Twenty-five years ago, casual discussions about the pros and cons of using hormone replacement therapy (HRT) would, no doubt, have been commonplace between friends in their late 40s and early 50s. Nowadays, the use of medication to alleviate menopausal symptoms is rarely discussed as many women are scared to take it and those who are taking it are scared to admit to taking it for fear of negative remarks.
The rise and fall of HRT is a pharma tale of how a medication was developed to treat a natural life stage – albeit a complex, confusing and difficult one for many women. And how, after 40 years of widespread use – with almost half of women taking it – its use has stopped completely.
HRT came on the market in the 1940s but became widely used only in the 1960s. It was mainly prescribed for the relief of hot flushes, night sweats, sleep disturbances, anxiety, genito-urinary problems and osteoporosis.
In the 1990s, two large studies of HRT began. Between 1993 and 2002 in the United States, the Women’s Health Initiative looked at the effects of HRT on heart disease and other conditions in more than 16,000 women aged between 50 and 79.
In the UK from 1996 to 2001, the Million Women Study looked at the effects of HRT on breast cancer and other conditions on 830,000 women over 50 attending breast screening clinics.
Preliminary results from the Women’s Health Initiative showed that those on HRT had an increased incidence of stroke, breast cancer and blood clots and a decrease in osteoporotic fractures and colon cancer.
The study was stopped three years early because the numbers of those with breast cancer were higher than a limit specified by the trial.
Meanwhile, results from the Million Women Study in the UK found that oestrogen-only HRT causes a small increase in the risk of breast, womb and ovarian cancer. Combined oestrogen/progesterone HRT increased the risk of breast cancer more than oestrogen-only HRT but reduced the risk of womb cancer. Both studies resulted in scary media headlines and between 2003 and 2007, HRT users in the UK fell from 2 million to fewer than 1 million.
Limited risk
Dr
Rachel Mackey
, author of
The Women’s Health Book
(Orpen Press, 2013), says that since then, the evidence from these two studies has been teased out to reveal that the risk of breast cancer was in women over 60 who used HRT continuously for many years.
“There was no increased risk of stroke, breast cancer or blood clots in women aged between 45 and 55. If you start HRT when you are over 60, there is a slight risk of heart attack or stroke in the first year of use,” she says. Drinking two units of alcohol every day or being extremely overweight are higher risk factors for developing breast cancer.
However, the results of the original studies have turned a generation of women off HRT.
“When HRT was first introduced, it was seen as a panacea and some women took it for trivial reasons such as to keep their hair and nails nice. Now the focus is to treat a small number of women who have marked symptoms,” says Mackey who runs the Women’s Health Clinic in Dún Laoghaire, Co Dublin.
Mackey says the National Institute for Health and Care Excellence (Nice) guidelines on the menopause and HRT issued in 2015 (nice.org.uk/guidance/NG23) have been the first positive reports on HRT since the fallout from the two large studies. They clearly state that oestrogen-only HRT causes little or no increase in the incidence of breast cancer, while HRT with oestrogen and progesterone can be associated with an increase in the incidence of breast cancer, but any increased risk reduces after stopping HRT.
The Nice guidelines also say that women with cardiovascular risk factors should not automatically be excluded from taking HRT as the cardiovascular disease risk applies to women over 60 who start HRT.
About 80 per cent of women will be able to cope with their menopausal symptoms without medication once they understand what is happening and are given accurate information, says Mackey.
The issue is the 20 per cent of women who would benefit from HRT, many of whom aren’t speaking to their doctors about their symptoms and not finding out if HRT will alleviate them.
Targeted use
The approach to prescribing HRT has changed radically in recent years. “It is only prescribed for relief of physical or psychological menopausal symptoms now and not as a preventative treatment for osteoporosis and heart disease,” says Mackey.
Doctors will also prescribe the lowest dose for the shortest time possible and women should expect relief of symptoms within 10 days of use. The Nice guidelines suggest using HRT for up to a maximum of five years and considering different forms of HRT before prescribing it for each patient.
As numbers of women using HRT declined, there was a subsequent rise in natural alternatives to treat menopausal symptoms, including expensive nutritional supplements.
Quitting smoking, cutting down on caffeine, alcohol and spicy food are recognised ways of reducing menopausal symptoms such as hot flushes.
Regular exercise and sleeping in a cool, well-ventilated room also reduces hot flushes and night sweats for many menopausal women.
Mackey says, “You can never overlook the benefits of optimising lifestyle, reducing calorific intake and daily exercise. I advise women to take any supplement they feel is beneficial to them unless they are overly expensive.
“You can’t ignore the huge placebo effect of taking something that you feel is good for you. But I advise women to stop any herbal remedies if they start taking HRT.”
The fact that there is no way of knowing exactly when menopausal symptoms will end complicates the picture. “There is a myth out there that HRT postpones the menopause, but [actually] it disguises it which means that a woman needs to come off HRT to see if the menopause is finished.”
GPs suggest weaning off HRT every 18 months or so to see if symptoms have abated.
“They might have waves of symptoms for about six months and then no more which means the menopause is over. But a small percentage of women will continue to have hot flushes until they die.
“I have women in their 60s, 70s and 80s on very low dose HRT,” says Mackey.
