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    You are here : Home » About MS » Health Consequences of MS » Hormone Replacement Therapy

    Hormone Replacement Therapy

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    Hormone Replacement TherapyHormone Replacement Therapy andMultiple Sclerosis

    This article has been written to explain what the female menopause is, the possible problems it can bring, its treatment with hormone replacement therapy (HRT) and the possible benefits and risks associated with the use of HRT specifically in relation to women who have MS.

    It is also possible that some men may experience a mid-life upheaval similar to that experienced by women. This has been called the 'male menopause'. However, the cause of the male menopause is different from the cause of the female menopause and has different treatments. Therefore, this article will not cover the male menopause.

    The menopause and HRT is a complex issue and there are a number of other risks and benefits associated with HRT use in all women. In addition, there may be personal risks which are specific to one woman and not to another. Also, various lifestyle factors such as exercise, diet and smoking habits can all play a part. It is therefore important that a woman discusses her medical background with her doctor, who will then decide whether or not she is suitable for HRT. However, if a woman does not want to take HRT, or if her doctor recommends that she should not take HRT, then there are alternative medications available for the management of menopausal symptoms, such as drugs to treat hot flushes and hormone and lubricating creams to relieve vaginal dryness.

    What is the menopause?

    The term 'menopause' really refers to the last menstrual period that a woman has. However, it has come to mean the stage of a woman's life when the ovaries (the glands which produce eggs and the sex hormones oestrogen and progesterone), gradually stop working and the body slowly gets used to the lower levels of hormones. This time of change is also known as 'the climacteric'. It can take some time for the body to adapt to these lower levels of hormones and various changes may occur as a consequence of this change from high to low levels.

    The changes are not sudden and may take place over a number of years. They usually start when a woman reaches her middle or late 40's, but may begin as early as the late 30's. Periods usually become irregular or infrequent, before they eventually stop altogether. However, even when a woman thinks she may have stopped having periods, she should continue to use contraceptive precautions for some time, because it is quite possible that her periods have just become irregular and she may still be at risk of pregnancy. She should ask her doctor when it is safe to stop using contraception.

    Symptoms of the menopause

    Various symptoms can occur as a result of the decrease in the levels of oestrogen. These symptoms may vary from one woman to the next and it is important to remember that few women suffer from all of these symptoms and that some women go through the menopause with no problems at all.

    The symptoms of the menopause can be divided into short-term and long-term symptoms.

    Short-term menopausal symptoms

    The earliest symptoms of the menopause almost always start some considerable time before periods have stopped. They are usually more noticeable after periods have stopped and may continue for several years. However, they are called short-term symptoms, because they always stop eventually. Many of these short-term symptoms can interact, one making another worse.

    Hot flushes and sweats
    The most common of these short-term symptoms are hot flushes and sweats, which can be embarrassing if they happen in public. The hot flushes are unpleasant sensations of heat beginning in the face, neck, head or chest and spreading in any direction, sometimes over the whole body. Often the face becomes reddened and this flushing is often accompanied by drenching sweats, particularly at night, which can lead to disturbed sleep. The hot flushes and sweats may sometimes be accompanied by fainting, headaches and palpitations.

    Emotional changes and stresses
    Emotional changes may also occur in some women and these may include anxiety, irritability, depression, poor memory and concentration and loss of self-esteem. Coping with these symptoms is often made more difficult for a woman by emotional stresses, such as the departure of children from the family home. Even the knowledge that she can no longer have any more children may add to the problems.

    Vaginal problems
    Several areas including the breasts, uterus (womb), fallopian tubes, ovaries and vagina are affected, due to the reduced levels of oestrogen. Because the womb is no longer needed, it begins to shrink. The vagina shortens, narrows, and loses its elasticity. The lining becomes thin and dry, which frequently makes intercourse painful. This, in turn, may be a cause of emotional stress in a sexual relationship. These physical vaginal changes can cause an increase in bacterial infections. Oestrogen deficiency can also contribute to loss of sexual desire after the menopause.

    Bladder and urinary problems
    The muscle that controls the opening of the bladder may sometimes weaken, resulting in leakage of urine, especially when the bladder is under pressure, e.g. coughing or laughing. The urethra (the tube which carries urine from the bladder to the outside) shrinks and this may lead to symptoms such as a sudden urge to pass water (urgency), the need to pass water more often (frequency) and pain and difficulty on passing water.

    Changes to the skin and hair
    The appearance of the skin and hair also changes. There is a loss of collagen (a protein found in the skin) and the skin becomes thin and dry, with loss of suppleness. Thinning and dryness of the skin mean that it is more likely to itch or bruise. In addition, there may be a reduction in hair growth or quality.

    Long-term menopausal symptoms

    In contrast to the short-term changes, long-term changes usually only become noticeable at a later stage, progressing with age, and result from a long-term lack of the hormone oestrogen. Various parts of the body may be affected by the long-term deficiency of oestrogen.

    Osteoporosis (bone thinning)
    Osteoporosis is a major long-term result of oestrogen deficiency. Oestrogen is important in keeping the bones strong and when the levels of oestrogen fall, the bones start to become thinner and weaker. This process is called osteoporosis, or "brittle bone" disease, and can result in the development of fractures. Backache and joint pains can also occur and the muscles can weaken.

    Changes to the heart and blood vessels
    Oestrogen also seems to be important in protecting the blood vessels. During early and middle life heart attacks and strokes are much more common in men. However, after the menopause they quite rapidly become as common in women as they are in men.

    Hormone replacement therapy (HRT) - What is it and what does it do?

    Hormone replacement therapy (HRT) simply aims to replace the oestrogen that is no longer being produced by the ovaries. The oestrogen in HRT is similar to that which is produced naturally by the body, and so is called a 'natural' oestrogen. In addition to replacing the lost oestrogen, some HRT preparations also contain the hormone progestogen, which helps to protect the lining of the womb. Progestogens may be added as a course of a number of days at the end of each cycle of oestrogen, or continuously with the oestrogen.

    The types of HRT available

    Unopposed oestrogen therapy
    This type of HRT only contains oestrogen and is designed for use only in women who have had a hysterectomy. The hormone is normally given continuously (i.e. every day).

    Sequential combined therapy
    Oestrogen alone is given to a woman for the first part of the cycle, followed by a combination of both oestrogen and a progestogen for 10-14 days. Menstrual bleeding (a period) usually occurs towards the end of the monthly cycle, or the beginning of the next cycle.

    Continuous combined therapy
    Both oestrogen and a progestogen are taken every day. With this type of HRT preparation, there is normally no menstrual bleed.

    Long-cycle HRT
    With this type of HRT, oestrogen is given for three months with a progestogen added for the last part of the third month. Menstrual bleeding will normally occur towards the end of the third month and beginning of the next (fourth) month, i.e. only four times a year.

    Routes of administration of HRT

    Although there are many routes of administration, in practice only four are in common use in this country: oral (tablet), transdermal (patch, gel), subcutaneous (implant) and intra-vaginal (rings, pessaries and creams). There is a choice so that a woman can decide which route is most suitable for her. If a woman feels that the type of HRT given to her by her doctor does not suit, then she should return to discuss this matter with her doctor as there are a wide range of HRT products available.

    What are the possible benefits of taking HRT if you are a woman with MS?

    Effects of HRT on the short-term symptoms

    Hot flushes and sweats
    Symptoms of MS can worsen for short time (sometimes called a pseudo-attack) and can be brought about by changes in heat. For example, a hot bath can have a major effect on a person's ability to function, perhaps making them too weak to get out again until the water has cooled down. It is not known why this happens, but it is known that heat can interfere with nerve signals passing along the nerve fibres. There is a possibility that menopausal hot flushes, which result in an increase in body heat, could worsen the signs and symptoms of MS for a short time. The hot flushes can be prevented with hormone replacement therapy and, therefore, HRT may help control unwanted temporary attacks. The night sweats which occur with hot flushes can also be very troublesome. Some women have to get out of bed to open a window, change items of clothing or have a cold shower in order to cool down. HRT can help to prevent night sweats and a good night's sleep is particularly important to people with MS, who often suffer from fatigue.

    Emotional changes and stresses
    Depression is fairly common in people with MS and, therefore, the depression which can occur at the menopause would not be very welcome. HRT may also have a positive effect on a woman's mood.

    Vaginal problems
    Some women with MS may have problems during lovemaking, which may result from a number of factors. One factor is a dry vagina, resulting in difficult and painful sexual intercourse. Menopausal women may also find lovemaking to be painful which can sometimes lead to problems within their relationships. Oestrogen can help to make the lining of the vagina thicker and healthier and also help to relieve the dryness, making lovemaking much more comfortable. HRT may therefore help to prevent worsening of any sexual problems that may already exist.

    Bladder and urinary problems
    Bladder and urinary problems can be uncomfortable and embarrassing for some people with MS. These disturbances may also happen during the menopause. Oestrogen therapy may help such menopausal problems, but cannot always compensate for physical damage (e.g. from childbirth) or nerve damage due to MS.

    Appearance of the skin and hair
    Some people with MS may experience bruising or pain in their joints, muscles or limbs, as a result of poor co-ordination or increased weakness. Changes in strength and co-ordination can mean there is a greater chance of getting arthritis. HRT has been shown to be of benefit in menopausal women who have joint and muscle pains and arthritis. Therefore in women who have MS, HRT may help to alleviate additional pains and aches. In the more severe forms of MS, it is possible to not feel pain in the limbs, or to be unable to move the limbs because of spasticity or weakness. In these situations, pressure sores on the skin may develop. These sores often start as blisters, but if left alone can become worse. HRT can increase the thickness and collagen content of the skin and so may have a beneficial effect in preventing or helping pressure sores to heal. HRT can also improve the appearance of the skin and hair, helping the woman to look and feel healthier. Feeling positive about yourself can be of great benefit to the body and mind. HRT may therefore not only improve physical condition, but may also contribute to general well-being.

    Effects of HRT on the long-term symptoms

    Osteoporosis
    With increasing age, there is a decline in new bone formation and an increase in bone loss. This can cause an increase in broken or fractured bones. In addition, lack of exercise can also lead to loss of bone strength. People with MS may also be more prone to osteoporosis, due to previous weakness and strains of the joints and bones, lack of exercise due to disability, or also due to steroid therapy which can weaken bones. HRT has been shown to prevent bone loss and to help prevent the development of osteoporosis. HRT may therefore be beneficial in women with MS who already have some bone loss.

    Decreased mobility
    There have been a number of published studies which have looked at the relationship between HRT and the development of blood clots in the veins and in the artery which connects the heart to the lungs. Some studies have suggested that HRT increases the risk of such events, whereas others have shown no risks. Other factors which can increase the risk of developing a blood clot include decreased mobility, increasing age, being over-weight and smoking. There is a possibility that a person with MS may be unable to move around as much as before. In this situation, the person is at an increased risk of developing a blood clot, because their blood is not circulating as well as it once used to. If this person with MS is also taking HRT, then they may be at an even higher risk of developing a clot.

    Other disadvantages

    Even if a woman's periods have stopped before she starts to take HRT, it is likely that she will start to have regular bleeds again, depending on the type of HRT she has been given. Some women may find this troublesome or unacceptable, especially if they have MS, as there may be occasions during the course of the disease when a woman may require help from either her partner or carer, which can sometimes be an embarrassing or uncomfortable situation. However, there are several HRT preparations available where a menstrual bleed does not occur every month (e.g. continuous combined and long-cycle HRT), and these women may therefore find these types of HRT preferable.

    What the experts say

    There is very little information which has been published on the use of HRT in women with MS. A pilot study by Drs. Smith and Studd, at King's College Hospital in London, has suggested that loss of the hormone oestrogen at the menopause may cause MS to worsen and that replacement of the oestrogen may have the opposite effect. However, the authors also indicate the need for further research to clarify the effects of the menopause and HRT upon MS.

    In Summary

    As multiple sclerosis is often characterised by relapses and remissions, it is difficult to determine whether or not drugs have had any influence. The possible risks and benefits for women with MS taking HRT are therefore currently uncertain. The decision as to whether a woman with MS should take HRT or not, therefore, always needs to be decided with the help of her doctor, taking into account all the issues previously discussed.

    People ask...

    • Will it make my MS worse?
    • Could it make my MS better?
    • Does having MS mean that HRT may be less effective?
    There really is no MS based research information on these questions, which means that right now there is no objective evidence one way or the other and therefore no source of objective answers. In this situation, any answers must appear to be evasive, so it is understandable that many people experience a degree of confusion about the effects they might expect.

    We also have information onour Hormones page.

    Multiple Sclerosis Resource Centre (MSRC)

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