Hormone replacement therapy during meno­pause: helpful or harmful?

When the body transitions into menopause

As a woman enters the menopause, her oestrogen and progesterone levels decline – and because of the reduction of eggs in her ovaries, this is later followed by a reduction of testosterone. Without eggs, ovulation stops and the ovaries no longer produce hormones on a regular basis.

Disrupted processes

This hormonal shift can throw things off balance. Hot flushes, sleep problems, mood swings and vaginal dryness are just some of the possible consequences. Not all women experience these changes to the same degree – but those in discomfort seek relief. Maybe with hormone replacement therapy?

Hormone replacement therapy: What is it exactly?

The aim of hormone replacement therapy (commonly known as HRT) is to ease menopausal symptoms. “The goal is to restore quality of life,” says Dr Karin Camastral, senior physician at the Department of Gynaecology, Cantonal Hospital Winterthur. “If a woman is overwhelmed by hot flushes and sleep disruption, or her mood and sex life are significantly affected, hormones can help. Many women say HRT makes them feel like themselves again,” the gynaecologist explains.

Protective effects for the body

But HRT isn’t just about getting through the day. It can also offer protection, as falling oestrogen levels increase the risk of osteoporosis and fractures. HRT also lowers the risk of cardiovascular disease and dementia, especially in cases where menopause begins before the age of 45.

Early menopause

Experts talk of early menopause when it occurs between the ages of 40 and 44 years. Before the age of 40, it’s known as “premature ovarian insufficiency”.

What hormones are used in hormone replacement therapy?

Oestrogen forms the basis of the treatment. If a woman still has her uterus, doctors also prescribe progesterone to prevent the lining of the womb building up excessively from the oestrogen. This overgrowth could otherwise increase the risk of uterine cancer.

Progesterone even without a uterus

Some women without a uterus may also benefit from progesterone, particularly those with severe sleep problems. “In these cases, I often prescribe it in tablet form at night, as it can promote sleep,” Karin Camastral says.

Testosterone – an option for low libido

In certain cases, testosterone is also used, such as for women experiencing a loss of libido. “It has a positive effect in around half of cases,” Karin Camastral says. “In others, it simply leads to oilier skin.” There is currently no testosterone preparation officially licensed for women in Switzerland, but some pharmacies produce it as an extemporaneous preparation – albeit with thorough assessments and close monitoring.

How are hormones taken and why does it matter?

Patches, gel or tablets? The gentlest option is applying hormones through the skin – in the form of a gel or patch. This method bypasses the liver and therefore carries a significantly lower risk of thrombosis than tablets. “For many patients, especially those with risk factors, that’s a very convincing argument,” the gynaecologist says.

Bioidentical hormones: close to the body’s own

Unlike synthetic hormones, bioidentical hormones have the same chemical and molecular structure as those naturally produced by the human body. That makes them particularly well tolerated – and popular with many women. Estradiol, estriol (both oestrogens), progesterone and testosterone are bioidentical hormones.

An individual choice

Another advantage is that bioidentical hormones are more often available as products applied to the skin, which come with a lower risk of thrombosis and breast cancer. “But this choice is also very individual,” Karin Camastral states.

When to start and how long to continue?

The very latest point at which to start hormone replacement therapy is ten years after the menopause. Beyond that, the risk of heart attack or stroke increases significantly. Many women now begin the therapy earlier – often during perimenopause. “Especially when symptoms are severe, starting treatment early can be very beneficial,” Karin Camastral says.

How long should hormone therapy last?

There’s no one-size-fits-all answer. “Some women take hormones for just a few years, others for longer if the benefits clearly outweigh the risks,” the gynaecologist says. She generally recommends continuing treatment for three to five years, provided the woman is doing well on it. The key is to review the treatment each year: “Together, we assess whether it’s still required, still effective or whether we need to make adjustments due to risk factors.”

Benefits and risks of hormone replacement therapy

Hormone treatments can greatly ease symptoms and improve quality of life, especially in this phase when the woman is still in her prime and eager to live life actively and to the full. Hormone therapy can also reduce the risk of osteoporosis, cardiovascular disease and dementia.

Hormone replacement therapy: not always the best option

That said, it’s important to take an individualised view. Not every woman benefits to the same extent, and certain factors may speak against HRT – such as breast or ovarian cancer, a history of thrombosis or stroke, or certain clotting disorders.

Breast cancer risk

The risk of developing breast cancer while on hormone therapy depends on conditions such as the type of hormones used and the duration of treatment. However, it’s worth remembering that being overweight, drinking alcohol and lack of exercise represent significantly higher risk factors for breast cancer than HRT. A pure oestrogen therapy – used for women who no longer have a uterus – doesn't increase the risk of breast cancer.

Thrombosis risk

The risk of thrombosis also plays a role. Taking oestrogen orally increases the risk of blood clots. Hormones applied to the skin – through gels and patches – avoid this effect.

What alternatives are available?

Hormone therapy isn’t the right choice for every woman – whether for medical reasons or personal preference. The good news is that there are plenty of other ways to ease symptoms.

Support from plants

Plant-based products such as black cohosh (Cimifemin) have proven effective in easing symptoms, as have lavender (for sleep), sage (for hot flushes) and St John’s wort (for mood swings).

Plant-based “hormone replacement”

So-called phytohormones – plant compounds with hormone-like effects – also play an important role. These include isoflavones found in soy or flaxseed. They're similar to the body’s own oestrogen and can have a gentle balancing effect. However, it’s essential to seek expert advice, as it’s hard to get the right dosage through diet alone.

Support from micronutrients

Vitamin D supports bone health – especially important when oestrogen levels fall. “I actually recommend vitamin D to all women, particularly in winter,” Dr Camastral says. “Magnesium in the evening can also help you relax, especially if you have trouble falling asleep.”

Complementary method: acupuncture

Many women find acupuncture helpful – for hot flushes, for example, or inner restlessness. It’s well tolerated and combines well with other approaches.

Exercise is key

Regular physical activity not only improves body awareness, it also has a positive effect on mood, sleep and bodyweight. In addition, it reduces the risk of heart disease and breast cancer and also supports bone health. “Being physically active is one of the best investments you can make in your health, especially during perimenopause and menopause,” Karin Camastral stresses.

No “either-or” – a combination is often best

Many women decide not simply for hormones or a plant-based method – but for both. A combination of hormone therapy and complementary approaches such as acupuncture, exercise or phytohormones can be particularly effective. The important thing is to find the right procedure in consultation with a healthcare professional.

Conclusion: Don’t just endure it – be proactive

Hormones aren't a must – but they’re not taboo either. Even if you can’t or don’t want to take hormones, there are still many ways to relieve menopausal symptoms. What matters is taking your own well-informed decision that is based on professional support. “We need to take women’s symptoms seriously and look for solutions together,” Karin Camastral says. “There’s no need to just drag yourself through the menopause. There are ways to be proactive.”