The happy menopause pill: It”s the natural drug said to banish hot flushes and pep up flagging sex drives
Could a popular anti-ageing supplement bought off the internet really be as good as HRT
That was the suggestion last week after a study by the University of Pisa, Italy, found that DHEA (dehydroepiandrosterone) is as effective as Hormone Replacement Therapy at managing menopausal symptoms, including hot flushes — while also increasing women’s enjoyment of sex.
HRT’s reputation has been tarnished in recent years by fears over its safety and fears that it raises the risk of heart attack, stroke and breast cancer.
Women who took DHEA had as few hot flushes and other symptoms as those on HRT; they also had significantly greater sexual interest and activity
But many doctors believe it would be misguided to consider DHEA as an effective alternative.
For a start, there is concern that its long-term safety is not yet proven.
Meanwhile, research over the past year has begun to restore HRT’s reputation in terms of both efficacy and safety.
In January, for instance, researchers reported that the oestrogen-only form reduces the risk of breast cancer.
In June, researchers at New York University reported that far from increasing women’s risk of heart disease, HRT actually protects women against furring of the arteries, a major risk factor for heart attack and stroke.
The message about HRT is not straightforward, and it’s understandable that women are confused about its safety, admits Professor Valerie Beral, director of the Cancer Research UK epidemiology unit at the University of Oxford and one of the leading researchers on HRT.
However most experts now believe emphatically that it is safe, provided that, rather than seeing HRT as a one drug fits all remedy, women should choose the most appropriate form for their needs.
In fact, there are two different types of HRT, which come in many different doses and forms (such as gels, tablets and patches).
Judicious selection of the most appropriate type — including the best method of delivery, the dose and even the age you take it — can prevent the worrying side-effects reported in research on HRT, while delivering the benefits, say the experts.
‘Women today need to be fully informed of all the choices,’ says Dr Heather Currie, a gynaecologist and menopause specialist at Dumfries And Galloway Royal Infirmary.
To help you make the right HRT choice, with the help of leading experts we explain the options.
DHEA is synthesised from wild yam in the same way that other “natural” forms of HRT are derived from plant extracts
WHAT IS IT DHEA is a naturally-occurring hormone, largely produced in the adrenal glands in both men and women.
It acts like a ‘parent hormone’, converting in the body into the sex hormones oestrogen, progesterone and testosterone as the body needs them.
Levels peak around the age of 30, and then tail off gradually.
Over the past decade some research has suggested supplements of the hormone, which was discovered in the early Seventies, could help tackle the symptoms of the menopause (by boosting oestrogen).
DHEA is synthesised from wild yam in the same way that other ‘natural’ forms of HRT are derived from plant extracts.
These products are increasingly popular because of the claims they are ‘bio-identical’ to women’s own hormones, unlike the ‘artificial’ hormones in prescription HRT. (They are also tailor-made for the individual woman).
PROS: Earlier this month, a study published in Climacteric, the journal of the International Menopause Society, found that women with menopausal symptoms who took the supplements had as few hot flushes and other symptoms as those on HRT; they also had significantly greater sexual interest and activity.
DHEA can also be a better choice for menopausal women suffering brain fog and low energy, says Dr John Moran, director of the Holistic Medical Clinic in Wimpole Street, London.
‘This is a symptom closely connected to the adrenal gland and DHEA brings almost instant reinvigoration and mental clarity — whereas HRT acts on physical symptoms such as hot flushes,’ he says.
CONS: There is concern about the lack of proper clinical testing. The latest study involved just 48 women of whom only 12 were taking DHEA, while a much-quoted 1999 study on DHEA involved only 24 women.
Meanwhile a review of ten trials published in the Journal Of Clinical Endocrinology And Metabolism noted there was no overall ‘significant effect on anxiety and sexual wellbeing’.
‘The marketing of this supplement’s effectiveness far exceeds its science’, it reported.
‘The short-term effects of taking DHEA are still controversial and the possible harmful effects of long-term use are, as yet, unknown,’ says Dr Sally Hope, a GP and member of the British Menopause Society.
Further, doctors are divided over whether DHEA supplements should now be considered a safe alternative to HRT (the hormone is sold in the U.S. as a food supplement but can be obtained in the UK only on a private prescription or bought online from overseas).
Some critics also argue that these ‘natural’ hormones are made in laboratories in much the same way as those produced by pharmaceutical companies — the main difference is their production, prescribing and dosing is unregulated.
‘The U.S. Food And Drug Adminstration has sent warnings to a large number of manufacturers of bioidentical hormones expressing concern about claims about safety,’ says gynaecologist Dr Currie. ‘Sadly, marketing and promotion remain widespread.’
A handful of UK practitioners, mainly in Harley Street, continue to promote ‘natural’ hormones, sourcing these unlicensed products mainly in Europe.
There are some licensed forms of bio-identicals (such as Estrogel), which come in a standard dose — some are available on the NHS.
HOW DO YOU TAKE IT DHEA is most commonly taken as daily capsules.
WHO SHOULD TAKE IT Experts recommend waiting until further evidence emerges before trying this product.
For women who do consider taking DHEA medical professionals stress the importance of speaking to your GP first, and above all having a saliva test to check your DHEA levels before taking the tablets.
Dr Daniel Sister, a general physician in West London, says. ‘Giving DHEA to women with normal natural levels can cause unwanted side-effects including facial hair and acne.’
OESTROGEN ONLY HRT
WHAT IS IT A hormonal supplement that replaces oestrogen during and after the menopause (or following a hysterectomy).
There are two main types of oestrogen-only HRT, conjugated equine oestrogen and synthetic oestrogen.
The first, which is similar to human oestrogen, is derived from mares’ urine and is the most commonly prescribed oestrogen-replacement, whether taken on its own or as a combined supplement. It usually comes in tablet form with the brand name Premarin.
Synthetic oestrogen is made from natural substances such as soya and wild yam and is virtually identical to human oestrogen.
PROS: Oestrogen-only HRT is considered very safe. Canadian researchers recently found it protects some women against breast cancer.
‘Naturally-produced oestrogen has always been linked with a higher incidence of breast cancer, yet oestrogen administered as HRT actually seems to be protective — at least for women with no family history of the disease,’ said Professor Joseph Ragaz, the lead researcher.
While experts agree it’s too early to say that HRT does protect against breast cancer, there’s almost universal agreement that, contrary to previous fears, the oestrogen in HRT has, according to Professor Beral, ‘at most a very small impact on raising the risk of breast cancer’.
It’s also widely agreed that many, if not all, of the positive health benefits of HRT are derived from oestrogen, including protection against menopausal symptoms including hot flushes, mood swings and ‘brain fog’.
Oestrogen has also been shown to boost bone strength, protecting against osteoporosis and fractures.
CONS: Oestrogen-only HRT can cause a small increase in the risk of endometrial (womb lining) cancer and unpredictable bleeding (these risks do not apply to women who’ve had a hysterectomy). There is also a small increased risk of blood clots.
HOW DO YOU TAKE IT There are several options, although a tablet, taken daily, is the most common form. It can also be taken transdermally (absorbed through the skin) as a weekly or twice-weekly patch or daily gel.
‘It’s definitely worth considering transdermal products,’ says Dr Wendy Denning, a private GP with an interest in women’s health.
‘Medication taken orally has to be pro-cessed by the liver where it acts to raise cholesterol levels and the risk of clotting. Transdermal products go straight into the bloodstream, avoiding this adverse effect.’
An ultra-low dose of oestrogen, delivered in a patch and providing just enough oestrogen to stimulate bone density without raising the risk of endometrial cancer, has just been launched in the U.S. and could soon be available in the UK.
Low dose oestrogen can be applied to the vagina as a cream, a pessary, a ring or with an applicator for local symptoms, including dryness.
Implants inserted under the skin release hormones slowly into the body and are replaced every six months.
WHO SHOULD TAKE IT Some specialists claim that oestrogen-only HRT may be safer overall than combined HRT.
However Dr Currie says: ‘Every relevant professional organisation, including the British Menopause Society, supports the view that only women who’ve had a hysterectomy should take oestrogen-only HRT.
‘This is because we know for certain that it raises the risk of endometrial cancer — whereas the small extra risk of breast cancer and heart disease from combined HRT are just estimates. Our recommendations have to reflect real risks compared to theoretical risks.’
The health risks of combined HRT are now seen to be relatively minor, including: some PMS-type side-effects including unexpected bleeding and headaches
WHAT IS IT: This involves taking two forms of hormone to replace oestrogen and progesterone (levels of which drop significantly around the menopause).
The synthetic chemical version of progesterone is known as progestogen and is usually derived from plant sources.
In many HRT products, the oestrogen and progestogen are combined in the same tablet, patch or implant. They can also be taken separately.
PROS: Progestogen is seen as an essential component of HRT for women who haven’t had a hysterectomy. It prevents overgrowth of the lining of the womb, thus protecting against a small increase in the risk of endometrial cancer.
It might also protect against heart disease. Research has shown that over five years, two in 100 women taking HRT are at risk of heart disease compared to 1.5 in 100 women not on it.
But Dr John Stevenson, a hormone specialist at the Royal Brompton Hospital, says the evidence suggests women who start taking HRT before the age of 60 do not face this increased risk and may indeed be protected against heart disease.
CONS: Two large studies, the U.S.-based Women’s Health Initiative and the UK-based Million Women’s Study, first published in 2002, caused a public storm with claims that women on HRT faced significant increases in the risk of stroke, heart disease, breast cancer and blood clots.
It’s now widely accepted these risks were poorly interpreted — partly because they were based on older women who’d already undergone the menopause when they started taking HRT.
The health risks of combined HRT are now seen to be relatively minor, including: some PMS-type side-effects including unexpected bleeding, tender breasts, headaches and mood swings — though these can largely be avoided by delivering progestogen directly into the womb; weight gain in some women initially.
Three women in 100 who are taking HRT are likely to have a stroke compared to two in 100 who are not on it.
Less than one in 100 women taking it got a blood clot in their lungs — but this is about twice the number of women who aren’t on the hormone therapy.
Three in 100 women taking combined HRT developed breast cancer compared to two in 100 women not taking it.
HOW DO YOU TAKE IT Combined HRT is best taken as a tablet. Women who are perimenopausal, i.e. still experiencing erratic menstrual bleeding, might prefer the ‘sequential’ form, where you get oestrogen every day and progestogen for the last 12 to 14 days of your cycle. This mimics the menstrual cycle and result in monthly periods.
But some experts recommend progestogen tablets for just seven days of the month.
‘A lower dose of progestogen will cause fewer side-effects,’ says gynaecologist Professor John Studd of the London PMS And Menopause Centre. For post-menopausal women, there is the ‘continuous’ form, which doesn’t produce periods and involves a daily dose of oestrogen and progestogen.
As with oestrogen-only HRT, you can also get the oestrogen via a patch, cream, ring, pessary or implants.
Lower dose progestogens, such as Utrogestan, have fewer side-effects.
Another option is a Mirena intra-uterine device, a coil-like device inserted in the womb, where it releases tiny daily doses of levonorgestrel, a type of progestogen.
A woman can have a Mirena fitted as she approaches the menopause, adding an oestrogen gel or patch as she hits her 50s. It halts periods safely and rarely causes PMS symptoms.
Progesterone vaginal gels are not licensed for HRT — only as an IVF treatment. However, some menopause clinics offer the gel as a form of low dose progesterone for HRT.
WHO SHOULD TAKE IT Any menopausal woman who feels that they will benefit and who has not had a hysterectomy.
WHEN SHOULD I START TAKING HRT
A woman’s hormone levels can start to drop a decade or more before she has her final period.
For this reason some doctors suggest starting HRT only after a blood test has confirmed enoughof a hormone decline to warrant treatment.
However, women’s hormones fluctuate considerably during the perimenopause (the precursor to the menopause) so a blood test ‘is fairly meaningless’ says Dr Heather Currie.
‘We find that it’s best for women to rely on their own perception of how they are feeling.’
The Department of Health advises women to stay on the smallest dose for the shortest possible time.
Because the risks of HRT such as breast cancer may rise for women over 60, many doctors advise women not to take the treatment for more than five years.