Written by Dr Karen Morton, consultant obstetrician and gynaecologist and Founder of Dr Morton’s – the medical helpline©
Hormone Replacement Therapy (HRT) refers in the main to giving a woman oestrogen after her body no longer produces it, either because her ovaries have stopped working, or because they have been removed. If a woman still has a uterus it is essential that the endometrium (lining of the uterus) is protected against the stimulatory effects of oestrogen, by progesterone. This can either be given through the blood stream or directly into the uterus by a Mirena or similar progesterone-releasing device. There is one exception to this. Tibolone (trade-name Livial) is an oestrogen-like molecule which stimulates oestrogen receptors giving all the beneficial effects on bones and other tissues, but in the endometrium it is converted to progesterone.
Testosterone is one of a number of male hormones which women have a small amount of, and which come from the adrenal glands, and is made in fat tissues as a by-product of oestrogen breakdown. Its role in women’s wellbeing is not well understood.
So……… most women take HRT because of symptoms of oestrogen deficiency, namely hot flushes and sweats, anxiety, aching joints and bones, poor memory and concentration, and vaginal dryness. For most women it is a case of weighing up the advantages and risks of taking it, and having made the decision to take it they will be given a tablet or a patch containing plant-derived oestrogen and a synthetic progestogen. Some women will already have a Mirena device in their uterus and so will start just oestrogen and then have the Mirena changed at an appropriate interval, as it is a concept they understand and like; progesterone only where it is needed and oestrogen through the body. If someone has a specific risk for deep vein thrombosis they will be advised to take the oestrogen through the skin using a patch or gel, to avoid the ‘first pass effect in the liver’.
So why haven’t I mentioned BIHRT yet in this piece? Well the truth is that most gynaecologists think that for 99% of women a standard regime as discussed above is absolutely fine, and most women will be very happy and apart from changing from the cyclical regime which they start at 50 to a continuous combined regime when they are 55, no other permutations will be needed. Simple!
Some women are more complicated and it has to be said that some women are hoping for more than HRT can achieve, and often it is those women who pursue more complex approaches. To be completely fair I do think that responses to hormonal medicines is a very idiosyncratic affair and there will be some women who need more subtle adjustments, but whether that extends to having something ‘designed in a bespoke fashion based on saliva hormone measurements and other (often quite expensive) tests’ is a debatable matter. I can understand women preferring not to take conjugated equine oestrogen, in other words oestrogen extracted from pregnant mare’s urine, although it has to be said that these preparations led the way in HRT and are perfectly effective. I can also understand a woman’s wish to reduce her breast cancer risk to an absolute minimum so regimes using natural progesterone will become increasingly popular. The manufacturers will have to take notice of all the recent published evidence and the NICE guidelines.
Testosterone is a whole other story, with most women not needing it and finding the hair on their chins quite bad enough without it. A few women feel that their sex drive and their energy levels are low without it. The problem here is that there is no licensed preparation available now. Subcutaneous implants are very difficult to get hold of, be they oestrogen or testosterone, and testosterone patches have been removed from the market so there is no licensed form of testosterone for women.
BIHRT on the NHS? There is no way that there is the funding for such things. There will be the occasional academic department which has a menopause clinic where they have research funding for investigating and treating complex cases, but the reality is that this sort of medicine is beyond the scope of public funding. But don’t worry…….. it is rarely necessary.