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Sharon Walker - HRT
How HRT can protect women against much more than just the menopause
Hot flushes and a bad temper are just some of the symptoms caused by a lack of oestrogen, but replacing that hormone can have a wider reach

First, the bad news. Menopausal women are more likely to catch Covid-19 than their hormonally flush sisters. According to recent, yet-to-be peer reviewed research from the Covid Symptom Study, they are also more likely to suffer from lasting symptoms.

Add that prospect to the hot flushes, erratic weeping, night sweats and the myriad other grim symptoms that come with the menopause – there are 34 in total, according to Google – and it’s enough to make you scream. It’s likely down to oestrogen – or the lack of it – say the scientists. The sex hormone that keeps us moving along nicely through our fertile years, oiling the wheels of our sex drive, veins, brain, skin and much else besides, drops off a cliff somewhere around midlife, along with other hormones. With it, we lose our oestrogen resilience, a protective buffer that makes young women less vulnerable to many different health issues including viral illnesses.

But wait: could this also mean that taking HRT to replace that missing oestrogen might somehow protect menopausal women against the ravages of Covid? It’s just one possible preventative benefit of taking hormone replacement therapy, as you’ll discover…

Covid and other viral infections

Data from more than 500,000 women using the Covid Symptom Study app suggests that menopausal women are more likely to develop Covid than those still having periods, leading scientists to suggest that oestrogen could play a protective role.

“Nobody really knows with Covid,” says Dr Jan Toledano, a menopause specialist and founder of the London Hormone Clinic. “But one of the side effects of the menopause is an increased susceptibility to viral infections in general. Oestrogen plays a role in 500 processes throughout the body, including the immune system. There are oestrogen receptors on all types of immune cells – the ones that fight Covid infection – so it could be partly down to that.”

Since post-menopausal women are also at greater risk of serious heart disease and diabetes than those having periods, these factors will also increase their risk of severe Covid.

What can you do about it? 

  • Maintain a healthy weight to reduce visceral fat and the risk of a cytokine storm, when the immune system goes awry and the inflammatory response flares out of control. 
  • It’s also worth taking a vitamin D supplement, since trials show a link between Covid-19 and vitamin D deficiency.

Brittle bones

Risk of osteoporosis skyrockets after the menopause, gathering speed in our 60s and eventually affecting half of all women. “When we have plenty of oestrogen in our reproductive years, it helps build bone density, which peaks around the age of 30,” says Dr Sheila Radhakrishnan, consultant gynaecologist at the Royal Free Hospital. “To understand bones, think about spreading out a piece of gauze and that is actually like the protein matrix bone is built from. Oestrogen is responsible for the strength of the matrix and everything else, like calcium is deposited on that. In osteoporosis, the matrix is very weak and even the smallest fall, bump or even cough can give you a fracture.”

Our bones are constantly building up, breaking down and reforming, but after the menopause bone loss often outpaces the rebuilding process.

Osteoporosis is a huge problem. A broken hip has a one in five fatality risk within 12 months. A fracture in the neck of the femur is also serious. “You’re going to need an operation,” says Dr Radhakrishnan, “but sometimes it’s so bad, you can’t. So we really need prevent these kind of fractures.”

What can you do about it? 

  • Walking is good for the long bones of the thigh and the hip and any exercises involving the back muscles will build the spine, so do bar work in the gym and yoga or pilates. 
  • Diet-wise we need sufficient calcium and vitamin D, the other building blocks of bones, so opt for calcium-rich dark green vegetable like kale and greens and dairy. Oily fish a good source of bone-boosting vitamin D. It can be difficult to get enough from food, so you may need a supplement.
  • Osteoporosis is hereditary, so if you have a family history of fractures, you should seriously consider HRT. Early menopause, before the age of 40, also greatly increases the risk of brittle bones, while slender, small-framed women are also more vulnerable because they have less bone mass to start with. A bone density scan will help your doctor decide if you need treatment.

Coronary heart disease

The risk of heart disease shoots up after the menopause, and any woman who is unlucky enough to go through the menopause before the age of 40 is at double the risk. 

“Women normally lag behind men in terms of getting coronary disease, but after the menopause, they start to catch up,” says Professor John Stevenson, who is a consultant metabolic physician at the National Heart & Lung Institute and a trustee of the British Menopause Society. “By the time they are in their 70s, a woman’s risk is virtually the same as a man’s.”

What can you do about it? 

  • “HRT is by far the best preventive treatment for coronary heart disease in menopausal women,” says Prof Stevenson. “The sooner you start, the bigger the benefit. You are talking about a 50 per cent reduction in coronary heart disease for women on HRT. If you start treatment within ten years, you will get the best benefits, but you can even see some benefit by starting later.”
  • Diet and exercise are also part of the equation. Protect yourself by doing cardiovascular exercise two or three times a week, and by maintaining a healthy weight.

Type 2 diabetes

Men generally have a higher prevalence of diabetes than women, because they carry more dangerous visceral fat in their midsection – but as oestrogen drops, women become more apple-shaped too. Visceral fat is dangerous since it results in greater insulin resistance, when the cells stop responding to the hormone insulin this leads to excess sugar in the blood.

What can you do about it? 

  • Keep your weight in a healthy range and avoid refined sugars and simple carbs. “Some midlife women will also need to steer away from high-sugar fruits, such as bananas, and go easy on pasta and bread, as well as cakes and biscuits,” says Dr Toledano. “Things that they could eat no problem might now start to cause weight gain.”
  • Work to balance your blood sugar by structuring meals around protein, such as fish, tempeh or organic meat.
  • Reduce alcohol to sensible levels. Aim for 150 mins of aerobic exercise a week, and strength exercises twice a week.
  • Muscles become more sensitive to insulin after exercise, and it’s possible to reverse insulin resistance with an active, healthy lifestyle.
  • HRT can also help. “There’s good evidence that HRT reduces the onset of diabetes in post-menopausal women,” says Prof Stevenson.

Painful sex and urinary issues

“The pelvis is really sensitive to drops in oestrogen,” says Dr Toledano. “Often long before women realise they are menopausal, they might notice vaginal dryness, or painful sex. They might also experience irritation on passing urine and thrush.”

So why is this happening? “When oestrogen drops, the cells in the vaginal wall lose their structure and the cell layer that prevents friction is no longer as thick or moist.” Urinary tract infections and thrush also become more common as the pH of the vagina increases and the bugs that are normally kept in check proliferate.

What can you do about it?

  • “All of this is 100 per cent preventable,” says Dr Toledano. “But when women don’t get treatment for it, it gets worse and worse.”
  • As well as HRT, Toledano recommends a topical oestrogen cream that can be used directly on the vulva, such as Ovestin, which tends to be better for the lower part of the vagina and vulva; and Vagifem pessaries, which are better for the top part on the vagina.

HRT – What about the health risks?

Should we be concerned about breast cancer? After all some GPs are still reluctant to prescribe HRT, for this reason.  “There is a very small increased risk breast cancer with HRT, but the magnitude of the risk is slightly less than the risk of drinking one glass of wine a day,” says Prof Stevenson. “It’s a very, very small risk.

“HRT can speed up the growth of oestrogen-dependent tumours that are already there, but HRT does not elevate the risk of dying. If anything it slightly reduces the risk, possibly because it brings it out earlier and you are more likely to catch it. The other statistic to bear in mind is that women who are taking HRT have a significantly lower mortality risk of all causes, at the same age, compared to those who are not on HRT.”

The body identical forms of hormones –  oestradiol and micronised progesterone –  which widely prescribed on the NHS, reduce the risks.

If your GP can’t help with body identical HRT, the British Menopause Society has a nationwide list of menopause experts, NHS and private.

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