Menopausal hormone therapy is not a treatment that can be recommended in the same way to everyone; the balance of benefit and risk changes with the timing of menopause, with age and with medical history. Starting within 10 years of menopause and before the age of 60 has a different effect on the cardiovascular and cerebrovascular system than starting after that point.
This article sets out, in turn, the conditions under which treatment can safely begin, the situations in which breast cancer risk rises, and how to handle side effects. Whether to treat has to be judged by weighing the severity of symptoms together with age and the time elapsed since menopause.
Is hormone therapy recommended in the same way for everyone?
The effects and risks of hormone therapy differ with age, with how long ago menopause occurred and with medical history, which makes a single standard hard to set. For anyone with a history of cardiovascular or cerebrovascular disease, of thrombosis or of breast cancer, non-hormonal treatment comes first.
In the early period around menopause at about 50, the benefit of hormone therapy outweighs the risk, but starting newly after 60 calls for full review because of the cardiovascular and cerebrovascular burden.
If menopause was long ago, or you are older, should treatment be reconsidered?
The time elapsed since menopause governs how safe treatment is. Started immediately after menopause it protects the blood vessels, but 10 years later the risk of thrombosis and of cardiovascular and cerebrovascular disease grows.
Age matters too. Starting in the early 50s and starting after 60 carry a different cardiovascular burden, so medical history has to be reviewed in deciding whether to start and whether to continue safely.
- Age — starting treatment newly after the age of 60 can increase the burden on the cardiovascular system, so age must always be reviewed alongside
- Time since menopause — 10 years after menopause, rather than immediately after it, the vessels have already aged, so the risk assessment differs
- Vascular ageing — as age advances the vessel walls stiffen, so the protective effect of the hormones is relatively reduced
- Thrombosis risk — the older the patient and the longer since menopause, the more likely a clot becomes, so risk factors have to be confirmed before treatment
If worry about breast cancer is holding you back, what should you weigh?
Breast cancer risk differs with the length of treatment and with medical history, and a regimen of oestrogen with progesterone lasting 5 years or more carries a somewhat higher risk, which is different from short-term use.
Where a personal or family history of breast cancer is clear, the approach shifts to non-hormonal treatment; during treatment the recommended interval for breast screening is kept to as well; and where risk is present, whether to continue is decided by the level of risk rather than by stopping everything at once.
What should you do if nausea or diarrhoea appears during treatment?
Early side effects such as nausea, diarrhoea, headache and irregular bleeding are a temporary response as the body adapts to the hormones, and they usually lessen within 6 months; if they are severe or last a long time, they should be checked at a consultation.
When a side effect appears, adjusting the dose or moving to a patch or a gel is more common than stopping on your own. Recording the type, the severity and the duration and bringing that to the consultation helps in identifying the cause and in finding an alternative.
- Nausea — common early in treatment, and in many cases it lessens by itself within a few weeks
- Diarrhoea — can appear as a response affecting bowel movement, and often eases with an adjustment of dose
- Irregular bleeding — a temporary change while the lining of the uterus adapts to the new hormone level
- Headache — can appear with changes in hormone concentration, and sometimes lessens when the formulation is changed
