You have probably noticed in life that every silver lining has a cloud! In the case of HRT, the cloud is called progestogen (a synthetic form of the hormone progesterone).

Up to now it has all looked pretty good: whether you have hot flushes, vaginal and bladder problems, mood changes, or even feelings of insects crawling over your skin, replacing oestrogen gives you a good chance of ending these troublesome symptoms of the menopause. HRT even protects you against osteoporosis, and reduces your chance of having a heart attack. It all sounds too good to be true.

If you have had a hysterectomy, you can skip this slightly depressing chapter, because progestogen is not a word that need bother you. But if you still have a uterus (womb) and are considering taking HRT.

Progesterone is produced in the ovaries after the ovulation phase of the menstrual cycle, and in pregnancy. Its main function is to prepare the womb for a fertilised egg, and to maintain the pregnancy. It also thickens the lining of the womb, reduces secretions from the cervix (the neck of the womb), prevents ovulation, contributes to the retention of water and salt, and works with oestrogen to stimulate milk cells in the breasts. During a menstrual cycle that doesn’t result in pregnancy, it is the production of progesterone that contributes to the pre-menstrual feelings of bloatedness, breast tenderness, and general irritability. So although it has an important role to play in the menstrual cycle and pregnancy, progesterone is not exactly an unmixed blessing, and its presence in HRT causes the single most important reason why women who have not had a hysterectomy either don’t want this form of treatment at all, or don’t stay on it for more than a few months.

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In deciding about HRT, the following points should be taken into account.

- HRT is effective in relieving hot flushes and night sweats, vaginal dryness and urinary symptoms.

- It is particularly helpful to women who have had a premature menopause (either natural or medically induced). They are likely to benefit most from HRT both because they tend to suffer more extreme symptoms of menopause and are at increased risk of osteoporosis and diseases of the heart and blood vessels, and because in many cases they no longer have a uterus and so the hormone therapy is simpler.

- Oestrogen used on its own seems to confer a worthwhile degree of protection against heart and blood vessel disease. This benefit is heightened for women who have had a hysterectomy and in whom there is no added risk of endometrial cancer.

- The decision about which HRT preparation is suitable for the larger number of women who have not had a hysterectomy depends on the balance between several potential benefits and hazards. On both scores, there are gaps in information that research will start to fill during the remainder of this decade.

-In deciding whether to undertake HRT for prolonged periods in the absence of worrisome symptoms, women should take account of both the anticipated benefits and the possible risks. On the benefit side, oestrogen use postpones bone thinning and reduces the likelihood of heart disease. When it is combined with a progestogen, there are still significant benefits for bones, but progestogen appears to negate some of the protective effect that oestrogen has on the cardiovascular system.

On the risk side, the biggest concerns lie with cancers of the breast and endometrium. Breast cancer is the most common cancer of the reproductive organs and the one most feared by women, so consideration of the link between oestrogen and breast cancer is tremendously important in helping women to decide about HRT. Statistical studies indicate that the number of women whose lives will be saved by HRT, through a reduction in serious bone breaks and heart attacks, is much greater than the number who will die through cancer. However if, for a particular woman, the avoidance of an increased cancer risk is more important than the numerically greater benefit in terms of osteoporosis or cardiovascular disease, this is clearly the basis on which her treatment should be decided.

For many women, drawbacks to combined oestrogen and progestogen include withdrawal bleeding, breakthrough bleeding and PMS-like side effects.

For women who use oestrogen on its own and who still have a uterus, an important consideration is the need for regular and extended monitoring of their gynaecological health.

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Sleeplessness

Calcium seems to help overcome sleeplessness, as do the popular herbal sedatives camomile tea and valerian root. Another ‘therapy’ for sleep disturbance that does not require ‘taking’ anything is physical activity. Attending a gym in the evenings or having a brisk after-dinner walk can have a dramatic effect on insomnia by reducing the time needed for falling asleep. Swimming releases excess energy that might otherwise cause tension, preparing the mind and body for sleep. Sex is also recommended.

Hints on increasing the likelihood of sleeping well and rising refreshed include the following.

- Spend some time, before you turn in, doing whatever relaxes you – listening to music, taking a warm bath, reading a book.

- Establish a simple routine every night before going to bed, even just having a shower and cleaning your teeth.

- Reduce or avoid alcohol, coffee and tea with your evening meal.

- Concentrate on relaxing every part of your body in stages as you lie in bed, from the tips of your toes to your forehead.

- Above all, don’t worry about the amount of sleep you are getting — it is surprising how little one can survive on. A good night’s sleep is whatever is normal for you, with some people requiring only a couple of hours.

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Hormone replacement therapy for postmenopausal women has won some advocates who regard it as a way to further reduce heart disease deaths, which have been declining in Australia and much of the Western world since the 1960s. Studies of postmenopausal women prescribed oestrogen in pill form consistently show a significant reduction (by about 20 to 50 per cent) in the risk of heart disease for these women compared with women not taking oestrogen.

Knowledge of how this protective effect works is increasing, especially oestrogen’s favourable impact on blood fats, including cholesterol, and its capacity to reduce heart disease risk by preventing the gradual build-up of fatty material inside blood vessel walls (known as atherosclerosis). It also seems to increase the width of the small blood vessels, enhancing blood flow and reducing the risk of clot formation and life-threatening blood vessel blockage.

Natural oestrogens in pill form seem to have greater benefits for the heart than oestrogen in other forms (implants, patches, vaginal creams and pessaries, for example), but the research is at an early stage. In addition, there are unanswered questions about dosage and duration of use.

The relationship between heart disease and the use of hormone preparations that combine oestrogen and progestogens is not conclusive. The studies performed to date have been short-term and confined in the main to women who are in good general health, are well educated and well off. No information is yet available regarding the long-term effects that these hormone combinations have on a woman’s risk of developing heart attacks, strokes and blood clot disorders. There have been some encouraging animal studies that suggest that pairing these hormones does benefit the lining of blood vessels. However, a number of short-term studies on women suggest that progestogens in higher-than-HRT doses reduce the degree of benefit provided by oestrogen.

There is strong evidence that oestrogen may protect women with pre-existing heart and blood vessel disease from a further deterioration in their condition. There are also early indications that oestrogen reduces the tendency of major blood vessels to spasm in women prone to the excruciating heart pain, angina.

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Skin patches containing natural oestrogens are often prescribed to women who experience troublesome nausea and vomiting while taking oestrogen in pill form, or who are at risk of blood clot formation or high blood pressure from oral oestrogen therapy. In the US, where patches have been used for longer than in Australia, this is the method for about 40 per cent of women taking oestrogen after menopause.

They are transparent, come in a range of sizes depending on dosage (see page 176), and are applied to the abdomen, buttock or upper arm twice a week (for example, Monday morning and Thursday night).

Patches containing combinations of oestrogen and progestogen are also becoming available in an increasing number of countries, though not in Australia at the time of writing. The small and relatively constant doses of hormone released from patches and absorbed through the skin into the bloodstream more closely resemble the oestrogen and progesterone secretions of the body than do hormones taken in pill form.

Studies have confirmed their effectiveness in significantly reducing hot flushes, night sweats, vaginal dryness and urinary symptoms. Preliminary findings of other studies indicate that patches maintain bone density and reduce fracture rates, although long-term studies are needed to confirm this. There is also evidence that patches increase blood flow to the major blood vessels of the heart, but it is too early to say whether this translates to reduced rates of heart disease and heart attack. Major advantages of the patches, compared with HRT pills, are their low rate of gastro-intestinal, bowel- and liver-related side effects, including blood pressure changes and blood clot abnormalities.

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