Doctors are reporting an increase in the number of menopausal women requesting prescriptions for Hormone Replacement Therapy (HRT), following Davina McCall's admission in her Channel 4 documentary Sex, Myths and Menopause that the drugs were a lifesaver for getting her symptoms under control.
But there's still confusion around what HRT is, what it does and the risks of taking it versus the benefits. Dr Philippa Kaye is a GP who specialises in women’s health. Here, in an abridged excerpt from her brilliant new book The M Word, she answers the most commonly asked questions around HRT including whether it's safe.
WHAT IS HRT?
HRT stands for hormone replacement therapy, and it does what it says on the tin – it replaces hormones that naturally fall to lower levels during and after the menopause.
HRT can consist of oestrogen, progesterone and testosterone, and which hormones are used, or in what combination, will depend on your medical history and symptoms.
WHAT ARE THE DIFFERENT TYPES OF HRT?
HRT involves giving oestrogen to replace the low levels that are causing your symptoms. So oestrogen is always required. The progesterone component of HRT is only needed if you have your womb, in order to prevent the oestrogen stimulating the womb and increasing the risk of womb cancer.
But when the progesterone is given will decide whether or not you still have periods while on HRT. These aren’t true periods, but withdrawal bleeds from the hormones, similar to the withdrawal bleeds while on the combined oral contraceptive pill (though new guidance says you don’t actually need to have the break, and therefore the withdrawal bleed, but can chose to take the packs back to back !).
Importantly, testosterone can be given no matter how the oestrogen and progesterone are delivered, be they sequential or continuous.
CAN EVERYONE TAKE HRT?
Not quite, there are a few contraindications, or reasons why you would not be prescribed HRT. Some of these are obvious– you can’t have HRT if you are pregnant for example. Other reasons include undiagnosed abnormal vaginal bleeding such as bleeding in between your periods or after sex, a current or recent blood clot in the leg or lungs, a current/recent heart attack or womb cancer.
If you are being investigated for suspected breast cancer, or if you currently have breast cancer, whether or not you are being treated for it, and if you have a liver disease causing current abnormal liver function tests your doctor may avoid prescribing HRT. Uncontrolled high blood pressure is also a reason to avoid HRT, though it can be started when blood pressure is under control.
Having one of these issues doesn’t mean that you will never be able to have HRT. For example, if you have abnormal vaginal bleeding and the cause is found and treated, such as a polyp, once this is done you will be able to have HRT. Or, if your liver disease is treated, or brought under control so the liver function tests return to normal, or depending on the disease itself, your doctor may ask for advice from a gynaecologist as it may be that delivering the HRT transdermally, avoiding the liver, would be appropriate. So although there are some contraindications, they may not affect you permanently! And if they do, then we do have prescribable alternatives to HRT available.
IS HRT SAFE?
For most people, if you are suffering, then yes! HRT is not the big, bad baddie that many people thought, or still think, that it was and is.
So why the furore? In order to answer that we need to look back at the history of the development of HRT. HRT has been available in the UK since 1965. Originally called Premarin, it was made from the urine of pregnant horses(PREgant MARe’s urine).
In 1993, the Women’s Health Initiative (WHI) began a trial that looked at the effects on health of HRT, of differing types, compared to a placebo. Then, in 1996 in the UK, the Million Women Study started to collect questionnaires on HRT and its effects on health.
In 2002, the Women’s Health Initiative stopped part of its study due to safety concerns about breast cancer, heart disease and other health issues. The results of both studies were then published in 2003, but there was no clear guidance as to what doctors and women should do, with many women being told to stop taking HRT. In the next four years, the number of users of HRT fell from 2 million in the UK to less than a million over concerns about its safety.
In the following years, more and more research was carried out showing the health benefits of HRT. Within a few years scientists involved in the Women’s Health Institute trial published further analysis of the data showing that there are additional benefits in starting HRT to those less than 10 years after the menopause, including decreasing the risk of heart disease. However, they did show that there is a generalised increased risk in starting HRT after the age of 60. Now, remember that the average age for the menopause in the UK is 51, so that means starting HRT nearly ten years after the menopause.
There is lots of science out there, some good, some bad, so it is important to look behind the headlines at the structure of the study, what it was and what it did. The WHI study was flawed. Essentially it was comparing apples and oranges; the women in the WHI study were on average 63 years old, and yet in the UK most women do not have over a ten-year gap between the menopause and starting HRT. We simply cannot use the data for women over the age of 60 to assess risk for those under the age of 60.
Two of the authors of the trial even recently published an apology in the New England Journal of Medicine as to how the trial was interpreted and the detrimental effect it had on prescribing rates.
Since then there have been further studies looking at the potential risks and benefits of HRT. The National Institute of Clinical Excellence (NICE) in the UK looked at all the available data and safety concerns, and guidelines were produced about the menopause and HRT in 2015, with other updates and quality standards since then. And yet, many women, and even some doctors, are still scared of using HRT, leading to many women continuing to suffer.
The bottom line is this: For most women under the age of 60 who have symptoms relating to the menopause or perimenopause, the benefits of HRT outweigh the risks.
WHAT ARE THE BENEFITS OF HRT?
Let’s start with the obvious – HRT works! It is effective versus all the symptoms of the perimenopause and menopause – sweats and flushes, insomnia, mood swings and irritability, joint aches and pains, tiredness, difficulties with memory and concentration, vaginal and urinary symptoms. For many women, it works. This shouldn’t be underestimated!
PROTECTION AGAINST OSTEOPOROSIS
HRT reduces the risk of developing osteoporosis, a condition where the bones become thin. HRT actually treats osteoporosis as well, but there are alternative treatments for osteoporosis available, so it generally isn’t used primarily as a treatment.
The evidence is that HRT prevents a fall in bone density and decreases the risk of fractures related to osteoporosis. Women taking standard dose HRT in the Women’s Health Initiative Trial had a third fewer hip and spine fractures than those not taking it; this isa decrease from 15 fractures per 1,000 women to 10 fractures per 1,000 women on a placebo.
PROTECTION FROM DEMENTIA
Oestrogen seems to be protective against dementia, particularly Alzheimer’s dementia. There have been multiple studies regarding HRT and dementia and the results have sometimes been contradictory. The current evidence suggests that HRT is not a treatment for dementia once it has developed but that if started within ten years of the menopause it may well be protective against it.
There is evidence that HRT is also protective against osteoarthritis, the degenerative “wear and tear” arthritis associated with increasing age.
Other possible benefits shown in studies include protection against colorectal cancer, reducing cases by approximately a third, from 16 per 1,000 women to 10 per 1,000 women on HRT.
It may also protect against eye conditions such as cataracts and macular degeneration. There is some evidence that HRT may improve muscle mass and strength, which also decrease with age. It also improves the quality and condition of your skin and hair, and while some doctors consider these issues to be superficial or simply cosmetic, for some women they have a big impact on their mental well-being.
There are also the knock-on effects of HRT which could be considered to be beneficial. For example, if you sleep better, feel less tired and your joints don’t hurt you are much more likely to exercise which will help prevent cardiovascular disease.
Cardiovascular disease – can be put in both the benefit and risk boxes. If started within ten years of the menopause, or before the age of 60, HRT does not increase the risk of heart disease. There is also evidence that it can be protective for the heart, especially oestrogen-only HRT.
What are the risks related to HRT?
Many women have read the headlines in the press or have heard about the risk of breast cancer with HRT, but in fact many women taking HRT do not have an increased risk of breast cancer. So let’s break it down clearly:
Although breast cancer is often oestrogen driven, the current research shows that oestrogen-only HRT seems to lead to a reduction in breast cancer. As such it appears that it is the progesterone in HRT which may be related to the breast cancer risk.
Women who have gone through a premature menopause and take HRT do not have an increased risk of breast cancer. (As ordinarily you would expect to have these hormones until the average age of the menopause at age 51.)
Taking HRT of oestrogen and micronised progesterone (Utrogestan), which is the same as that made naturally in the body, is not associated with an increased risk of breast cancer for the first five years and even after that point the risk is so low it is not considered to be significant.
Combination oestrogen and progesterone HRT (using non-micronised progesterone) is associated with a small increase in breast cancer. The key here is “small”. [Dr Kaye goes into more detail on this in the book].
The jury is still out on this one. Some studies have been inconclusive, some showed no increased risk with HRT but the Million Women study suggested a slight increased risk. And I do mean a slight risk, one extra case for every 2,500 women taking HRT for five years, an increase from 5 per 2,500 – in percentage terms an increase from 0.2% to 0.24%– so this increase is tiny. More research is needed as currently there is no good-quality evidence with respect to ovarian cancer and HRT.
Blood clots can occur in the legs (deep vein thrombosis or DVT) or in the lungs (a pulmonary embolism) or in the brain. Taking oral HRT tablets causes an additional two cases of blood clots per 1,000 women aged 50–59 (without HRT the number of cases is 5 per 1,000). The risk is greatest in the first year of using HRT and in women who have other factors for developing a clot, such as a family history, a clotting disorder, smoking, or obesity.
However, delivering the oestrogen component of HRTtransdermally, through the skin via a patch or gel, is not associated with an increased risk of clots.
DOES HRT WORK STRAIGHT AWAY?
That depends. For some women, their sweats or flushes reduce quickly, within a few days, but if often takes three to four weeks, though the maximum effect can take up to three months or so. Other symptoms such as insomnia tend to improve within three months of starting. You may also find that any initial side effects settle down within three months. In general, a preparation will be used for three months before changing.
SHOULD I TAKE HRT?
Everything in medicine, or indeed in life, is a balance between the potential benefits and potential risks or side effects.
Even something as simple as putting on a plaster, or taking over-the-counter paracetamol could lead to an allergic reaction or even anaphylaxis. However, for most people this risk is small when compared to the potential benefit of the plaster applying pressure to stop bleeding covering a wound to prevent infection, or the benefit of the paracetamol to relieve a headache or other pain. So, too, the risks and benefits of HRT can be weighed in the balance.
Personal choice of course matters, and for each woman that may well be different, with a different emphasis on what matters most. However, from a medical point of view, looking at the evidence, it is possible to produce the following general guidelines.
These are generalisations and your own medical history may affect the choices made:
Under the age of 50 – there are no risks associated with HRT at this age, as it replaces the hormones normally expected to be present until the average age of the menopause, which is 51 in the UK.
Women who start HRT within ten years of the menopause,and then continue to take it in the long term, have a lowerrisk of all causes of death, including cancer.
Ages 50–59 – the benefits of HRT outweigh the risk.
Ages 60–69 – the benefits of HRT are approximately equal to the risks.
Over the age of 70 – the risks of starting HRT outweigh the benefits.
But there are choices in the route and form of HRT which reduce even these small, known risks:
Start HRT within ten years of the menopause, or before the age of 60, as this can help protect against cardiovascular disease.
Using transdermal oestrogen via a patch or a gel decreases the risk of clots.
If possible, use a Mirena IUS for the progesterone component, as the continuous delivery of progesterone is better to protect against endometrial cancer.
For more advice on HRT, speak to your GP. This feature is an abridged excerpt from The M Word by Dr Philippa Kaye (out now).
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