Ten reasons to be happy about HRT

Ten reasons to be happy about HRT
By Professor John Studd

This is an update on the article that first appeared in Total Health - Top 10 reasons to be happy about hormone replacement therapy

1. HRT will stop your hot flushes and sweats

Troublesome hot flushes and severe night sweats that can cause chronic insomnia are characteristic symptoms of the menopause. They may last for years and apart from being socially embarrassing they result in tiredness because of lack of sleep as well as depression. These symptoms can be cured with the correct dose of oestrogen. No other treatment is nearly as effective.

2. Oestrogens will treat vaginal dryness and many causes of painful intercourse and lack of libido

Thinning of the vaginal skin producing vaginal dryness is another characteristic sign of oestrogen deficiency that occurs after the menopause. This also can be successfully treated with oestrogen either by tablets, or through the skin by patches or gels or implants. Going through the skin is probably the safest and most effective route. Oestrogens can also be given for this symptom by local vaginal applications of a weak oestrogen that is not absorbed. Other related problems of painful intercourse, loss of libido are, depending upon the cause, also effectively treated by oestrogens.

3. HRT increases the bone density and prevents osteoporotic fractures

Every study confirms that oestrogens are the most effective way of increasing bone density and this treatment is certainly very safe when started in women under the age of 60. It is much more effective and beneficial than the bisphosphonates frequently used by bone physicians and general practitioners. These non-hormonal drugs with their considerable long term complications have no place in maintaining bone density in women under the age of 60. For younger women receiving oestrogen therapy for flushes, sweats or vaginal dryness there will be a considerable increase in bone density over the years to such an extent that osteoporotic fractures 20 years later are much less likely to occur. For women who have low bone density, even without typical menopausal symptoms, oestrogens must be seen as first choice therapy.

4. HRT protects the intervertebral discs

The oestrogens prevent the collagen being lost from the intervertebral discs. These discs make up one quarter of the length of the spinal cord and act as cushions preventing crush fractures of the vertebral bones. It is these crush fractures that result in loss of height and of the bending forward of the upper spine known as a Dowager’s hump. This important protective effect of oestrogens seems to be unique as bisphosphonates and the other non hormonal treatments of low bone density do not have any affect upon the discs.    

5. HRT does reduce the number of heart attacks

There is about 30 years of evidence from many observational trials showing that oestrogens reduce the problems of coronary disease and heart attacks. This has subsequently been questioned by the 2002 Women’s Health Initiative (WHI) study which showed an increase in heart attacks. However, this study looked at the wrong aged patients, using the wrong dose and subsequent reports from the same investigators showed a very much reduced incidence of heart attacks in women who start HRT below the age of 60. This is particularly so in women who have had a hysterectomy and can have oestrogens without progestogen. The view now is that HRT particularly oestrogen alone is very safe and very beneficial if started below the age of 60.

6. Oestrogens help depression in many women

There is no doubt that depression is helped in post menopausal women who have been suffering from night sweats, insomnia or vaginal dryness, painful intercourse and marital problems. However, the most impressive effect on mood is seen in younger perimenopausal women in the two or three years before the periods cease. This is known as the menopausal transition period. Such depression often occurs in women who previously have had post natal depression and premenstrual depression. As premenstrual depression becomes worse with age it blends with the more severe depression of the transition phase but is very effectively treated by oestrogens through the skin i.e. transdermal  therapy.

7. HRT improves libido

HRT certainly improves libido if oestrogens are used to cure vaginal dryness and painful intercourse. However, if necessary, the addition of testosterone has an even more dramatic effect upon libido, frequency of intercourse and intensity of orgasm. Women must be aware that testosterone is not a male hormone. It is an essential female hormone that is present, in women, in 10 times the blood levels as is oestrogen. It is an essential hormone, important for energy, mood and sexuality in women and is particularly needed in women who have had a hysterectomy with loss of ovaries and ovarian androgens

8. HRT improves the texture of the skin

After the menopause, women lose about 25% of their body collagen which are manifested by thin inelastic skin, brittle nails, loss of hair and loss of the collagenous bone matrix. This latter loss is an essential cause of osteoporosis and osteoporotic fractures. Oestrogen therapy replaces the lost collagen in the skin and the bone and nails. Its effect on the skin of the face is a very obvious useful cosmetic effect.

9. “I am a nicer person to live with”

Many women say that when oestrogen therapy stops their depression, their loss of libido and their irritability, they become nicer people for their partners to live with. The depression, grumpiness and loss of energy can usually be improved considerably by the appropriate doses of the appropriate hormones. This may be testosterone as well as oestrogen.

10. HRT is safe

In spite of the press reports stressing bad news, virtually all of the major side effects from the WHI study have been withdrawn even by the investigators. It seems quite clear that the major side effects occurred in women who started the wrong dose of HRT over the age of 60. In women who started below the age of 60 there were fewer heart attacks, fewer deaths, fewer osteoporotic fractures and even less breast cancer. The one residual side effect is that there probably is a very slight i.e. 1% extra lifetime risk of developing breast cancer but this is no more than the breast cancer risk of being overweight, drinking wine, having no children or even taking statins.

A growing number of reasons:

11. HRT decreases the risk of Alzheimer's disease

There is perhaps another - Number 11 advantage to add to this list. There is increasing evidence that HRT decreases the risk of Alzheimer's disease. This is logical because the earlier the menopausal the greater the risk of Alzheimer's in later life but it's difficult to prove this to everybody's satisfaction. Certainly, population studies particularly the huge Utah study suggest a decreased risk, but the demands of precise epidemiology insist that a randomised controlled trial with the placebo group is conducted. The problem is at what age should this huge study begin - at the age of 60 ,50, 40 or even earlier and what happens to the placebo group when the patient begins to suffer hot sweats insomnia and depression. She will then move on to estrogens. The problem will never be solved by a vastly expensive and impossible study, so we have to rely on the population data that we have at the moment. It is worth remembering that when Sir Richard Doll’s observation that lung cancer was 13 times more common in smoking doctors than non-smoking doctors was criticised for the absence of a trial, he famously replied that you don’t need a randomised trial to prove the bleeding obvious.


The next challenge is to clarify the role of estrogens in the treatment of depression in women. Depression is twice more common in women than men with more hospital admissions for depression the use of antidepressants and suicide attempts. The clear message is that depression in women is often different from depression in men because there is a massive hormonal component in women not occurring in men.

Depression occurs at times of hormonal flux often beginning within a few years of the first period becoming worse with age. Significantly this depression usually disappears during pregnancy when there are no hormonal fluctuations only to recur as post-natal depression after delivery when estrogen levels fall. This post-natal depression can be delayed if the woman breast feeds for a long time but when she stops breast feeding the periods return and depression returns as PMS often becoming worse with age particularly in the few years before the menopause in the period called the menopausal transition. Thus, we have a combination of Premenstrual depression, postnatal depression and premenopausal depression occurring in the same woman. This is Reproductive Depression , Unfortunately psychiatrists are not aware of this and do not want be bothered with this new information . I have tried!!