Hormone-based medications for early menopause: Women’s knowledge and perspectives

Hormone-based therapies for early menopause (EM) include oestrogen-based therapies (Hormone Replacement Therapy – also known as Menopause Hormone Therapy – hormonal contraception), and testosterone (androgen) therapy. These therapies work differently and therefore suit women in different circumstances, but they can ease the symptoms of EM. Oestrogen-based therapies may help reduce long-term health risks such as osteoporosis and heart disease.

Women with EM able to take HRT are advised to do so until at least age 50, unless they have experienced oestrogen sensitive cancer (e.g. breast and endometrial) (see Non-hormone based medications for early menopause). Findings from studies of HRT in older post-menopausal women may not necessarily apply to women with EM, especially under age 50. For more information, see the Box at the end of this Talking Point.

Benefits and risks of HRT: What women knew

Women’s knowledge about the benefits and risks of HRT varied. Some were well-informed; others less so. Jessica, who had experienced relatively few menopausal symptoms and whose GP had not suggested HRT, admitted: ‘I don’t know what HRT is, to be honest.’ Symptom relief, and protection against osteoporosis and heart disease were the main reasons women gave for taking oestrogen-based therapies. A couple of women were not aware of the benefits for bone health, and very few mentioned the protective effects of HRT on heart health.

Melinda described what her endocrinologist had told her about the benefits and risks of HRT.

> Click here to view the transcript

She talked about the risks of heart disease and breast cancer as I recall. And I think I knew that anyway, but being two risk factors associated with taking HRT. But she really said in my case the benefits would far outweigh those risks, that I would probably be best to take HRT for at least 10 years and then maybe rethink it, review. But she said at least until I’m really up over 50 years of age. Again, just to support my skeleton really. To also take Vitamin D and also to exercise.

She said you just need to be looking after yourself and it’s not just about taking the HRT, you need to do all those other things as well. So I actually do take calcium and Vitamin D supplements and that was recommended for me to do that, but also try and exercise a couple of times a week. So, I’m doing weight-bearing exercise and she said that is really just as important. For me the role HRT has played has allowed me to have the energy to actually undertake exercise because I think I would have really struggled. Well, I certainly would have back at that time, having the energy to do that.

So she certainly talked to me about, eating well and she did talk holistically about looking after myself. It’s not that HRT will just fix everything, but that it was just so vital for my bone health. So they were the main things I recall and she said you can go away and think about it. She said you don’t have to do it starting tomorrow, but I would like you to really consider that.

Making sense of information about HRT

Several women commented that ‘confusing’ information and new research findings they had encountered about HRT had meant they were unsure about the risks, whether or not to take HRT, or for how long. As Ella said: ‘I’m not sure, the whole thing with heart health… I can’t understand whether HRT’s good for your heart or not because of the different studies.’

While some women received helpful information and advice about HRT from health practitioners, others were not satisfied with the information they received. Tracey, who had a risk reducing BSO after being diagnosed with Lynch Syndrome, recalled talking to her gynae-oncologist about HRT beforehand: ‘He basically asked if I was on the pill and [said], “[HRT] is similar to that, you just keeping taking your pill every day.” He didn’t really talk to me about what that meant and what the symptoms were or how to manage it or anything like that.’

Debra ’s gynaecologist provided her with ‘lots of’ information about HRT, but she still felt that making an informed choice was difficult.

> Click here to view the transcript

My gynaecologist was good in many ways in that I could go and ask questions and he’d give me the time, and he’d give me lots of print outs, and lots of like research, studies and things. So, in some ways, I felt like I was always making as an informed choice as I could. But all along I felt like that there’s not enough information. I just would search websites, and search chat rooms.

And then over the years, there’s been so much back and forth like “HRT is safe, no HRT isn’t safe”. “You’re going to increase your risk of breast cancer, and other cancers.” And then, “Well if you’re not on it you’re going to increase your risk of other problems”. And just so hard to know what the best thing to do is.

HRT and genetic predisposition to increased cancer risk: Women’s views

Women who carried genes pre-disposing them to cancer (e.g. BRCA1/2 or Lynch Syndrome) varied in how they felt about HRT. Tracey felt comfortable taking HRT. In contrast Lydia, who had a risk-reducing BSO after discovering she had the BRCA gene, had decided not to take systemic HRT (which affects the whole body). Despite her doctor’s assurances of its safety, she was worried about increasing her cancer risk, attributing these fears to experiencing several close family members die from cancer. She said she struggled with using even vaginal oestrogen regularly: ‘I don’t know, I think I just have issues with oestrogen-based things.’

Kirsty had been diagnosed with both POI and the BRCA 2 gene mutation. She was initially told she could not take HRT, but five years later the research changed and she began taking it.

> Click here to view the transcript

I go and see my oncologist every year for my BRCA 2. I have gone to another woman’s clinic recently to get a five year check-up where I’ve got the amazing news that I can take HRT because the research has changed for women who have early menopause and have the BRCA 2 gene.

So the HRT that I’m on at the moment is the lowest dose. It’s a patch that I put on myself twice a week, and it took me a little while just to even be okay about showing my husband the patch, because, again, you know, it’s weird in some ways to be young and putting on an HRT patch. I’ve only been using it for three weeks. So I’m yet to see the full benefits of it, but I’m feeling hopeful. And I have got over my fear about the HRT potentially triggering breast cancer which was the biggest concern and why I haven’t been taking it for the last five years. But the research is looking more solid, and I guess as part of my diagnosis, I got the fear in me. It was a big process, being told that having premature menopause means that you are at a higher risk of heart disease, you’re at a higher risk of osteoporosis and dementia. That’s a hard thing for a woman in her early 30s to hear. On top of, I have the BRCA 2 gene, and all the other complications in my body. That was hard to hear.

Not taking HRT

A couple of women delayed starting or avoided taking HRT because they wanted to avoid medication and instead try to manage their symptoms through diet, exercise or complementary and alternative medicines (see Complementary medicines and alternative therapies for early menopause and Lifestyle changes to help manage early menopause. Note that current recommendations are that women with EM take HRT until age 50 unless they have experienced hormone sensitive cancer).

Theresa explained her reasons for waiting two years after having a risk-reducing BSO before starting HRT.

> Click here to view the transcript

So what was the hesitation around HRT? Because was that offered earlier?

Yeah, they always let you know that you will likely experience menopause symptoms and, again, some are mild, some are severe, some are impacting on your life, some are not as much, and that, you know, there’s no need to suffer. You can always speak to someone and get, not necessarily HRT, but there’s different interventions that are available.

But I think – maybe I didn’t want a daily reminder about what was happening, or I just felt like, “Oh no – I am an exception, because I am so healthy and fit that I don’t need assistance,” and that sort of thing. So in retrospect it seems quite silly actually [laughing]. There was no need to suffer, and things could have been easier and managed better, but at the same rate – I did manage.

Is that your general view about like medication more broadly?

I would say so. But any time it has been prescribed to me for a particular reason or something like that, I’m not philosophically against it. But again, I just felt like, “Oh, do as much as you can with just healthy living and that sort of thing to prevent having any problems.” But you know, if I ever had an infection, absolutely I would take whatever is available. If I had a surgery, give me the drugs to put me out. I’m not philosophically against them.

I’ve worked – much of my career has been in prevention, so again, I was just trying to prevent any problems, as opposed to being treated for them, which is really why I had the oophorectomy in the first place because that was going to prevent cancer instead of having to be treated for it. So again, it was just sort of the right timing with the right person asking the right questions that made me realise that that’s sort of silly, I’ll just give it a try.

The Women’s Health Initiative

Publication of two large clinical trials (the Women’s Health Initiative) in 2002 and 2004 has led to confusion about the risks and benefits of HRT. Women involved in these trials were on average 63 years old and only HRT in tablet form was used. Findings from these studies do not necessarily apply to women with EM, especially under age 50. Risks and benefits of taking HRT are individualised to each woman and depend on her age, cause of EM, type and duration of HRT preparation, and other health issues. What form of HRT suits one woman will not necessarily suit another. See also Hormone-based medications for early menopause (Health Practitioners’ perspectives).

Further information:

Talking Points (Women)

Talking Points (Health Practitioners)

Hormone-based medications for early menopause

Other resources

Webpage: Early and premature menopause (Jean Hailes)
Video: What is MHT? (AMS)
Information Sheet: What is MHT and is it safe? (AMS)
Information Sheet: Risks and benefits of MHT / HRT (AMS)
Video: Is MHT safe? (AMS)