Although the menopause is a natural life change, the symptoms can be debilitating. Dr Lesley Hickin looks at the benefits of hormone replacement therapy

Some women view the onset of menopause as a blessed relief from periods and a new start in life, while others mourn the loss of their fertility. Whatever your point of view, there are symptoms associated with 'the change' that vary from slightly inconvenient to very troublesome emotional and physical problems. Some of these symptoms occur during the time leading up to periods stopping (the perimenopause), and some gradually appear as time goes on.

Oestrogen replacement in the form of pills, patches, implants, vaginal creams and pessaries can alleviate these immediate symptoms and delay the onset of others. If you have not had a hysterectomy to remove your uterus, you also need to take another type of hormone called a progestogen. This is to prevent abnormal thickening of the lining of the uterus (endometrium) that can increase the risk of developing cancer of the endometrium. The risk in the general population is 1 in 1,000 per year; if you take oestrogen alone your risk increases by fivefold. Taking progesterone as well prevents the increased risk, but does decrease some of the benefitial effects of oetrogen and must be weighed against a possible increased risk of breast cancer, although the risks are relatively small. Out of 1000 women aged 50?64 years, around 14 who are NOT using HRT have breast cancer diagnosed over 5 years. In those using oestrogen-only HRT for 5 years, breast cancer is diagnosed in 15.5 per 1000 women. In those using combined HRT for 5 years, breast cancer is diagnosed in around 20 women per 1000. The view of the Committee for the Safety of Medicines (CSM) is that these results do not provide a reason to stop taking HRT but emphasise the importance of breast awareness and regular mammograms.

How will it help me feel better?
These are the most common symptoms of the menopause: Hot flushes and night sweats

• Fatigue and mood swings
  
• Vaginal dryness and reduced lubrication
  
• Loss of libido (sex drive)
  
• Thinning of the lining of the vagina causing discomfort during sex and bladder irritability

Taking HRT will alleviate all these problems while you continue to take it, but there will probably be a recurrence when you stop. If you start taking HRT during the perimenopause and continue taking it through the time when your natural menopause occurs, you may find that the symptoms return with a vengeance when you stop taking oestrogen. However, the sweats don't seem to last as long.

Will it do me any long-term good?
HRT can help with many chronic and life-threatening conditions:

• Osteoporosis - loss of bone minerals. Bone mineral loss starts at around the age of 30 but accelerates at the menopause so that between the ages of 50 and 80 it drops by 30 per cent. When you are on HRT the rate of bone loss is reduced by half.
  
• Memory loss and Alzheimer's disease. There is growing interest in the possibility that oestrogen may help preserve short-term memory in women after the menopause and also slow the onset of and progress of Alzheimer's disease (twice as common in women compared with men).
  
• Skin and hair changes. After the menopause women notice thinning of the skin and hair - this is caused by loss of collagen which is the supporting tissue of the skin. HRT can delay this occurring.

Will I experience side effects?
HRT can cause side effects and has been linked to an increased risk of other diseases, so you should carefully weigh up the risks and benefits of HRT with your health care professional (GP, gynaecologist or menopause clinic staff) before deciding to take it. There are many HRT preparations available now, so you should be prepared to try several before you find the one that suits you best.

The most common side effects from oestrogen are irregular bleeding, breast tenderness, leg cramps at night, nausea and mild fluid retention. There is very little evidence to support the feeling that weight gain is caused by HRT; this is more likely to be caused by changes in lifestyle.

If you are taking progesterone cyclically you will have some monthly bleeding. Sometimes this is painful or heavy. When you are truly past the menopause you can take 'no-bleed HRT' which is preferable for most women. If you bleed unexpectedly, when you feel you should not, you need to see your doctor for further investigations to rule out serious disease.

How long should I take HRT?
There is no fixed time for taking HRT. If you are taking it to stave off hot flushes and associated problems then three-five years is a reasonable duration of treatment, unless your menopause came very early. If you are at high risk from developing osteoporosis or heart disease you may wish to continue for much longer. This has to be weighed against a possible, though small, increased risk of breast cancer in women who have been on HRT for more than ten years. Your doctor can advise how long HRT is likely to suit you.