Women are often given a range of reasons why they can’t have HRT, but are they correct? Dr Naomi Potter sets the record straight.

‘Too old’, ‘too young’, ‘you have migraines’, ‘you’ve had a clot’ – these are just some of the reason women are given by their doctor as justification for not prescribing hormone replacement therapy (HRT) to treat menopause symptoms.

Many women may sail through menopause with barely a symptom, but for others they can be debilitating. Yet, 44% of respondents to a poll by Harley Street Emporium said they had been turned away when they had asked their doctor for HRT.

GP and menopause doctor, Naomi Potter, says she hears this regularly from patients who end up in her clinic seeking help. Here she dispels some of the common reason women are given so you can have an informed conversation with your medical practitioner.

You can see the Instagram Live interview with Dr Potter here.

1.You can’t have HRT because it’s dangerous.

Wrong, says Dr Potter.

“I think this is a hang over from the Women’s Health Initiative study that came out 18 years ago [which implicated older forms of HRT with an increased risk of breast cancer]. GPs who were in practice then and are still in practice now probably have that hangover effect where the information that HRT is not dangerous hasn’t seeped through because it doesn’t it doesn’t grab headlines. To say ‘HRT is not as dangerous as we once thought’ isn’t quite as catching as a headline that says ‘HRT gives you breast cancer’ – so I think that’s one of the reasons why.

“Women may remember their mothers being taken off HRT and doctors remember the headlines, but the reality is that in most instances HRT is beneficial rather than harmful. It prolongs life, prevents death and morbidity from so many different illnesses. So to say that it’s dangerous is just not true – but we just need to get that across to people.”

2. You can’t have HRT because you have a history of blood clots.

It depends, says Dr Potter.

“If you have oestrogen delivered through the skin using patches or gels, there is no known increased  risk for clots or DVTs or pulmonary embolisms. In women with a history of clots, I would always delve much more deeply into the history of that clot. I would discuss it with a haematologist. I ask has the women had a clot that was provoked (eg a long plane flight), do they have a clotting disorder? Often women with clotting disorders may be on anti-clotting medication – in which case it would be fine to have HRT. If it’s provoked, such as from a long flight, then it could be excusable. Basically, you just have to take a really good history and discuss it with colleagues, and often you’ll find women can take it. But I would stress here that it should be transdermal – that is through the skin rather than orally.”

3. You can’t have it because you have migraines.

Wrong, says Dr potter.

“Women who have migraine with aura shouldn’t take the contraceptive pill, but it’s a different oestrogen at a much higher dose. Women who have migraines with aura who want to take HRT can, but we often just use a bit more caution. Migraines can get worse toward menopause and during perimenopause and HRT can make that better, but we tend to start gently and see what happens with those migraines. If they got worse or you had new auras then we’d consider changing it or tweaking it. You’d look a little harder at it. But, no, migraines should not stop you from having HRT.”

4. You can’t have it because you have high blood pressure?

It depends, says Dr Potter.

“That just seems bonkers to me. Why are they not treating the high blood pressure? It’s topsy-turvy. If you’re perimenopausal or continuing into the menopause HRT is cardio-protective and it helps keep blood vessels soft and flexible, so why would you not give it? If you’re 65 or 70 and have high blood pressure then you have a cardio-vascular risk and that may be a reason for saying no, but if your perimenopausal or not far past menopause, then there is no reason why you shouldn’t have it. Treat the high blood pressure and have the HRT. But every situation is different, it depend on age and cardiovascular risk and that’s why you treat people as a whole. Treat the blood pressure, it’s not an excuse to say no.”

Does the blood pressure have to be controlled before you start?

“If its very high, yes, you’d want to find out why and  bring it down, but in border-line cases you’d start HRT simultaneously with the treatment for blood pressure.”

5. Your symptoms are because of something else or aren’t related to menopause.

It depends, says Dr Potter.

“I call menopause a master of disguise. It’s really hard when you have someone in front of you who doesn’t have the obvious symptoms like hot flushes, night sweats and period changes at 49, especially when it’s symptoms that can be serious like heart palpitations or shortness of breath, you are obliged to investigate them in the same way as some neurological symptoms need to be investigated. But, it doesn’t preclude you from digging a bit deeper and asking the question, ‘could this be the menopause?’ and often you can treat the symptoms with HRT while you’re waiting for the other specialists.

6. You can’t have HRT because your blood hormone levels are normal.

Wrong, says Dr Potter.

“You never treat a number. You ask how they’re feeling – if they’re feeling fine then you probably wouldn’t do anything. But if they’re feeling symptoms you’d treat them. Hormone levels in the blood fluctuate so blood results aren’t always a great indicator of when to treat. It’s the way you feel that matters.”

“If your bloods are normal, a little augmentation to get the symptoms under control is fine. You don’t want to be giving bucket loads but a little bit is safe to give to relieve symptoms and can be adjusted until you get it right.”

7. You can’t have HRT, you’re too young.

Wrong, says Dr Potter.

“That’s a biggie. Even women who are 48-49 get told their too young, but you’re never too young. You can go through menopause in your teens – so you’re never too young. If you suspect it, and you’re under 45 get some bloods done. But even if they’re normal you can still be perimenopausal because you’ve just caught the bloods when the levels are high, and they fluctuate a lot. If you repeatedly find you’re banging your head against a brick wall with your doctor then you really need to see a doctor who specialises in menopause.”

(It’s important to note here that early – before 45, or premature menopause – before 40, means women are without the protective effect of oestrogen on their blood vessels, heart, brain and bones for longer than women who go through menopause at the average age of 51-52. So, it is important if you are under the age of 45 that you seek medical advice. Menopause is said to have occurred if you’ve gone 12 months without a period.)

8. You can’t have HRT because you’re too old. 

It depends, says Dr Potter.

“Ideally you start in the perimenopausal window, and the rationale behind that is that your arteries are still nice and flexible. Once you lose your oestrogen your arteries are more prone to developing a lining of fatty plaque and the theory is that if you then add oestrogen you can destabilise those plaques and that could make you more prone to having a heart attack or stroke. So, that’s the reason why we want to get in there while they’re still nice and flexible.

“In reality though I find most women are entirely competent to make informed decisions about their own health so if you have women in their 60’s and they are pushing through with the menopause symptoms and are struggling and can’t deal with anymore, then they can have HRT. If you’ve got a non-smoking, fit, slim woman who went through the menopause in her 50’s then you be entirely justified to start on a low dose and see how that goes.

“If on the other hand someone is obese, a smoker and unfit, then you’d have to counsel them on the risks. But even then – who am I to say ‘you can’t have it’ – to make that decision about somebody else’s quality of life. Some of these women are desperate, so I’d always be open to discussion.”

9. You can’t have HRT because you’re still having periods.

Wrong, says Dr Potter

“No, just no. You can still have periods and be hugely symptomatic. So, no, that’s just wrong.”

10. You can’t have HRT because your periods have stopped.

Wrong, says Dr Potter.

“No, you can, but it’s related to how long since you’ve stopped having periods. But, yes, you can have HRT when your periods have stopped.”

11. You have to stop HRT after 5 years

Wrong, says Dr Potter.

“You don’t have to stop after 5 years and this is especially important for younger women to note because you’re replacing what would have been there naturally unto they reached menopause in their early 50’s anyway. So, no, if your GP says you must stop, I’d question that and have a discussion.”

So what do you do when your GP says ‘no’?

“You’ve got to go back and demand it or see a GP who knows more about,” says Dr Potter.

Things that could help during your consultation:

• Take an advocate into the consultation with you – a family member or friend to help support you
• You can refer your GP to the NICE Guidelines on HRT 
• You can refer them to the British Menopause Society
• You can refer them to Dr Louise Newson’s easy prescribing guide

Alternative places to find help:

• You can ask for a referral to a NHS Menopause clinic
• You can visit a Women’s Health Centre or Sexual Health Centre in your area
• You can ask to see a different GP in the practice or ask if there is a women’s lead in a clinic
• You can change practices
• You can see a private menopause specialist.

If you aren’t happy with the way you’ve been treated you can:

• You can write a letter of complaint to the practice
• You can write a letter of complaint to the General Medical Council (GMC).