HRT

HRT, hormone replacement therapy, tops up the hormones that fall around the menopause, mainly estrogen. The Pakistan Menopause Society uses the international name, MHT, and counts estrogens, progestogens, combined treatments, androgens and tibolone under it (section 5).

The two main types

If you have had a hysterectomy, HRT is usually estrogen on its own. If you still have your womb, a progestogen goes alongside it to protect the womb lining. The PMS recommendations set out that split (section 5.4).

The NHS website describes two patterns of combined HRT: sequential, with a period at the end of each progestogen cycle, for women still having periods, and continuous, with both hormones every day, once periods have stopped. The PMS recommendations add that continuous combined HRT brings no withdrawal bleed (Table 8).

Ways to take it

Women's Health Concern says estrogen can be a tablet, or it can go through the skin as a gel, a patch or a spray. The progestogen can come with it in a combined tablet or patch, be taken separately, or come from the hormonal coil (LNG-IUS). Vaginal estrogen is a separate, local treatment for dryness; the NHS website says it does not treat hot flushes.

Starting HRT is rarely a switch flipped overnight. The NHS website says you usually start on a low dose and symptoms ease over days or weeks. Side effects such as headaches, sore breasts or spotting are usually mild and pass within the first few months.

NICE NG23 recommends reviewing each menopause treatment "at 3 months to assess efficacy and tolerability", then once a year.

The NHS website says HRT may not suit women who have had breast, ovarian or womb cancer, who have untreated high blood pressure or liver disease, or who are pregnant. After blood clots, it says patches or gel may be used rather than tablets. The Pakistan Menopause Society adds vaginal bleeding nobody has explained yet, which needs checking first (section 5.2).

NICE NG23 points some women to a specialist rather than ruling HRT out: a haematologist first for women at high risk of clots, such as with an inherited clotting condition (1.5.29), and a menopause specialist after coronary heart disease or a stroke (1.5.30), or with a history or high risk of breast cancer (1.5.31). For a higher risk of clots, including a higher BMI, it suggests HRT through the skin (1.5.28).

Two things do not rule HRT out on their own. The British Menopause Society says migraine with aura does not, and prefers estradiol through the skin for women with migraine. Women's Health Concern says fibroids are no reason to refuse or stop HRT.

The European Menopause and Andropause Society (EMAS) has guides for two long-term conditions. With epilepsy, it prefers estrogen through the skin and says some seizure medicines may need adjusting once HRT starts. With chronic kidney disease, it says HRT can be given.

On timing, the Pakistan Menopause Society's recommendations say the balance of benefit and risk is most favourable when HRT starts before 60 or within 10 years of the menopause (section 5.12). The Menopause Society, in the US, says the same and rates that evidence as strong. Starting later is not ruled out. NICE NG23 says the rise in stroke risk with estrogen-only HRT tablets "is greater if HRT is started after the age of 60", and The Menopause Society says starting after 60 needs careful weighing of your own benefits and risks.

On how long, the PMS says no fixed limit should be set: carrying on is a joint decision between you and your doctor (section 5.14). EMAS and The Menopause Society agree, and EMAS says stopping routinely at 65 is not recommended.

NICE NG23 recommends offering HRT for hot flushes and night sweats (1.5.1), and the PMS recommendations call it the most effective first-line medicine for them in women who can take it (section 7.1.1). NICE NG23 also says HRT can be considered for low mood that starts alongside other menopause symptoms and falls short of depression (1.5.21).

The weighing up is on HRT risks and benefits. If HRT is not right for you, the guidelines list non-hormonal treatments and CBT. NICE NG23 is also clear on one thing: "Do not routinely offer selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) or clonidine as first-line treatment for vasomotor symptoms alone."

If you are over 45, have symptoms and want to talk about HRT, that is reason enough to book. Under 45 with symptoms, the NHS website says to see a doctor too, because it may be early menopause.

Once you are on HRT, the NHS website lists signs to act on. Heavy bleeding, or unexpected bleeding after the first six months, needs checking, and so does any bleeding at all after a hysterectomy. Pain, redness or swelling in one leg, usually the calf, needs a doctor's advice straight away. A lump or other change in a breast needs a GP appointment. Chest pain with breathlessness, or a face, arm or speech that suddenly changes, needs emergency help straight away.

Women ask whether a hormone medicine is something their faith allows, and whether it changes anything in Ramadan. Fair questions, rarely answered straight. The fast is a question for a qualified scholar; when to take a medicine while fasting is one for whoever prescribes it.

At home, the hardest part can be a relative repeating what she heard years ago: HRT causes cancer. The risks page sets out what the guidance says now, in words you can share.