Menopausal hormone replacement therapy: Urban craze or necessary care?

I have never physically met Sue Mbaya, but technology has allowed us to bond remotely over matters menopause for the last few years. Sue has not only challenged me to be a better care provider to women in menopause care, but she has also taught me so much about the first-hand patient experience with regard to the same.

Sue’s basic grounding with regard to education is a Bachelors Degree in Biological Sciences. Despite the fact that a lot of her professional life has been spent on policy advocacy for development work, focusing on land governance, peace and security, Sue has gravitated back home, towards women’s health. She founded Menopause Solutions Africa, to give a voice to herself, and to all women, with regard to this largely tumultuous yet grossly ignored, downplayed and largely condemned period of a woman’s life - menopause.

It comes as a surprise to many that I attend to a rapidly increasing cohort of women seeking care in menopause. These are women at a stage in their lives when they have pretty much achieved self-actualisation. They know what they want from care and they are not afraid to demand for it.

For many years, the use of hormone replacement therapy (HRT) in menopause care was frowned upon in Kenya. This was along with other reproductive health care services targeting women such as pain relief in labour using epidural analgesia and even basic care such as access to contraceptives, especially for single women.

As sexual and reproductive health and rights awareness increases, so does demand for comprehensive reproductive healthcare services. Menopause care had taken a leap in the last decade in Kenya, with demand driving access to HRT.

Barbara* is an extremely busy senior-level manager for a multinational company, who travels a lot for work. For her, it does not matter where in the world she is. Once her supply of HRT starts to dwindle, she is sure to send a reminder message for renewal of her prescription. For her, missing her prescription for a week puts a huge dent in her well-being, compromising her comfort and productivity.

Four years ago, as we were grappling with the Covid-19 pandemic, she scheduled an appointment out of desperation. She could not travel to the UK to see her regular gynaecologist for a prescription. She was at the end of her rope with the menopause riot. She had to find a solution closer home. Unfortunately, the product she was using was not available locally. Her desperation pushed her to try what was available and it worked like a charm, at an even lower dose than she was previously on. It has been a smooth four years.

HRT refers to exogenous reproductive hormones given to replace the naturally produced oestrogen when its levels decline in menopause. The therapy may be made up of oestrogen only or a combination oestrogen and progesterone. Other products include tibolone, a synthetically manufactured drug which when activated, its compounds mimic oestrogen, progesterone and androgens, producing similar effects to the actual compounds.

HRT was available as early as the 1950s, having been shown to effectively manage the menopausal hot flashes associated with the end of the reproductive lifespan of the woman. Initially, oestrogen was used alone to achieve the desired effect since menopause symptoms are a direct result of the decreased levels of oestrogen in the body.

The oestrogen use was noted to increase the risk for endometrial cancer (cancer of the inner lining of the uterus), in women who still had an intact uterus. This was quickly resolved by the addition of progesterone into the prescription for women who still have a uterus, eliminating this risk. HRT grew in popularity over the decades but suffered a setback in 2002, when an ongoing study, the Women's Health Initiative, conducted by the National Institutes of Health, was stopped because women on HRT seemed to have a slightly increased risk of stroke, heart disease and breast cancer.

Over the years, this evidence has been reviewed and further studies carried out, including the Million Women Study, providing evidence-informed guidance on the use of HRT to care providers and to the women themselves.

Menopause symptoms vary from woman to woman, by severity and even by combination. The hallmark of menopause is the onset of irregular menstrual cycles as one gears towards complete cessation of periods. The disturbing symptoms include the autonomic symptoms characterised by hot flashes, palpitations, excessive sweating and night sweats.

The sexual experience is remarkably affected by vaginal dryness and soreness with intercourse, and painful sex (dyspareunia), both of which contribute to decreased sexual desire. The urinary system is not spared either, with frequent urination, frequent urinary tract infections, urgency (difficulty holding urine once the urge to go comes), and sometimes outright incontinence.

Central nervous system manifestations vary, and these include mood changes, depression, anxiety, insomnia, forgetfulness, poor concentration, irritability and loss of energy. There is an impact on appetite, sometimes with outright cravings and change in usual feeding patterns. This impacts on weight and body mass index. Women begin to notice a change in their body habitus (shape and redistribution of body fat) and this can impact on self-esteem.

Other changes include skin texture, hair texture and volume; a change in severity of existing allergies or new manifestation of previously unknown allergies; new occurrence of other hormonal conditions such as hypo- or hyperthyroidism; and muscle and joint discomfort.
HRT has been proven to remarkably improve these symptoms, while additionally protecting against osteoporosis by preventing loss of bone density; protecting against cardiovascular disease and strokes by managing serum cholesterol; and slowing down the progression of dementia and Alzheimer’s disease.

In the same vein, it has also been demonstrated to increase risk for breast and endometrial cancer, thromboembolic disease (clots in the blood vessels and in the lungs, that are life-threatening), and conversely, stroke too.

So what does this mean? After much combing through research findings to inform recommendations, what is coming out is that HRT is likely to be most beneficial and with much less risk when it is actually initiated within the first five years of menopause and within the first decade of its use. Continued use beyond 10 years is what results in increased risk, especially for breast cancer and cardiovascular disease. Initiation of HRT past the age of 65 is of little benefit, with high risk of negative effects.

Despite an array of conditions where HRT may not be recommended, including women with history of breast and endometrial cancer, and thromboembolic disease; women with severe liver disease, porphyria (inherited blood disorders affecting skin and nervous system); increased triglycerides; endometriosis; undiagnosed abnormal vaginal bleeding; and in some instances, fibroids, the decision to start the use of HRT or not is highly individualised.
A patient must be educated, properly counselled and fully evaluated for suitability to use HRT. It is important to correctly depict the risks to avoid scare-mongering. For instance, the risk of breast cancer in HRT use increases in women over 50 - using HRT continuously for five consecutive years. It is important to also note that this risk is reversed when one finally gets off HRT. Or that the risk of developing blood clots among women using combined HRT is 15 per 10,000 women per year.

Additionally, the woman must understand the possible side effects that can result from HRT use, especially at the initiation of treatment, such as nausea, bloating and fluid retention, weight changes, breast soreness and moodiness. Finally, both the woman and the practitioners must know about the available HRT options such as tablets, skin patches, under-the-skin implants, gels, vaginal pessaries and rings. This enables the woman to make a choice on what best suits her needs; even when some of this options are not yet available locally for lack of demand.

Menopause comes to all women. While approximately 20 per cent will wade through with no challenges, 60 per cent will suffer one symptom or the other; and another 20 per cent will suffer intolerable symptoms that cannot be wished away. Our challenge is to create awareness so that all women, irrespective of their walk of life, access menopause care. It is their constitutional right, and our moral obligation as a country, to deliver!

Dr Bosire is an obstetrician/ gynaecologist