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‘Subcutaneous’ means ‘beneath the skin’, and this is how the implant works. A tiny pellet, about the size of the tip of a lead pencil, is inserted under the skin of the lower abdomen. The technique is simple, takes about 5 minutes, and can often be carried out in a general practitioner’s surgery under a local anaesthetic, leaving little or no mark. The big advantage of an implant is that, once it has been inserted, you can forget about it for several months. No need to take tablets or change patches. Unlike other forms of HRT, it can also be combined with small quantities of the hormone testosterone if your doctor thinks this would help you. Although testosterone is the male hormone, it is also produced in the ovaries of women, so it is not unnatural to receive it. It can be helpful for women who have certain psycho-sexual problems, a drop in libido (interest in sex), much reduced energy levels or severe loss of confidence. Being a male hormone, it may cause a slight increase in facial hair.

Nearly all women with implants gain relief from hot flushes, and three-quarters gain relief from depression. Improved collagen levels lead to better skin and stronger bones.

As with the patch, the oestrogen is released straight into the bloodstream, and avoids the digestive system, so a lower dose can be used, giving fewer side-effects than oral HRT. There is no question of forgetting to take it, or of suffering the skin irritation some women get with the patch. It also avoids the necessity of ‘popping a pill every day’, which is what many women don’t like about HRT; until it needs replacing you can forget you are using it at all. It also offers good protection against osteoporosis, except at the lowest dosage.

The implant does not last forever, and it will need to be replaced every 4-6 months, depending on when the level of oestrogen in the implant falls and the menopausal symptoms return. You will need to return to your GP or gynaecologist for a replacement Although this may seem rather a nuisance, it does ensure that you are regularly monitored, and a check-up may also detect irregularities that might otherwise have gone unnoticed.

This condition is called tachyphylaxis, and has received unfavourable publicity following reports of some recent research into it One or two newspapers decided that it suggested the women were ‘addicted’ to oestrogen, because they needed ever-higher doses at ever-more-frequent intervals. This type of reporting is irresponsible and unjustified, but many newspapers seem unwilling to present HRT in a neutral light, choosing either to extol its ‘sexy forever’ image or to condemn it for exaggerated side-effects.

The problem of tachyphylaxis should not, however, be dismissed as irrelevant, because for the small minority of women affected by it, it can be a serious disadvantage, and one for which doctors can’t at present agree on a solution. Simply to refuse further HRT in any form produces a return of the symptoms and much suffering; it may also be a dangerous approach in women whose falling oestrogen is producing feelings of depression. However, to replace the implant at ever-closer intervals in a woman whose oestrogen level may be well above normal is not desirable either. It is obviously an area in which more research is needed. If you feel you are developing this condition, talk to your doctor about a gradual withdrawal from this type of HRT, as a different type might be the solution for you. He may decide to monitor your blood oestradiol level regularly, and to replace the implant when it falls to a certain level.

The second disadvantage of the implant concerns those women who still have a uterus and who need to take progestogen. The raised levels of oestrogen from an implant are eliminated from the body only very slowly, so that even once you have stopped using implants the lining of the womb continues to thicken every month and you need to continue taking progestogen until this stops happening.

Implants come in three different strengths (25, 50 and 100 milligrams); the higher dose lasts longer, and continues to relieve severe symptoms longer.

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Progesterone

With the approach of menopause and less frequent ovulation, production of progesterone by the ovaries dwindles. However, the level of progesterone after menopause is similar to that of the early part of the menstrual cycle in the fertile years. This progesterone is produced by the adrenal glands.

Androgens

There are three kinds of androgen, and the balance changes after menopause. Overall, the level of androgens produced at that stage is lower than beforehand, with a more marked reduction in women who have had a surgical menopause.

Because testosterone is the most dominant androgen, and because its level after menopause is still relatively high, it plays a rather more dominant role in the sex hormone system after the menopause than beforehand.

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Bone is a living substance and, like tissues such as the skin, it is constantly being removed and replaced. Normally this process is in balance, with the amount of old bone removed being replaced by an equal amount of freshly formed bone. To keep this balance it seems that bones need mechanical stress (the harder they have to work against the force of gravity, the stronger they get), together with a dietary supply of calcium, phosphorous, and tiny amounts of various other nutrients.

The types of exercise that seem most beneficial for bone strength are the weightbearing ones, such as walking, dancing, jogging, lawn bowls, gardening, golf and tennis. Associated benefits are an increase in flexibility and an opportunity for mixing with other people. How you feel during exercise is an important guide. Try to maintain a feeling of being a little ‘pushed’ without moving to the breathless stage.

Australian health authorities say that women at and after menopause need an estimated iooo to 1500 mg of calcium a day to be in calcium balance. The Melbourne Women’s Midlife Health Study indicates that only 5 per cent of women aged between forty-five and fifty-five have sufficient calcium in their diet to meet this recommendation. The study found that about 20 per cent of women get about 250 mg of calcium a day, a quarter of the recommended daily intake, and another 35 per cent have a calcium intake of less than 500 mg.

Eating foods rich in calcium or taking calcium supplements each day can bring calcium intake up to recommended levels. Foods rich in calcium include milk, tofu, cheese, soy milk, yoghurt, green vegetables, parsley, cabbage, seaweed, almonds, hazelnuts and oily deep sea fish. Calcium-rich herbs include alfalfa, camomile, oatstraw and skullcap. For women who have cut back on dairy foods because of concerns about weight gain, low-fat alternatives are the ideal substitute. Some women have a deficiency of the lactase enzyme, which means that their bodies are incapable of metabolising dairy products. If you are one of these people you will need to get your calcium from other sources, such as yoghurt, which itself contains the lactase enzyme.

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The influence of hormone therapy on breast cancer risk is uncertain, despite numerous studies focused on this issue. The findings to date suggest the following.

- There is no increased risk of breast cancer from use of oestrogen for up to five years.

- For five to ten years of use a grey area exists, and any increase in breast cancer is probably below 30 per cent.

- For ten years or more of use, there may be a 30 to 80 per cent increase in the risk of breast cancer. This risk appears to be at the higher end of the range in women with a family history of breast cancer (including a mother, sister or daughter affected by the disease) and those using above-average doses of oestrogen.

- It is unclear whether use of a progestogen in combination with oestrogen increases or decreases the risk of breast cancer. Dosages, and hormone types and methods, are not always documented fully in research studies, and this results in unnecessary ambiguity.

- Unanswered questions remain about whether breast cancer risk is increased by the use of oestrogen alone (in women with and without a uterus). There is also debate about whether progestogens teamed with oestrogen are more likely to reduce breast cancer risk if they are taken continuously or for ten to fourteen days a month, as described in chapter 2.

Because of these uncertainties it is very important, if you are on HRT, to be particularly careful to examine your own breasts regularly for any unusual lump or thickening, to have an annual examination of your breasts carried out by your doctor, and to have a mammogram every one to three years. Regular mammograms seem to be a particularly valuable safeguard.

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Books about menopause often seem to imply that the only forms of HRT available are Premarin (an oestrogen isolated from the urine of pregnant mares) and Pro vera (a progestogen of long standing). It is certainly true that the most common mix of hormones prescribed as HRT is an oestrogen (taken in every day by pill, patch or implant), plus a progestogen (taken daily for ten to fourteen days, then not used for the rest of the month), but the numerous options available mean that hormone formats can be tailored to meet each woman’s needs.

COMBINED CYCLICAL THERAPY Many varieties of oestrogen and progestogen can be used in this combined hormone format, referred to as cyclical progestogen. The oestrogen component is the main agent for relieving menopausal symptoms, while the addition of a certain amount of progestogen puts the brakes on growth of the endometrium. A withdrawal bleed occurs when you stop taking progestogen.

There is variability in the types of oestrogen and progestogen prescribed, and these hormones may be taken together in a single pill or patch, or separately. For women taking separate hormone pills (for example, because the doctor wants to use dosages not found in the available combined-pill formats), an easy way to remember when to start the progestogen is at the beginning of each calendar month. The progestogen is then stopped on the tenth, twelfth or fourteenth day of the month (depending on the doctor’s instructions). You could, on the other hand, use a ‘calendar dial pack’, which contains ten oestrogen-plus-progestogen tablets followed by eighteen oestrogen pills.

You can expect a withdrawal bleed to begin anywhere between the tenth day of taking progestogen and a week after it is finished. If bleeding starts outside this time (that is, before day ten or after day seventeen, nineteen or twenty-one, depending on how many days the progestogen is taken), it is likely that the hormone dose is inadequate and needs to be altered. Most women taking progestogen for ten to fourteen days a month (that is, cyclical progestogen) have a withdrawal bleed each month at the end of the progestogen phase. The first few bleeds tend to be heavier than later bleeds. In about 50 per cent of women taking this cyclical progestogen, withdrawal bleeds disappear after about ten years; in most other users, withdrawal bleeds continue for however long the hormones are taken, usually becoming lighter with time.

In a small proportion of users, of whom Marita is an example, cyclical progestogen therapy never causes bleeding. The absence of bleeding after she started taking oestrogen and progestogen caused Marita some initial concern, but she was reassured by her doctor that nothing was amiss. She then wondered whether she needed to take progestogen at all, but her doctor impressed on her the necessity of continuing with this part of the therapy as she still had a uterus, which would be at increased risk of abnormal tissue growth, and possibly cancer, if she took oestrogen alone. Provera is the progestogen best documented as preventing abnormal growth of the endometrium.

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