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Menopause: what is hormone replacement therapy and what are the risks and benefits

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Hot flashes, joint pain, insomnia… The symptoms that can accompany menopause are many, and that’s why some women going through this transition in their reproductive life take the so-called hormone replacement therapy (HRT).

Most experts recommend starting therapy as soon as the first symptoms of menopause appear. Evidence is mixed and limited when it comes to starting it over age 60, although some women experience relief from persistent symptoms.

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Like any treatment, HRT can have both benefits and risks. BBC News has a small guide with this and other information about therapy.

What is HRT and what are the benefits?

As women approach menopause, their levels of the hormone estrogen fluctuate and decrease.

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This hormone has many functions: it is part of the regulation of menstrual cycles, contributes to bone strength and influences our temperature, among others. Therefore, when estrogen levels are altered, women can experience various symptoms.

HRT raises estrogen levels and thus helps relieve these symptoms. Women generally don’t use this treatment forever, only in the transition to menopause.

The therapy may have some additional benefits, such as preventing bone loss, fractures, and colorectal cancer. For women under 60, HRT may also offer some protection against heart disease.

You may have heard about other possible benefits, such as brain health protection and improved skin and hair, but so far the evidence for this is limited.

On the other hand, some types of HRT are associated with an increased risk of some cancers (read in the topic below).

What does HRT look like in practice?

This therapy comes in many shapes and sizes—from pills and patches to gels and rings.

The main ingredient is estrogen, but one of the most common forms is combined HRT, with estrogen given along with a synthetic version of the hormone progesterone. Adding progesterone helps protect the lining of the uterus, as taking estrogen alone can increase the chance of endometrial cancer. On the other hand, there is evidence that this combination increases the risk of breast cancer compared to estrogen-only therapy.

The best type of HRT varies from person to person and depends on symptoms and lifestyle. These characteristics, in addition to the risks and treatment period, should be part of the conversation between patients and healthcare professionals.

Most therapies work throughout the body, but some are used vaginally to relieve symptoms specifically in that area.

How long does it take to take effect?

Initially, women are usually given the lowest possible dose of HRT.

It can take up to three months for a patient taking HRT to feel the full effects. In this process, some may also need their dose and type of HRT to be adjusted.

According to gynecologist Rogério Bonassi, president of the Brazilian Climacteric Association (Sobrac), the entity and other international institutions, such as the International Menopause Society and the North American Menopause Society, do not define a deadline for the end of the use of the HRT, as was done in the past — setting, for example, a limit of three or five years for stopping treatment. Bonassi adds that there is also no regulation on this by Brazilian health agencies.

“There is no standard for interrupting HRT according to the time of use. How long can you use hormone replacement therapy? We usually say to patients: until the next appointment: So year by year, if the case, it will be evaluated how much the benefits outweigh the risks”, explains the doctor, who has a doctorate in medicine.

However, while for many experts and societies there is no time limit for HRT, the UK Medicines and Healthcare Devices Regulatory Agency recommends using it for the shortest time needed and with the smallest dose possible.

What are the risks?

There seems to be some consensus among experts that hormone replacement therapy has more benefits than harms, but studies continue to be produced seeking to elucidate the issue.

Some types of HRT have been linked to a slightly increased risk of cancer, as mentioned in relation to the endometrium and breasts.

The British Menopause Society, however, says that in the case of breast cancer, the therapy carries fewer risks than being overweight or drinking more than two units of alcohol a day. And the risk gradually decreases after the drug is stopped.

There is also a small risk of clots forming when taking HRT. But that depends on other things too, like smoking, weight and age. The risks are reduced if the treatment is via a patch or gel instead of pills. Still, the risk of a clot forming after using HRT is much lower than that of a woman who is pregnant or taking birth control.

What are the side effects?

Many side effects pass within three months of starting the medication. They can include:

  • breast pain
  • Headache
  • nausea
  • Indigestion
  • Stomach ache
  • vaginal bleeding

It’s common to gain weight as you approach menopause, but there’s no evidence that HRT is behind it.

Who should not do HRT?

It may not be appropriate to follow this treatment if the patient:

  • Had cancer of the breast, uterus or ovary
  • Have untreated high blood pressure
  • Had blood clots
  • Had liver disease
  • be pregnant

Are there alternatives or additions to HRT?

Physical exercise can improve sleep, mood, and feelings of warmth. A healthy diet, stopping smoking and reducing consumption of coffee, alcohol, spicy foods can also help.

Other medications like tibolone — which works by mimicking the activity of estrogen and progesterone — or certain antidepressants can help, but they can also have side effects.

With additional reporting by Mariana Alvim of BBC News Brasil in São Paulo

This text was originally published here

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