Questioning Hormone replacement therapy (HRT) Hormone replacement therapy helps treat menopausal symptoms. However, questions abound over the treatment By Eleanor Yap Hormone replacement therapy (HRT) has earned quite a bad reputation in the past few years, to the point where menopausal women in their 50s and 60s have started having second thoughts about it. Even today, some uncertainties linger.   What is it? HRT is a treatment that replaces the hormones your ovaries stop making at menopause. Oestrogen and progesterone are general names for the families of hormones prescribed for and after menopause. Oestrogen is the main hormone used in HRT; however, if the woman still has an intact uterus, then progesterone is added as a combination because progesterone helps to protect the uterus from endometrial cancer (womb cancer).   The treatment helps alleviate symptoms of menopause, like hot flushes, vaginal dryness, mood swings, sleep disorders and decreased sexual desire. There are a number of forms of HRT available, including pills, patches, implants or vaginal creams to replace the level of sex hormones in your body.   Risks & benefits There are both benefits and risks to the use of HRT. It relieves hot flushes and vaginal dryness, delays bone loss and osteoporosis, and protects against fractures of the wrist, spine and hip. It also indirectly improves some emotional symptoms by relieving the physical discomfort of menopause and may help memory or prevent Alzheimer’s disease. It appears to be safe for short-term use.   However, those who take it for more than five years may be at risk of breast cancer as evidenced by several reports. The now famous Women’s Health Initiative (WHI) Study done three years ago in the US confirmed an increased risk of breast cancer and the lack of protection against coronary heart disease. It also confirms the long-term benefits, which include reduced risks of colorectal cancer and hip fractures. It concluded that there were risks for long-term use of combined HRT, although the risk for an individual is very small.   Other bad points – HRT may cause pre-menstrual syndrome (PMS) symptoms such as bloating or irritability, as well as a whole slew of side effects such as vaginal bleeding, nausea, bloating, hair loss, weight gain, depression and migraine headaches. There is even a report stating that it can induce or worsen urinary incontinence.   So what should you do? It is best to discuss your needs with your doctor to decide what’s best for you. Make a decision based on your family and medical history, and weigh the benefits against the risks. Additional medications such as calcium tablets may be recommended for some women to help prevent menopause, especially for women who are at very high risk for osteoporosis or heart disease. Those on HRT should make some lifestyle changes, including eating healthy foods and getting regular weight-bearing exercises. For those who decide against HRT, it is advisable that they continue to go for breast and vaginal examinations every year. As Dr Selina Chua, consultant obstetrician and gynaecologist at Women’s Specialist Associates, Mount Elizabeth Medical Centre, explains, most women don’t use HRT as their symptoms may not be so severe, but about 10% to 20% of these women really do need to go on it.   Despite all the studies touting the risks of taking HRT in the long term, Dr Chua recommends that if a woman is badly affected by her symptoms, she should use it for one to two years and then rethink the need for it after that.   Associate Professor P C Wong, chief of the Department of Obstetrics and Gynaecology, National University Hospital, agreed in a recent newspaper report, saying that from the available evidence, there is no increased risk in the first five years, so any time within that period is fine. He led a group that came up with the Guidelines on the Care of Menopausal Women, which is now in effect at all National Healthcare Group polyclinics, hospitals and institutions.   Going natural Besides HRT, there are also some alternative options including bio-identical hormones and alternative medicine. Bio-identical hormones are made of plant-derived ingredients such as soy and wild yam, which have structures identical to the oestrogen and progesterone naturally found in a woman’s body. In the US, these products are gaining in popularity and proponents claim they are safe. Despite this, bio-identical hormones are coming under scrutiny and the Food and Drug Administration in the US advises that both doctors and patients should assume that all hormones have a similar profile of benefits and risks, regardless of how they are made.   There are also a number of common herbs that can help ease menopausal symptoms, according to Justin Morais of Sports Acupuncture Centre, a pioneer of alternative medicine in Singapore. These include black cohosh, chasteberry, red clover, soy and wild yam.   “Which herb you need depends on which hormone is imbalanced. You will need to do a hormone test first to determine if it is an oestrogen or progesterone deficiency. Not every woman is the same,” says Morais.   For an oestrogen deficiency, herbs that can be effective include alfalfa, liquorice, parsley, red clover, sage, soya bean and dong quai (traditional Chinese medicine). If a lack of progesterone is the culprit, then try fenugreek, sarsaparilla and wild yam.