Why you might be able to stay on HRT for the rest of your life, writes DR PHILIPPA KAYE

Over the past few weeks I’ve written in these pages about potential downsides of staying on some common medications for too long – such as aspirin, certain acid reflux drugs and even antidepressants.

My message isn’t to stop – it’s vital not to make changes without proper medical guidance – but just because you’ve been on something for years, doesn’t mean you still should be.

There is one drug, however, that I’d give almost the opposite advice about, and that’s hormone replacement therapy, or HRT. For menopausal women, these medicines can be life-changing. And, frankly, too few take them – often because of misconceptions about side effects.

With any drug, before prescribing, we look at the risks and benefits. And with HRT, the positives usually vastly outstrip potential problems.

Yes, some kinds of HRT raise the risk of blood clots and breast cancer. For this reason, it’s not routinely recommended to women who’ve had breast cancer. Those who’ve suffered clots can still have certain types. 

We know the treatment also reduces the risk of osteoporosis and heart disease, and for these reasons alone it’s usually worth taking – quite aside from the improvement in quality of life, from better sleep, more energy, no hot flushes… the list goes on.

It also surprises patients when I tell them they don’t have to stop taking it, ever, if they so wish – as long as it’s safe for them to do so.

NHS guidelines say: ‘Most women stop taking HRT once their menopausal symptoms pass, which is usually after a few years.’

In reality, as with many medicines, you don’t just stop but gradually reduce the dose. But it’s perfectly acceptable to be on HRT for life – you just need to get an annual review to check blood pressure.

Older patients might be switched to a different type of HRT. Women who are on it longer-term might be given patches, gels or creams, as delivering oestrogen through the skin reduces the slight risk of blood clots to almost zero.

There’s also topical vaginal oestrogen, in the form of a gel, cream or pessary, which relieves specific vaginal symptoms. As this only acts locally, it can be used long term without risk.

Of course, if women choose not to continue taking it, we do have other medicines we can offer to help tackle specific symptoms. As before, my message is: talk to your GP and find out your options.

With this in mind, in the last part of my series, I’ll outline some other commonly taken medications that it might be time to rethink…

CRAMP DRUG COULD DO MORE HARM THAN GOOD

It never fails to surprise me that quinine tablets continue to be given for leg cramps, despite the fact that studies have shown it to be not all that effective.

For many patients, cramps are caused by dehydration, too much exercise or medication such as diuretics, given for blood pressure problems. Once these causes are tackled, the cramps often subside.

Taking quinine long term has been shown to cause a change in heart rhythm and, rarely, a drop in platelets, components of the blood involved in clotting – which can be extremely dangerous as it can lead to heavy bleeding.

After underlying causes of cramp have been ruled out, quinine should be used for a trial period of a month and stopped if there is no benefit. If there is a benefit, patients should be re-assessed every three months by their GP.

WHAT’S THE ALTERNATIVE?

For most people, the best way to prevent and treat cramps is to drink plenty of fluids to avoid dehydration and regularly stretch your calf muscles. But if you’re struggling, a lower-risk alternative called naftidrofuryl can be prescribed by the GP, and may prove more effective than quinine.

TAKE CARE WITH ANTI-INFLAMMATORIES  

All too often, patients are given a repeat prescription for non-steroidal anti-inflammatory drugs, such as ibuprofen and naproxen, when they are waiting for a hip or knee replacement. And many remain on them post-op, even after they have recovered. Long-term use of these drugs can cause kidney damage and, similar to aspirin, there’s a risk of bleeding in the intestines.

For those with inflammatory arthritis, a doctor may decide to continue a repeat prescription, due to its ongoing benefits.

Proton pump inhibitors – the very same thing I wrote about in my previous column – actually come in useful here, protecting the stomach against injury in those who have no choice but to keep taking the pills.

WHAT’S THE ALTERNATIVE?

Paracetamol is often a good option for pain relief, as are ibuprofen gels or similar. These are effective and have lower risks.

… AND THOSE POWERFUL PAIN MEDICATIONS

Roughly eight million Britons are living with chronic pain disorders, which can be utterly life-destroying. When over-the-counter painkillers like paracetamol fail to work, GPs may resort to prescribing stronger and stronger medications over time.

Quite often, drugs also used to prevent seizures in epilepsy, called gabapentin and pregabalin, are given as a last resort. But in my experience even these often fail to stop the pain.

And so patients end up getting all the side effects of painkillers, such as constipation, drowsiness and nausea, without the benefits. There is also mounting concern that these medications can be addictive. If there is no improvement after a few weeks on gabapentin or pregabalin, talk to your doctor.

WHAT’S THE ALTERNATIVE?

THE best option if you have chronic pain despite medication is to ask for a referral to a specialist pain clinic and gradually stop the painkillers. There may be alternatives, such as pain-relieving injections, as well as psychological therapy to help you manage the pain.

ARE YOUR BLOOD THINNERS OUTDATED?

Warfarin is a powerful blood thinner, usually given to people with heart conditions that put them at high risk of a stroke. It can be a difficult drug to manage: if the dose is too low, there’s a risk of clots. Too high and patients can suffer haemorrhages. Warfarin needs to be taken at the same time each day. And it requires regular monitoring with blood tests in hospital.

WHAT’S THE ALTERNATIVE?

YOU should never stop taking warfarin unless advised to by a doctor, but there are newer, not only easier to manage but often less risky medications available, called NOACs. These do not need the same level of monitoring. They are not suitable in every situation, but may be appropriate after discussion with your doctor.