Hormone replacement therapy in menopause

Menopause is a physiological event in women, characterized by the cessation of the menstrual cycle, which marks the end of the fertile period . After a gradual reduction in follicular supply, the ovaries begin to produce less estrogen and progesterone until they are completely depleted.

In this period of transition (perimenopause) which can last even a few years, the menstrual cycle becomes irregular and occurs more and more rarely.

When the cycle has ceased for more than 12 months, the doctor can order hormone measurements to confirm the occurrence of menopause.

The average age of this important stage for every woman is around 50, we speak of premature menopause if it occurs before the age of 40. Menopause can also be surgical, i.e. subsequent to an operation to remove the ovaries, or secondary to radiation therapy or chemotherapy for a tumor.

Menopause side effects

Menopause is an event that can lead, in about 80% of women, to non-negligible disturbances such as:

• mood swings,
• hot flushes with flushing of the face,
• sweating and palpitations,
• disturbed sleep,
• reduced sexual desire and vaginal dryness with relative difficulty in having intercourse with the partner.

These symptoms last an average of 2-3 years but in 10% they can last for
over 10 years. “Sexual dysfunction” however, if not addressed and treated, is lifelong.

Another aspect to take into consideration is the marked decalcification of the bones in the 5 years following menopause which often leads to osteoporosis, i.e. significant bone fragility.

Think of all those old ladies with hunched backs or all the hip fractures from trivial falls after the age of 70: it’s all caused by untreated osteoporosis.

What is hormone replacement therapy?

It is a therapy based on estrogen (which can be given orally, intravaginally or transdermally) associated with progesterone (which can be given orally, transdermally or via an intrauterine device).

Progesterone is only necessary in women who still have a uterus to avoid endometrial hypertrophy, and can be given in conjunction with estrogen continuously or cyclically according to the patient’s needs.

An example: a woman with an early menopause at the age of 28 will be advised to undergo cyclical hormone replacement therapy which can allow the onset of the menstrual cycle, to make her “routine” more similar to that of her peers.

In a 55-year-old woman, who may be anemic because she has always had very heavy periods, continuous therapy can be given to avoid the discomfort of menstruation. Furthermore, Tibolone (eg Livial) is widely used, which is a synthetic preparation with estrogenic, progestogen and androgenic action.

What are the benefits of this therapy and how long should it be done?

The benefits of this therapy are many and often underestimated. For it to be more effective and safer, it should be started immediately at the time of the diagnosis of menopause and continued for an average of 5 years.

After 5 years it loses effectiveness and the risks (see below) begin to outweigh the benefits.

Women with premature menopause are an exception because they must continue it at least until the age of 50 and it is strongly recommended.

Hormone replacement therapy is absolutely the most effective on vasomotor symptoms such as hot flashes (much more than phytoestrogens or natural products), stabilizes mood, improves night rest, restores normal vaginal lubrication, rekindles sexual desire, reduces bone loss and therefore reduces the risk of osteoporosis fracture, prevents diabetes.

In practice it helps to cushion the trauma of transition from youth to more mature age.

Contraindications and side effects of hormone replacement therapy

The main risks of hormone replacement therapy are:

• thromboembolic disease,
• cerebral ischemia,
• cardiovascular disease,
• breast cancer,
• gallbladder diseases.

Therefore it is very important to avoid this therapy in women who :

• have had thromboembolic events or have a predisposition to such events,
• have had cerebral ischemia,
• have a known cardiovascular disease (heart attack, severe hypertension),
• have had or are familiar with breast cancer,
• have unresolved gallbladder problems,
• have severe liver disease.

What are the benefits given that these risks exist?

The risk of these diseases , excluding those who already have them from therapy a priori, taking hormone replacement therapy in the correct way, i.e. immediately after menopause and not after 10 years, and choosing the safest route of administration with the lowest dose possible (the patch, for example, is excellent because the hormones enter the circulation directly without needing to be metabolised first by the liver), it becomes very small .

Studies show that the most serious events occur in women who have abused this therapy well beyond the recommended age, ie over 60 years.

However, I would like to report an objective fact and that is that according to an important study (Women’s Health Initiative Study of 2002) the risk of breast cancer after 5 years of replacement therapy with estrogen and progesterone increased overall by 0.1%. So it is right that every woman decides for herself whether it is worth taking this risk or not.

Who is hormone replacement therapy recommended for?

It is recommended for all healthy women who have symptoms due to menopause such that their working, emotional and sexual lives are put to the test.

Does anyone who can’t or doesn’t feel like doing this therapy have alternatives? 

Of course yes. It is important to focus on which problem caused by menopause is more relevant and to follow a targeted cure.

For example: a woman who has experienced severe osteoporosis after menopause may be treated with a bone-resorptive drug such as a bisphosphonate; a woman who has severe vaginal dryness can use topical estrogen or lubricants; those who have many hot flashes can try a natural product that can at least reduce them in duration and quantity.