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Despite the fact that we do now talk about menopause, I still hear of women being refused HRT treatment by their doctors or being told to stop because of their age.
The advice around HRT has changed so much over the years that we’ve ended up with a pervasive received wisdom that you take it for around five years and stop in your early 60s. But let’s get this straight: the decision to take HRT depends on your symptoms, your health and what you want to achieve. Age doesn’t come into it.
The British Menopause Society, the authority on HRT guidelines, is clear that women do not have to stop at a specific time if they are finding HRT improves their quality of life. It adds that there is no evidence to justify stopping it on the basis of age and it should be decided on an individual-case basis.
I have certainly started women on HRT long after their menopause, or helped them continue. Only this month I spoke to a lovely patient to review her HRT. She is 79 and was worried about the length of time she has been taking it, but didn’t want to stop. It alleviates her aching joints and, when she did take a break, she experienced bladder soreness and insomnia. As her GP, I can see it’s fine for her to continue with HRT because we discussed her background health, which is good, and I make sure she takes a very low dose in patch form to keep any risks minimal.
Menopause has more than 30 symptoms and these don’t just stop because you hit 60. Many women I speak to find symptoms such as night sweats never end, while other debilitating problems including vaginal dryness, recurrent urine infections and joint pains get worse as you get older. Hot flushes, insomnia, depression and fatigue are well recognised features of menopause that for some women continue afterwards and lead some of my patients to continue taking HRT long term. It is particularly good for bladder symptoms, lack of libido and hot flushes, and helps with brain fog and memory loss.
Another very good reason to use HRT long term is that it is a recognised treatment for osteoporosis, the bone-thinning disease that puts people at risk of nasty fractures and declining mobility. It is very common in the UK, affecting around three million people, with menopausal women the most likely to suffer from it. Many women who need HRT for menopause also use it for osteoporosis rather than taking separate drugs – two benefits for the price of one.
So, why would you want to give up that support, what are the downsides? The risks of taking HRT increase longer you stay on it. The main ones, such as breast cancer and stroke, increase naturally with age anyway. But the risks with HRT are related to how long you have been taking it. The threats of breast cancer and stroke remain small, on average, but it is essential to understand they do increase. This would be more pertinent if you have a family history of cancer or high blood pressure, and may be your reason to stop.
If you want to take HRT long term, you need to review it every year with your doctor and discuss what, if anything, needs to change to keep you safe and reduce risk. This might involve decreasing your dose, changing to a lower-risk type such as patches, or taking vaginal oestrogen, which is considered safe for long-term use. Your GP should also help you control other health factors – for example, by addressing further causes of stroke, such as having high cholesterol or drinking alcohol.
The HRT pendulum has swung back and forth and, I hope, is settling in a pragmatic place that serves women best. Some have taken HRT for decades and, as long as they weigh up the risks with their GP, there is nothing wrong with that.
FIVE QUESTIONS TO ASK YOUR GP ABOUT CONTINUING HRT
1. What is my stroke risk?
This depends on considerations such as blood pressure and whether or not you smoke. It also impacts which HRT you take: patches are safer than tablets.
2. How are my bones?
HRT can treat osteoporosis, so a menopause check is a good time to discuss the need for a bone scan.
3. Can I try vaginal oestrogen?
This is considered a low-risk form of HRT that helps with vaginal and bladder issues. Some women don’t need anything more and use it for decades.
4. Can I try a lower dose?
You should always be on the lowest dose that works.
5. Am I at an increased risk of breast cancer?
If the answer is yes, it will affect your HRT choices.
