However, there are two factors that may prevent you ever getting that far: one is that the initial side-effects put you off the whole idea of HRT and you decide just to give up without trying different types; the other is that your doctor may be unable or unwilling to suggest alternatives for you. With the best will in the world, no doctor is able to remember every variety of every form of treatment that is available for all his patients, so he has his ‘favourites’ that he uses most of the time because he knows they work well. If one of them doesn’t work, he then has to start referring to the various publications that list different forms of treatment, and just hope that the one he chooses is the right one for that particular patient. Usually, when the average general practitioner suggests that HRT may be the answer to your menopausal problems, he will almost certainly prescribe his ‘favourite’ preparation because his experience has shown it to work with most of his patients. It may well work for you, or it may not. It may relieve your symptoms without producing side-effects, or it may not. However, if this one doesn’t help, another one probably will.

The number and types of HRT preparations available have increased enormously in the last 10 years, and are still increasing each year. Those most commonly used in the UK are in the form of tablets, patches and implants, all available in different strengths. Less commonly used here, but varying in popularity in other countries, are creams, gels, pessaries, suppositories and injections.

Some preparations come as combined ‘calendar packs’ of oestrogen and progestogen, others come with each hormone packed singly. If you are taking a combined pack, and can’t get the balance of oestrogen and progestogen right to give relief of symptoms without side-effects, your doctor can prescribe the hormones separately to get the right dosage of each. Both hormones are available in different strengths from different pharmaceutical companies, which allows great flexibility and should make it possible for you and your doctor to get it right.

With the exception of implants, any treatment can be stopped at any time, or the dosage can quickly be adjusted, but you will probably get a return of menopausal symptoms if you stop suddenly.

The first decision you and your doctor will make is whether HRT is suitable for you at all. The next thing to consider is whether you take HRT in an oral form, that is as tablets, or whether a non-oral route (patch, implant or cream) would be better.

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Oestrogen hormones

The change in the oestrogen hormone profile is a matter of altered balance between the various types of oestrogen produced.

OESTRONE This is the most constant form of oestrogen circulating in the bloodstream from childhood onwards. In postmenopausal women (with or without ovaries), its level is about the same as in the early part of the menstrual cycle before menopause. (Much higher levels occur at mid-cycle and in the late part of the cycle.) It is mainly produced from androgens (described later) in muscle and fat tissue. This is why body fat is a major factor in determining oestrogen levels in postmenopausal women. The ovaries (if present) produce some oestrone too.

OESTRADIOL Oestradiol is the most powerful of the oestrogen hormones and it has the greatest influence on the function of the heart and blood vessels, bone growth, brain metabolism, reproduction and menstruation. A postmenopausal woman (with ovaries) has about half the level she had in the early part of her menstrual cycle, which is about one-tenth of the average level for the whole menstrual cycle. Oestradiol levels of women without ovaries are somewhat lower.

Oestradiol is mainly converted from oestrone in fat and muscle tissue throughout the body, and from androgens in the adrenal glands — two small organs above the kidneys. Hot flushes and night sweats typically correspond with low levels of oestradiol.

OESTRIOL A third type of oestrogen produced in large amounts by the placenta during pregnancy is called oestriol. It is a weak form of oestrogen and is converted from oestrone. It is present in measurable amounts both before and after menopause in women with and without ovaries.

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Sticking to an exercise plan for a couple of weeks does wonders for morale and, instead of inventing excuses to avoid exercise, you will find it becomes something to look forward to with pleasure. In working out an exercise plan, there are some important factors to consider.

- The aim is to make regular physical activity part of your life, so choose something you enjoy — something that is convenient, interesting, can be done independently and is realistically achievable.

- If you are over forty or have high blood pressure, diabetes or a known heart problem, check with your doctor before you start your plan. A preliminary health check is sometimes advisable anyway, especially if you intend working up to strenuous forms of activity.

- Always warm up for at least five minutes before exercising, and cool down after it. Include some stretching exercises in the warm-up to reduce the risk of muscle strains.

- Never exercise if you are not feeling well. If illness interrupts your plan, resume at a lower level than before and slowly build up again.

- Tell your doctor about any symptoms you experience during exercise, particularly chest discomfort or undue dizziness.

Any woman at midlife who smokes should consider giving it away. If you are a typical twenty-cigarettes-a-day smoker who quits, you will experience changes something like these:

- Between twelve and twenty-four hours after stopping, you will start to feel less short of breath when you exert yourself.

- Within a couple of days you will begin to feel and smell fresher. Your taste buds will come alive and your sense of smell will return.

- Within three weeks your lungs will be working better and physical activity will be easier.

- Within two months, blood flow to your limbs will improve and you will have more energy.

If you have tried quitting repeatedly without success it may be time to consider a Quit group, which will provide a sound educational approach and ongoing support.

Finally, help for lethargy and depressed moods may be obtained from plants that contain oestrogen-like substances, called phyto-oestrogens. They seem to have less powerful effects than the oestrogens used in HRT, but are worth trying. Plants with a considerable amount of oestrogen-like content include alfalfa, aniseed, basil, caraway, chervil, the common beans, fennel, fenugreek, hops, licorice (which should be avoided by people with blood pressure problems), parsley, red clover, sage and soya bean sprouts.

Foods containing smaller amounts of oestrogen include fresh corn, corn oil, green peas, cabbage, wheat bran and wheat germ, rice bran and milk. The list is so long that you should have no difficulty finding something you can add to salad, vegetable or other dishes each day.

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It is still unclear to what extent cardiovascular disease and osteoporosis are due to oestrogen deficiency and to what extent they can be remedied by HRT.

There is good evidence that heart disease risk factors for men, on whom most research has been done, cannot be applied holus-bolus to women. Since the risk of heart disease is figuring more and more among the reasons why doctors prescribe HRT, this raises questions about the basis on which such decisions are made.

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The amount of hormone absorbed from the implant varies according to how long it has been there, its position (for example, more hormone is absorbed if the implant is in the upper arm of a swimmer than if it is placed in a buttock), its depth under the skin (the deeper the implant, the greater the absorption), physical activity levels (exercise increases blood flow) and the presence of inflammation or scar tissue around the implant.

Women who find implants useful include those who for one reason or another cannot tolerate oestrogen in pill or patch form, and those needing large doses of oestrogen. These advantages may offset a common problem with implants, which is that the dose of hormone entering the body is initially high and reduces with time.

For example Natalie, a young woman who had an artificial menopause following cancer treatment, required relatively large amounts of oestrogen to alleviate recurring bouts of severe hot flushes. She found the implant both more convenient and more effective than pills, although she experienced sore breasts for some weeks after the implant was inserted (a higher than average hormone dose was entering her body), and a return of flushes as the time for a replacement implant approached (the hormone dose released by the implant had dropped significantly).

Many doctors believe that oestrogen implants should not be used as first-line HRT in women who have a uterus. This is because implants deliver substantially higher levels of oestrogen than other HRT formulations (at least part of the time) and, while helping women to feel wonderful, these levels can greatly increase the risk of severe, uncontrollable bleeding and possible hysterectomy. According to Dr John Eden from the University of New South Wales, some women on oestrogen implants feel a euphoria similar to that experienced by men on anabolic steroids. ‘But women pay a price if they have a uterus; they run the risk of heavy, uncontrollable periods.’ In the case of Margo, a patient with fibroids who had an implant inserted, the bleeding was so heavy that hysterectomy was the only option. ‘You rarely see this with other therapies, because the oestrogen levels are relatively low’, Dr Eden says. ‘Women with fibroids may get irregular bleeds, but you don’t see the activation and growth that you may get with an implant.’

It is extremely important that any woman with an intact uterus who is using an oestrogen implant realises the necessity of teaming progestogen with it for one to three years after the last implant is inserted. Implants continue to release small amounts of oestrogen for a very long time after their ‘use by’ date. It is unwise to discontinue the progestogen until two to three months after withdrawal bleeds have stopped.

An advantage of implants is their convenience, with no need to remember a daily pill or twice-weekly patch.

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