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Hormone Replacement Therapy (HRT) after menopause
With great advances in medicine, the life expectancy of a person is increasing progressively and a women can easily expect to spend one–third of her life span after the age of menopause. In this period, women in the present era continue to be physically, intellectually and sexually active and due consideration needs to be given to their health and well being during this phase of life.

Menopause
Menopause is that point of time, when permanent cessation of menstruation occurs following the loss of ovarian activity (ovaries are the glands which produce the female sex hormones like estrogen). Climacteric is a more encompassing word, indicating the period of time when a woman passes through a transition from the reproductive stage of life to the post–menopausal years. The average age of menopause is from 48–55 years. Thinner women and smokers may have an earlier menopause. Removal of uterus per se does not constitute menopause if the ovaries are left intact. However, it has been observed that these ovaries tend to decline faster that usual in such cases.

Symptoms of Menopause
  1. Disturbances of menstruation including decreased/heavy menstrual flow, irregular menses followed by total cessation of menses.
  2. Hot flushes and sweats: These are present as episodes of a feeling of intense heat followed by sweating and weakness. The episode may last from several seconds to minutes and tends to recur. Flushes are more common at night or during times of stress. Flushes may disappear in about 1–2 years after menopause, but may persist for 5 years or more.
  3. Psychological symptoms like anxiety, increased tension, mood changes, depression and irritability do occur in increased frequency at the time of stress. Flushes may disappear in about 1–2 years after menopause, but may persist for 5 years or more.
  4. Atrophic changes: Estrogen deficiency causes poor lubrication of vagina and results in itching, dryness of vagina and painful intercourse. Poor tone of pelvic muscles may cause recurrent urinary infections and occasional stress urinary incontinence (leakage of urine on coughing, laughing, lifting heavy objects etc.). Estrogen treatment also has a favorable impact on the skin, however, whether it can prevent wrinkling is not clear.
  5. Reduced sexual interest.
  6. General skin changes: Part of the changes of ageing evident in the skin and due to menopause.
  7. The most important implications of menopause are the long term problems which are caused by deficiency of estrogen:
    • Increased risk of heart diseases: As compared to men, women are usually protected from developing cardiac problems due to the effect of female sex hormones. This protection is lost after menopause. In women undergoing early menopause, this risk may suddenly double.
    • Osteoporosis: After menopause, bones, tend to become weaker and more prone to fractures. There is a 50% reduction in the bone mass in the first 20 years after menopause, this loss is much faster if you have undergone a surgical menopause (both ovaries have been removed at an early age).
Benefits of Hormone Replacement Therapy (HRT)
Effect on hot flushes and sweating
Estrogen produces a remarkable reduction in the intensity and frequency of these symptoms and most patients will become symptom–free after about 6–8 weeks of therapy.

Psychological Symptoms
Patients put on Hormone Replacement Therapy do report an increased feeling of well being after starting treatment and part of the effect is due to the reduction in hot flushes. However patients with frank depression may not necessarily improve with Hormone Replacement Therapy alone and may not be prescribed HRT to you for these symptoms alone.

Effect on Bones
Estrogens are very useful in preserving the bone mass and arresting the bone loss that occur after menopause. The benefit is maximum if Hormone Replacement Therapy is started immediately around menopause and continue for about 5 years at least. The risk of fractures will be half. The efficacy of HRT tends to reduce as age advances, but is said to be beneficial even if started at the age of 65 years. Addition of calcium can reduce the fracture risk by almost 50–60% with Hormone Replacement Therapy. Improvement in bone mass and muscle strength will reflect in improved work performance and endurance.

Effect on the Heart
Hormone Replacement Therapy has been proven to reduce the risk of heart problems to which a postmenopausal woman is vulnerable. Blood levels of total cholesterol and LDL cholesterol or ‘Bad’ cholesterol tends to reduce and the ‘Good’ cholesterol or HDL level increases. Initially it was feared that BP goes up with HRT, however it has now been demonstrated that with the types of medication used at present, BP in fact decreases a little. These and other effects translate into a 50% less risk getting a heart attack.

Side Effects of Hormone Replacement Therapy
There were a lot of fears. Initially Hormone Replacement Therapy use would produce number of side effects like increased risk of cancer of breasts, uterus, high BP, increased risk of clotting in the veins etc. The risk seemed more when high doses of estrogen were used for prolonged durations. With the present day medication and the doses used, most of these fears are unfounded.

There is no increase in the risk of breast cancer with low doses of estrogen given for 10 years. However the risk may increase if there is a self/family history of breast cancer, and obviously, Hormone Replacement Therapy will not be offered to such patients. The same applies to cancer of the uterus, and in the West, even patients with very early grades of uterine cancer are not denied HRT if they genuinely deserve it. The only real risk at present seems to be occasionally developing gall stones this is a minor problem and can be easily monitored.

Treatment
Hormone Replacement Therapy is a long term treatment and one needs to understand all the benefits, pitfalls and implications of therapy before starting it. Some routine investigations are necessary before therapy is begun.

These include
  1. Blood sugar levels to check for diabetes and cholesterol, triglyceride and HDL levels.
  2. PAP smear to rule out any early uterine or cervical cancers.
  3. Mammography: this is a special X–ray of the breasts and can detect breast cancers very early.
  4. Others: Hemogram etc.
Regimens used in HRT
Two types of regimens are used in Hormone Replacement Therapy: In one, regular menses resume (Like in the pre–menopausal years), however there is no pain, excess bleeding or any chance of pregnancy. Some women would not like to have periods again, and for them another type of regimen which does not result in monthly bleeding can be designed.

Frequency
Frequent follow up is really not necessary unless you have a specific problem. Mammography, PAP smear, blood sugar and lipid levels are repeated yearly. Self examination of the breast, is recommended every fortnight and any lump, pain, hardness should be reported immediately.

Contraindication
The most important contradiction is a family or self history of breast or uterine cancer. Relative contraindications include very high triglyceride levels, grossly uncontrolled diabetes or severe migraine or vascular eye problems.