Menopause, the cessation of menstrual periods is defined as a natural transition, much like puberty. It is thus not considered a medical condition and not covered by insurance companies. And yet, it seems to have become more of a struggle for so many women.

Female hormones decline a 100-fold in the space of five years around the transition into menopause, during a time when our usual duties towards our families and society increase rather than diminish. We expect of ourselves to carry on as though nothing is happening to our biology.
The role of oestrogens on maintaining bone, brain and cardio-vascular health is now increasingly recognised.

However, what seems to sway our decision towards HRT is not the occurrence of hot flushes (unpleasant as they can be) nor a preventative drive to maintain health long term, but rather the frightening psychological symptoms associated with menopause (insomnia, anxiety, irritability, mood swings, brain fog/ memory problems and a sense of loss of self and diminished stress-resilience). Hot flushes are the fifth most common symptom in my practice.
Many women leave their jobs around menopause and the suicide rate in women also peaks around peri- and menopause.

We usually enquire about HRT when we are quite symptomatic, and brain fog and difficulty making a decision are all part and parcel of menopause. often after trying a whole range of complementary therapies.

THE FEAR ABOUT HRT

I recently had a patient who was determined to make it through the natural way; after all it is supposed to be a natural transition. She tried more or less everything; acupuncture, herbal treatments, homeopathy, supplements. She was in chronic pain from her joints and most recently her insomnia had become unbearable. A friend offered her ‘a joint’ which seemed to help her to fall asleep, at least initially, alongside with a couple of glasses of wine, but after a while this didn’t work either and she had a truly miserable holiday as she hadn’t been able to take her smoke there. She had previously been fit and healthy and a non-smoker and had finally realised her life was slipping away and maybe time had come to think about HRT again.
The extent of our fear about HRT cannot be under-estimated.

After a decade of headlines and fears around HRT and breast cancer, we are understandably concerned.

The million women study (http://www.millionwomenstudy.org/aims/) found an increased risk of breast cancer, stroke and increased clotting risk with HRT. This study did not use human-like hormones (but equine oestrogens alongside synthetic progestins) and also included many older women who had been menopausal for some over a decade. We have learned from that study that there is an optimal window for starting HRT (within 10 years max since the last menstrual period) and, since 2015, the British menopause society acknowledged that oral micronized progesterone is the best tolerated with the least side-effects when compared to synthetic ones. Also, some studies showed that human-like progesterone (bio/body identical) may have a lower risk of breast cancer when compared to other synthetic progestins. Also, oestrogen given via skin (transdermal) as a patch or gel has a much lower risk of clots or other cardio-vascular complications.

So, the combination of transdermal oestradiol (gel/patch) with oral micronized progesterone (licensed as Utrogestan and available in a fixed dose 100mg capsule) is the best bio-identical hormone option. This is available on the NHS.

BHRT and HRT

A brief history of hormone therapies
We have now established that bio/body identical hormone replacement therapy to include oestradiol and progesterone HRT is available from your GP and is perhaps, given our current knowledge, the safest form of pharmaceutical type of HRT.

But this has not always been so. Up until -5-6 years ago, women on the NHS were often prescribed equine oestrogens (extracted from the urine of pregnant mares) alongside synthetic progestins, which worked well to protect the lining of the womb against the effect of oestrogens. However, synthetic progestins had more breast cancer risk.

Equine oestrogens and synthetic progestins were not just licensed medication but also first line/ guideline recommendation treatment not that long ago as women were enrolled to the ‘million women study” in the largest ever women’s health trial. A trial which was stopped early as risks became more apparent.

Therefore, licensed doesn’t always mean perfectly safe.

BHRT and why unlicensed does not necessarily mean unsafe

As human-like hormones were not easily available, many women preferred to have hormone therapy using custom-made bio-identical hormones.

Currently there is increasing media coverage that these types of hormones are not licensed and not regulated and therefore may be unsafe.

Custom made bio-identical hormones are made in a compound pharmacy, which is regulated by the General Pharmaceutical Council. The outcome of the last inspection is usually readily available on request from the compounding pharmacy (specialist pharmacy gained the highest rating). As the prescriptions are personalised to one’s specific hormone deficiency, each prescription may differ. Not everyone is prescribed the same standard pill and patch or gel combination.

Therefore, there are no clinical trials done as all prescriptions are different and it would be hard to do a clinical trial with personalised products, when usually dose A is compared to dose B and in personalised medicine there is so much variation.
Doctors prescribing hormones from Compound pharmacies have worked in this way for many decades, largely based on a keen understanding of how the biology of the body works. There are however studies showing that this approach is effective . https://www.magonlinelibrary.com/doi/full/10.12968/jprp.2020.2.7.384

Sex hormones- oestrogen and progesterone fluctuate over time and eventually decline, therefore replacing them to optimal levels (not too low but not as high as they would be in our reproductive years) seemed to improve wellbeing. The same woman, in her transition towards menopause may need a different prescription at different stages of hormone decline. Moreover, different women may need different hormones- for some testosterone is beneficial as an add on and others maintain good levels of it well into menopause. It is based on measure and replace. As these hormones are made in compound pharmacies, additional safeguards have to be in place. Blood tests are done every six months and sometimes pelvic scans every 18-24 months to ensure the lining of the womb is protected as well as breast screening with regular mammograms. The risk of breast cancer is also considered very carefully, often by looking at the latest data on oestrogen metabolism. Some oestrogens (4 methoxy oestrogens) have a higher risk of breast cancer. Lifestyle changes are discussed in detail in long consultations and individualised recommendations are based on one’s specific risk and often genetic profile and hormone metabolism. The downside may be that this comes at a cost, and the licensed option may have worked just as well, so it is perhaps better to start there first if you are unsure about BHRT.

Women that opt for BHRT are perhaps the most monitored and often most health-conscious women I ever met. They tend to understand the importance of balancing blood sugar, maintaining gut health, benefits of exercise and often practice yoga and relaxation. They tend to be on much smaller doses that control their symptoms perfectly.

Celia’s story

Celia came to see me after she had a hysterectomy. She had been on an Oestradiol patch, oral micronized progesterone and some testosterone gel for about 18 months when she started bleeding. Investigations found endometrial cancer and her womb was removed. She was upset and confused that she had this diagnosis; after all, she had been on licensed body-identical hormones. We discussed that whilst Utrogestan- as oral micronized progesterone is licensed to protect the lining of the womb, this is not always 100% effective. Moreover, the prevalence of endometrial cancer has in increased by 20% in women in the UK over the past two decades, outside any HRT-related risks, possibly driven by changes in our environment, mostly related to increased weight (obesity) but also more oestrogen-like chemicals (xenoestrogens) that are ever present. Would BHRT have been better? As part of BHRT protocols she would have had a pelvic scan before starting treatment and 12-18 months thereafter, oestrogen levels would have been monitored every six months and the issue of weight may have been discussed at length.

Tina’s story

Tina was well on BHRT for a 4-5 years, but she was getting fed up with the costs of prescription and monitoring. A visit to her NHS nurse for a smear test led to a conversation about BHRT and she was told that they are unsafe. She visited another menopause clinic, where she was started on Estrogel and progesterone capsule, the licensed bio-identical combination. She however felt very anxious on it, her sleep was disturbed, and her wellbeing suffered. She went for a review and was told she was progesterone intolerant and advised to further reduce the dose of progesterone; this lower dose was below the recommended dose; her anxiety did not improve and moreover she started bleeding, having not had a period for more than five years; she was now referred for a hysteroscopy to be investigated further, but luckily there was no cancer and the bleeding was really a consequence of unbalanced hormones, too much oestrogen, not enough progesterone. She returned to the BHRT clinic upset with herself that she went through all this and went back to her old prescription, which she tolerates well with no bleeding and full symptom control.

The key is to balance hormones and if this can be achieved with the standard doses of licenced estradiol and progesterone it is perhaps ideal. But if that isn’t tolerated