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Hormone Replacement Therapy

Menopause is a condition where the ovaries seize to function (stop producing eggs) and the woman stop menstruating.  It occurs in women between the ages of 45 to 55 years old.  A woman is considered post-menopause if she stop menstruating for more than 12 months.  In Malaysia, the average age of menopause is 52 years old (between 45 to 55 years old).

During menopause, the level of estrogen hormone decreases. This causes menopausal symptoms such as hot flushes, joint pain and muscle arches, difficulty sleeping (insomnia) memory loss, anxiety, vaginal dryness, feeling tired and moody. These symptoms would subside within 2 years in 80% of women.

What is Hormone replacement therapy (HRT)?

Hormone replacement therapy consist of 2 types: estrogen and progestin (hormone similar to progesterone).  The function of estrogen is to reduce the menopausal symptoms (as above) while progestin helps prevent uterine (endometrial) overgrow or cancer during the intake of estrogen. For patients who have had their uterus removed, they only need to take estrogen therapy.

Types of Estrogen:

The estrogen hormone comes in many froms and can be administered in different ways: oral pills, patches, cream or gel and spray. In Malaysia, the oral pill is more widely use.  The treatment usually starts with a lower dose and would increase it if necessary until the vasomotor symptoms subsides.

  1. Estrogen pill:  there are various types and brand in the market. Premarin ® and Estradiol Valerate (Progynova) are commonly used in Malaysia. It comes in doses of 0.3 to 0.625mg. Progynova tablets comes in doses of 1 to 2mg, it contain oestradiol valerate, a precursor of natural human oestradiol, which is the major and most active form of the female sex hormone oestrogen. There are also other preparations produced from plants called phytoestrogens. There several preparations of such supplements available in Malaysia.
  2. The Patch: it consists of either estrogen patches alone or in combination with progestin. It is applied (patched) onto the skin for a week then replaced with another patch. This method offers the benefit of bypassing the liver, so it is preferred in patients with liver disease. However, it is not very popular in this country because of our weather (high humidity). This causes the patches to detach easily and there is a slightly higher incidence of skin reactions.
  3. Cream or gel: it is for topical use or used as a vaginal cream. It is more useful for those with problems of vaginal dryness (see menopause), dyspareunia (see dyspareunia) and vulval itchiness due to atropy.

Types of progestin:

  1. Oral progestin pills: the commonest type in the market is medroxyprogesterone acetate. Other types include dydrogesterone, levonogestrel, noresthidone, nogestrel etc.
  2. Natural progesterone:  e.g. Prometrium ®.  Natural progesterone do not have adverse effect on the lipid levels (fat) and suitable for women with high cholesterol levels.
  3. Locally acting progestins (Mirena ®). Mirena is a levonogestrel impregnated IUD that are used for family planning. Small amount of a progestin called levonogestrel is released into the cavity of the uterus for a period of 5 years.

“Natural” or “Bioidentical” products: Many women now change to these product because they feel it is more “natural” or “bio-identical” (i.e. it mimics the dosage of hormone which is more identical to the body). The saliva or blood specimen of the woman is taken to monitor the level of hormones in the body. With that the dosage of estrogen, progestin, testosterone, DHEA and others to be given to the patient will be adjusted accordingly.  Until today, there is no robust medical scientific evidence to support the efficacy or safety of this method.  Therefore, many gynaecologists advise women not to take such medication until strong evidences are available and it is proven to be safe.

What are the advantages and risks of Hormone therapy?

One of the main benefits of taking HRT is the improvement in the quality of life. Menopausal symptoms affect women both emotionally and physically, in some but less in others. HRT will relieve these symptoms. Survey showed many feel that taking HRT improves their quality of life and some are keen to take it for long term.

Prevention of osteoporosis is another major benefit of taking HRT. A woman would on average lose about 0.5% of their bone mass every year in the menopausal age. A woman could lose up to 30% of their bone mass by the age of 80 years and this puts them at risk of osteoporotic fractures. However, there are medications available for osteoporosis treatment (see osteoporosis)

Depression:  HRT may reduce depression in some menopause women, however, anti-depression medications are found to be more effective if given together (see Depression)

Difficulty sleeping (insomnia) – this could be due to the hot flushes which leads to sweating and feeling uncomfortable. HRT is very effective in women suffering from hot flushes.

Other postulated advantages may include delaying the onset of dementia or Alzeihmer’s disease.

There are risks associated with taking HRT. A large multicentre trial called Women’s Health Initiative (WHI) study revealed that there are some risks. These include a slightly higher risk for heart disease, stroke and breast cancer. However, a significant number of the women in the trial are obese and are smokers. The average age is also 60 years old and some only started on HRT some years after menopause. The risk is also mainly attributed to the progestin being used (medroxy progestogen) as those only on estrogen (patient who had their uterus removed earlier) do not show an increased risk of heart disease or breast cancer.

Breast cancer risk:  This risk increases slightly in patient taking the combined estrogen-progestin HT but not those taking only estrogen. The increase risk is only seen in those who had used the combined HRT for more than 5 years.

Who should take HRT and for how long?

Women in general should be offered HRT unless it is contraindicated. Those suffering from menopausal vasomotor symptoms should be offered HRT. Most experts believe that HRT by enlarge is safe and offers benefits that outweigh the risks. Your doctor would usually recommend you to take it for up to 5 years. This is because of the slight increase in risk of breast cancer if taken more than 5 years. Your Doctor may reduce the dose gradually before completely stopping the HRT, to avoid recurrence of the vasomotor symptoms.

Another group of women who should take HRT are those who has had premature menopause or those who attain menopause earlier than 45 years. Those who has had their ovaries removed surgically at an earlier age would also need HRT until 50 years of age or longer if the patient request it.

Who should not take HRT?

HRT is not recommended in those with:

  • History of or currently having breast cancer or endometrial cancer.
  • History of or having myocardial infarction (heart attack) or coronary heart diseases.
  • History of vein thrombosis or stroke
  • Women who are at risk of the above

HRT may not be contraindicated in women who are keen to be on it but have a past history of breast cancer or endometrial cancer that is considered cured. In such cases please consult your Gynaecologist.

Follow up

You are encouraged to follow up with your doctor or Gynaecologist before starting on a HRT. An assessment would be performed and may include a mammogram, ultrasound scan of the pelvis and blood test screening. A suitable HRT would be started based on your suitability and preference. Following this the doctor may see you a few months later to assess your response to the HRT. Once you are happy with the HRT, an annual follow up schedule would be sufficient.

Last Reviewed : 23 August 2019
Writer / Translator : Dr. Hj. Mohamed Hatta b. Mohamed Tarmizi
Accreditor : Dr. Haris Njoo Suharjono
Reviewer : Dr. Rafaie bin Amin