HRT - from bones to your brain - what can it help

Fiona Clark

Menopause, bones and sex – how HRT could help. Dr Sarah Ball explains.


Dr Sarah Ball is a GP with a special interest in Menopause who works with Newson Health. Here she explains how HRT could benefit women in a myriad of different ways. You can see the original interview here.

Brittle bones

Bone density and the risk of scanning?

After menopause our bone density decreases. This puts us at an increased risk of fractures which can in turn lead to decreased mobility and independence and a decline in health. A scan, known as a DEXA scan, can determine your bone density. But is the scan safe?

“DEXA scanners are beautifully safe and the risk of radiation is tiny,” Dr Ball says.  “It’s not like an x-ray which has a lot of radiation. Our bones can get extremely fragile and we can lose a lot of density after menopause without even knowing it – it’s a painless condition.

“Often the first things we know about it is after we’ve tripped over the curb or fallen over the dog and we break something and then there’s an affect on mobility and a deterioration in health. But when you’ve got oestrogen on board your bones are highly likely to be able to remodel. Our bones are always breaking down and remodelling but after menopause the breaking down outweighs the remodelling, but the oestrogen balances that out. Obviously calcium and vitamin D and weight bearing exercise are important for bones, as well as not drinking or smoking.

“The good thing about a DEXA scan is that you can find out if there is a problem and take the appropriate steps and improve your bone density. If you have a history of osteoporosis in the family you can ask to have a bone scan on the NHS.”


Sex – how important is testosterone?

During the lead up to menopause (perimenopause) or after menopause women often find they’re lacking in energy and their libido declines. Can testosterone help?

“It’s extremely important. We have quite a lot of testosterone in our 20-30’s and it declines with age. It is important for our libido and often we may not notice it declining when we’re in our 40’s as we’re busy with work or families. It’s also important for our brain function and our energy levels and it does have an effect on our mood as well. So when it drops away when we reach menopause it is kind of ‘exposed’ if you like.

“Sex is really important. We know that men who have regular sex do better in their long term health. No one has ever done the same studies on women but the same has probably got to be true. I know many women may think sex isn’t their top priority in menopause and, there are certain prerequisites for it.

“Having a dry vagina will be a problem, similarly if you have water works issues that may put you off – you don’t want to be leaking. You need to like yourself – if you’ve gained weight or lost self-esteem, or if you want to kill your partner because you find them so irritating – that’s not going to put you in the mood either. So, oestrogen is good at putting those building blocks in place – evening your moods, helping your vagina and water works – but there’s one final ingredient and that’s sex drive and that usually comes from the testosterone.

“So we like to start women the oestrogen initially and after about 3 months if that’s still missing we’d consider introducing it to help with the libido.”


Do you need to have a blood test before being prescribed testosterone?

Dr Ball says, no, you do not have to have one but some doctors like to establish a baseline so they can measure again later one to see where you’ve come up to and how your symptoms have responded to that dose.


Your brain and dementia

Dementia – can HRT help prevent it?

“This is the mega-emerging area of menopause. We know HRT is great for our hearts and we have thought for a while that it is good for our brains and we’re now getting more and more momentum on this. My colleague Louise Newson did a brilliant Instagram Live with Lisa Mosconi who wrote the ‘The XX Brain’. It’s about how the seeds of dementia are laid in perimenopause and how oestrogen is the ‘master regulator’ – in her words – of our brain function, so if you can get it in the perimenopause or soon into the menopause you will go a long long way toward reducing your risk of dementia. Two thirds of all dementia cases are women and it’s a dreadful disease and it’s often preventable, but you have to prevent it early. There is no point in waiting until you’re 70 to think about your brain. If you can start early and prevent those plaques that cause dementia from forming then you’ll be better off.


Menopause Tips 

What can you do about heavy periods in perimenopause?

“Very heavy periods are common in perimenopause. Its important to make sure there is nothing sinister going and if that’s been done usually the most effective way to treat heavy bleeding is with a mirena coil. They can help control bleeding and they can be the progesterone part of your HRT.”


Painful smear tests – what can help?

If you’re struggling with smear tests one thing we suggest is to use a topical oestrogen for about 6 weeks prior to the test. What’s really important is that practice nurses who have women coming in every 3 to 5 years and they could be our angels here because they have a great opportunity to talk about menopause.

“I’ve had ladies tell me they been told to have a shot of whisky or to take a diazapam, and it makes me so cross because these women just need a bit of help. So we would normally say, use the ovestin cream or a vagifem pessary for about 6 to 8 weeks and then come back for the smear.”


Can you use it externally for vulval itching/burning?

Yes, Ovestin is a great one for this because it’s a cream its easy to use on the outside.


Menopause Myths

If I have high blood pressure I can’t have HRT?

Wrong – you can have HRT. Normally women’s blood pressure goes up around menopause because they’re so stressed and feeling so awful. If you do have high blood pressure it should be treated but it doesn’t mean you can’t start HRT or that you have to come off HRT. And the body identical HRT with your transdermal oestrgoen and micronised progesterone  is beneficial for blood pressure.


If I have a history of DVT’s I can’t have HRT?

It depends. If you have a history of DVTs you’d try to avoid the oral and synthetic forms of HRT but we know that transdermal oestrogen is ok. However, that is something that should really be dealt with by a menopause specialist.


I can’t have HRT if I have migraines?

Yes, you can but you really want to stick to the best form of HRT. Most migraines are caused by fluctuating hormones, so if you can stabilise the hormones you can reduce the migraines. So stick to the transdermal oestrogen and the mirconised progesterone or a mirena coil – it is very good as it’s very stable with hormone levels. The reason why this sometimes gets confused is because you can’t have the combined pill if you have  a certain type of migraine but the modern HRT that is body identical is very different to the synthetic contraceptive  pill.

You can read more about Dr Ball and book directly here.

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