An expert guide to the menopause and hormone replacement therapy

The menopause is the natural phase in a woman’s life that signals the end of her reproductive years. This transitional period, often accompanied by a range of mental, physical and emotional symptoms, commonly prompts many women however to seek treatments like hormone replacement therapy (HRT) to enhance wellbeing.

Here, Dr Sandar Hlaing, renowned GP and specialist in women's health, provides an expert insight into the menopause and the use of HRT.

What are the first signs of the menopause?

The menopause is a highly individualised experience, and each woman undergoes unique symptoms. Some signs that are often overlooked during the initial stages include unusual fatigue, heightened emotional sensitivity, irritability, and unexplained aches and pains that don’t have a physical cause.

Irregular periods, changes in flow, and hot flushes are well-known symptoms of the menopause, but these may not always manifest initially. It is actually during the perimenopause that other symptoms may become noticeable, such as extreme tiredness, susceptibility to fatigue, increased emotional response, persistent aches and pains, forgetfulness, brain fogs, temperature sensitivity, sweating, and hot flushes.

Is there anything that can trigger early menopause?

A family history, physical or mental stress, intensive chronic illnesses, and eating disorders can all trigger early menopause. However, if the menopause occurs as a secondary result of these conditions, it may also revert back to normal afterwards.

When should I consider HRT for menopausal symptoms, and what is a typical starting dose?

Starting HRT to alleviate menopausal symptoms can be beneficial at any stage. However, for optimal bone health and heart disease prevention, it is recommended to commence HRT within the first 10 years of the menopause.

Depending on a woman’s age, the initial oestrogen dose can range from 25 to 50. Younger women typically require a higher oestrogen dosage.

Is it normal to keep on changing my HRT dose until I find one that suits me, or is there any way of knowing beforehand which type of HRT would suit me best?

It can be frustrating, and some doctors may suggest that precise blood testing and dose titration are possible. However, this isn’t the case in reality, as the current HRT is body-identical to each individual patient, removing the need for laboratory tests to determine whether a HRT dose is suitable. Modern plant-based hormone-derived HRT options will also generally suit most patients.

In the initial phase of the menopause, without HRT, the production of hormones by the ovaries will be significantly reduced. Once a woman starts HRT, she will tell by the improvement in menopausal symptoms as to whether she is taking the right dose of HRT.

With HRT, blood levels and symptom improvement don’t always align, because the primary goal of HRT is to improve wellbeing and functionality rather than achieve correct blood levels. Doctors will typically provide patients with a plan for safely titrating their HRT dose up and down, instead of changing the HRT form or brand.

However, if a woman remains asymptomatic despite appearing to be on a suitable HRT dose, a blood test can help determine if medication absorption is an issue. In such cases, considering a change in the form of HRT, rather than adjusting the dosage, will be more beneficial.

Is there a link between breast cancer and the use of HRT?

Breast cancer is very prevalent among women, and as a woman’s age increases, her overall risk of any cancer increases too.

Studies show that in a group of 1000 women, 24 of women will have breast cancer even without having taken HRT. The use of HRT may contribute to an additional 4 cases to this group. Being overweight can increase the number by an extra 23 cases. Conversely, regular exercise for at least 30 minutes a day can reduce the incidence by 5 cases.

The decision to opt for HRT depends on each woman’s individual perceptions and risk acceptance. Some women may feel comfortable considering the risk is minimal, while others might be concerned about being one of the 4 in 1000 cases.

Can HRT cause palpitations and an increase in blood pressure?

All medications have potential side effects and individual responses can also vary, so it is possible. Women who are menopausal are already susceptible to palpitations, and with age, blood vessels tend to thicken, increasing the risk of high blood pressure.

In all scenarios, it is advisable to maintain a diet low in salt and sugar, minimise intake of processed food, and engage in regular weight-bearing exercises for 30 minutes daily.

If blood pressure is elevated, it should be addressed and the use of HRT should be temporarily withheld. Once blood pressure is effectively managed, HRT should be reintroduced with ongoing monitoring of blood pressure.

How long can I take HRT?

Women have the flexibility to remain on HRT for as long as necessary and then discontinue it when they feel ready. However, I recommend stopping slowly to allow the body to adjust more smoothly.

To schedule an appointment with Dr Sandar Hlaing, head on over to her Top Doctors profile today.