It is currently recommended that all woman who have not had cancer and who have had their ovaries removed take HRT until they are 50 years old to maintain bone density, and heart health and avoid symptoms of the menopuse
• Hormone Replacement Therapy (HRT)
• Non-hormonal treatment of the menopause
Hormone Replacement Therapy (HRT)
The main component of HRT is oestrogen, which is replacing the oestrogen that is no longer produced by the ovaries. For women who have not had a hysterectomy, HRT treatment must also include progesterone to prevent thickening of the endometrium of the uterus(lining of the womb). The progesterone can be taken for at least 12 days per month and will result in a withdrawal bleed or can be given continuously in a no-bleed preparation.
The increased risk of breast cancer is associated with combined oestrogen and progesterone HRT and there is no significant increase in the risk of breast cancer with oestrogen only preparations. There is an associated risk of blood clots with the oestrogen in HRT similar to with the contraceptive pill however this is mainly with oestrogen taken in tablet form.
HRT can be taken as tablets or prescribed as a skin patch or gel. The patches can cause skin irritation but it can be worthwhile trying a different brand as the reaction may be to the adhesive rather than the drugs it contains.
Progesterone can be delivered by an intrauterine system, (known as a Mirena coil) which many women already use a contraceptive coil. This keeps the progesterone mainly in the uterus where it is required to prevent endometrial thickening with reduced levels within the rest of the body. This should be considered as the preferred form of HRT for women who have not had a hysterectomy and where there are no other contraindications for the IUD. The coil can be inserted at the time of surgery to remove the ovaries and tubes. This makes it easier to adjust the dose of oestrogen to manage symptoms and for women who have not had breast risk-reducing surgery the lower level of progesterone may reduce the risk of breast cancer.
Women who have had a premature menopause will often need a higher dose of oestrogen to relieve their symptoms. If they continue to have hot flushes after the first month of HRT they should go back to their doctor to discuss increasing the dose.
HRT should be used at least until age 50, and once a woman is in her fifties she may find that a lower dose of oestrogen will give symptom relief.
Unlike a woman without a BRCA mutation, a woman with a BRCA mutation who has had risk reducing breast surgery and not had breast cancer, could stay on HRT for much longer as she will continue to get the benefits without having the concerns of breast cancer risk.
There are many specialist menopause clinics that can provide expert advice and this can be especially important for younger women who are finding it difficult to get a HRT preparation that is providing good relief of symptoms.
Non-hormonal treatment of the menopause
Replacing oestrogen is the most effective means of relieving the adverse effects of the menopause but these are not suitable for all women, especially if they have had breast cancer. Some women decide not to take hormonal preparations. Other treatment options can be discussed with your GP or at the HRT clinic.
Clonidine is a drug which can be used for migraine or high blood pressure and can relieve hot flushes for some women. It is usually well tolerated but possible side effects include difficulty sleeping, dry mouth, dizziness, constipation and sedation.
SSRI Drugs (Selective Serotonin Reuptake Inhibitors) are most often used as anti-depressants but also work on the receptors within the brain that help regulate the body temperature. They are particularly helpful if women are also experiencing symptoms of depression with other menopausal symptoms.
Some of the drugs cannot taken with Tamoxifen as they interfere with the action of Tamoxifen but venlafaxine is less likely to have this effect and so is the preferred option in this situation. The dose of SSRIs can be started low and increased gradually to minimize side effects. A greater reduction in hot flushes is seen at higher doses but the side effects such as nausea, dizziness, problems with sleeping, agitation and confusion may be worse.
Gabapentin, a drug which is used to treat epilepsy, migraine and nerve-related pain, has been shown to reduce flushes.
It may be particularly beneficial for the symptoms of aches, pains and paraesthesia which some menopausal women suffer. Possible side effects include dizziness, fatigue, tremor and weight gain but side effects can be reduced by starting at a low dose and increasing the dose gradually.
There are an increasing range of natural remedies marketed for the relief of menopausal symptoms. There is no evidence that these are as effective as HRT but may help ease some of the symptoms in some women. Women who have had breast cancer should speak to their GP or oncologist before starting these treatments.