthcare provider a few times to change the type, dose, or preparation of your HT if you are struggling or if side effects are lasting longer than anticipated. Your prescription can sometimes need a bit of fine-tuning – and that’s normal.

Talking to your healthcare provider about HT risks

There is a huge amount of information about HT out there. Being informed about your HT risks and options is important, but where should you start?

Make sure to use a reputable source of information. These include:

How long can you stay on HT?

There is no set limit for how long you can stay on HT. However, it’s important to check in for a review with your healthcare provider every year once your treatment has been established.

Although your HT prescription may stay the same over the years, you probably won’t! It is normal to collect new medical conditions, medications, and risk factors as we age. These changes can mean that HT is either no longer suitable for you or that there is a higher risk. Your healthcare provider will want to discuss any changes at your annual reviews, and they may recommend changing or stopping HT in some circumstances.

Can I take HT over 60?

When you reach age 60, your healthcare provider will probably want to have a more in-depth discussion about whether to continue HT. By this age, your symptoms are likely to have settled down so stopping HT may be a smooth transition.

Many women love their HT – but don’t despair if you are advised to stop. HT is just part of the picture when it comes to controlling your symptoms and living well through menopause.

Stella can help you make lifestyle changes, whether HT is on the menu or not. Paying attention to diet, exercise, and other lifestyle choices is every bit as important and can pave the way for a healthy later life.

Final word

Depending on what you read, HT can be portrayed as either a danger to health or a wonder drug. The truth is that it’s neither. 

HT is a useful part of our menopause toolkit, but it is not a one-size-fits-all solution to every menopause symptom. 

The fact that we are still learning about this treatment even after decades of prescribing it tells you that this is a complex and nuanced area. If you feel like HT may be right for you, it’s a good idea to read about the subject and ask your healthcare provider for their advice. They can guide you to the best treatment for you personally – whether that is HT or something else entirely.

Read more about menopause on our blog or in our symptoms library.

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