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MENOPAUSE AND HORMONE REPLACEMENT THERAPY (HRT): WHEN TO START AND WHEN TO STOP

When to start HRT

A considerable reduction in ovarian sex hormones occurs about two to three years before menstruation finally stops. Significant bone loss can occur during this transition phase, when infrequent periods and other peri-menopausal symptoms such as hot flushes, sweats and dryness of the vagina are experienced. If these vasomotor symptoms are mild, simple self-help measures and a non-hormone approach as suggested in Chapter 5 may be sufficient.

If the symptoms become severe and disruptive the commencement of HRT could be considered at this time, especially if menstruation is becoming infrequent. The preventive effect for osteoporosis and coronary heart disease will be an important bonus. Hot flushes, sweats and vaginal dryness will be greatly alleviated within 7-10 days of starting HRT.

Some women, however (perhaps up to 15 per cent), find they are intolerant of HRT; they tend to experience symptoms such as fluid retention, breast tenderness, weight gain, nausea, headaches, itching skin and rashes, and PMS-type symptoms.

Women who have had a premature menopause or surgical removal of the ovaries (oophorectomy) will be advised by their doctors to start HRT (provided there are no health factors that make it inadvisable). It will immediately help to control menopausal symptoms as well as providing long-term preventive benefits.

There appears to be no age above which HRT should not be considered, but if opposed therapy provokes recommencement of vaginal bleeding, where the uterus is still present, this may not be acceptable to a woman who is many years past the menopause. Breast tenderness is also more likely to occur in this context, and research has not yet clarified whether the protective effect on bone and blood vessels is as great.

Another (controversial) form of therapy for certain cases in the over-70 age group where osteoporosis is very troublesome, causing pain and extreme weakness, is the use of an anabolic steroid (stanazolol); this can improve the quality of life and retard osteoporosis, but may provoke menstrual bleeding.

There is plenty of evidence to suggest that HRT benefits elderly women with osteoporosis, preventing further bone loss and even to some degree reversing it. If oestrogen/progestogen combinations are used, the oestrogen-induced breast tenderness which is commonly experienced may be overcome by starting the oestrogen (in combined therapy) at a very low dose, then increasing it gradually after 4-6 weeks to the more appropriate bone-protective level.

Whatever the patient's age, HRT is of course more likely to prove successful with considerate counselling and careful clinical management.

When to stop HRT

Most women who start HRT do so to reduce peri-menopausal symptoms because these have become troublesome and affect their daily living; others take it because they have experienced premature menopause, have had hysterectomies with removal of the ovaries or are at risk of osteoporosis. There is at present no consensus as to how long HRT should continue for optimal long-term benefit. Treatment for three to five years is usually sufficient to relieve annoying symptoms, but for the protection of bones and blood vessels therapy should continue for much longer.

If HRT is carefully managed, as detailed later in this chapter, and the risk/benefit ratio is closely monitored, there is no reason why it should not be continued for 20 years or more. HRT should not be stopped suddenly but discontinued gradually over several months to reduce the possibility of symptoms recurring.

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