The 2023 Practitioner’s Toolkit for Managing Menopause has been created and endorsed by global menopause experts including the British Menopause Society and offers guidelines for treating menopause. It states that perimenopausal symptoms suggesting low oestrogen, such as hot flushes and vaginal dryness, are considered indications for HRT.
What should I do if my doctor says “no”?
“If you’ve been refused and aren’t happy, you can hopefully find someone else in the practice who can help you,” says Dr Balfour. “Ask the receptionist if there is anyone who has a particular interest in women’s health or menopause training. If you are really struggling, ask for a referral to an NHS specialist menopause clinic.” You might also consider going private. You can find your nearest specialist clinic via the British Menopause Society’s website, thebms.org.uk.
The toolkit states that doctors should be cautious about prescribing HRT to “women with high risk of VTE (venous thromboembolism or blood clots) or breast cancer, untreated cardiovascular disease, undiagnosed vaginal bleeding, active liver disease and migraine, notably migraine with aura.” But this doesn’t mean that HRT is always completely out of the question in these cases, though you may need to be seen at a specialist clinic. However, having oestrogen dependent cancer, blood clots, and severe liver disease are usually a no-no for HRT.
Will HRT sort out my anxiety, depression and brain fog?
Dr Balfour says: “Many women develop anxiety and feel low during their menopause transition, and for them HRT is likely to be the first line option to try. However, some women will need antidepressants.”
Dr Briggs says: “There is no evidence to support using high-dose oestrogen to manage significant depression and it could make symptoms worse.” The toolkit states brain fog alone is not a reason to prescribe HRT as studies have not shown it helps more than a placebo.
What are the different ways to take HRT?
The safest way to take oestrogen is through the skin, via a gel, patch or spray as, unlike tablets, these don’t raise the risk of blood clots. However, “tablets can be an option for younger women with no risk for blood clots,” says Dr Balfour. “But they will need to switch to transdermal oestrogen by 60 at the latest.”
If you haven’t had a hysterectomy, you will need to use a progestogen to prevent the womb lining becoming too thick, which is a risk factor for uterine cancer. Dr Balfour often recommends micronized natural progesterone in the form of a tablet called Utrogestan, but says for younger women who still need contraception, the Mirena coil, which delivers progestogen directly to the womb, is a “brilliant option”. Combined patches containing both oestrogen and progestogen are another convenient option as they only need to be applied twice a week. Most women who have had a hysterectomy only need oestrogen.
What about the risk of breast cancer?
“Combined HRT slightly increases the risk of breast cancer. That’s not something we can ignore,” says Dr Briggs. “However, in most cases, the benefits of HRT outweigh the risks.” Lifestyle factors such as weight management, exercise, reducing alcohol consumption and stopping smoking may help reduce the risk of developing breast cancer.
Do all women need HRT?
“Menopause is a life stage, and women should be able to choose how they manage this life stage,” says Dr Briggs. “Nobody should feel that they must take HRT.”