Do the advantages of HRT outweigh the disadvantages – yes or no? This was the question posed in a fascinating debate I attended at The Guild of Health Writers last week.
The controversy and conflicting research surrounding Hormone Replacement Therapy (HRT) is a minefield for any health professional to negotiate, let alone the average menopausal woman, so it was enlightening to listen to four of the UK’s top experts in Gynaecology, Epidemiology and women’s health argue the case for and against the use of HRT in menopausal women.
HRT: Yes or No? Meet the Experts
In the Yes corner were:
Professor Janice Rymer, Professor of Gynaecology at King’s College London School of Medicine and Consultant Gynaecologist at Guy’s and St Thomas’ hospitals and
Mr Tim Hillard, Clinical Lead for Gynaecology and Consultant Obstetrician and Gynaecologist, Poole Hospital NHS Foundation Trust, past Chairman and current trustee of British Menopause Society.
In the No corner:
Professor Klim McPherson, Leading public health expert and visiting Professor in Epidemiology at Oxford University known for his outspoken views on HRT and
Marilyn Glenville PhD, nutritional expert specialising in women’s health, and author of Healthy Eating for the Menopause.
The Benefits of HRT
First up was Mr Tim Hillard who said there is no doubt that HRT is highly effective in treating menopausal symptoms. It improves quality of life, sexual function and helps in the prevention of osteoporosis and cardiovascular disease (CVD).
However, The Nurses’ Health Study of 1987 found that there is an increased risk of:
- Breast cancer – if taking oestrogen plus progestins for more than 5 years, or oestrogen alone for more than 10 years and
On the positive side, the study also found that taking HRT:
- May reduce the risk of Coronary Heart Disease (CHD)
- Reduces the risk of hip fracture
- Reduces the risk of high tension glaucoma and ‘wet’ Age-related Macular Degeneration (AMD).
The way the risks of HRT are communicated to the public can be misleading and Mr Hillard stressed the importance of putting the risks of HRT into perspective. When it comes to the risk of breast cancer, being obese with a BMI of over 35, having a high saturated fat intake or drinking more than 2 units of alcohol a day carry a far higher risk than taking HRT.
The Women’s Health Initiative
Of course, no talk about studies into the risks of HRT would be complete without reference to the Women’s Health Initiative (WHI) Study of 2002. The study was stopped after 5.6 years when researchers found that the associated health risks of combination hormone therapy outweighed the benefits.
The results of the WHI study sent shockwaves throughout the medical world. Women were told to stop taking HRT immediately and millions more were denied access to the hormones which could have improved the quality of their lives and safeguarded them from other health risks associated with the menopause.
A decade later, critics of the WHI study say that it over-emphasised a relatively small increase in breast cancer. The data was also skewed because the dose of HRT was too high for an elderly population of women with an average age of 63 years.
The current view amongst more enlightened health practitioners is that HRT is a perfectly acceptable treatment for relatively young and healthy women (up to the age of 59) experiencing moderate to severe menopausal symptoms. After the age of 60 the risks of taking HRT increase.
Other research has found that supplemental oestrogens may promote the growth of existing cancers rather than actually cause them.
In summary, Mr Hillard concluded that the benefits of HRT outweigh the risks for most women under the age of 60 and is definitely beneficial.
The ‘Scandal’ of Women deprived of HRT
Also in the pro HRT camp was Professor Janice Rymer who spoke of the ‘scandal’ against women after the WHI study deprived women of HRT. In a passionate presentation she said that since 2002 the use of HRT had fallen significantly and seen a rise in complementary therapies which were ineffective at best, harmful at worst. The WHI scandal had left women and health professionals scared and confused with its ‘Stop HRT immediately’ message.
She accused the HRT naysayers of the medical profession of being like ‘ostriches with their heads in the sand’ and epidemiologists of ‘creating hysteria’ and said women stand more risk of dying in a plane crash than from anything HRT induced.
‘Cardiovascular disease is the biggest cause of death in women and because they are being denied HRT women are dying prematurely,’ she said.
The Danish Osteoporosis Prevention Study (DOPS) concluded that women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, and no apparent increase in the risk of cancer, venous thromboembolism, or stroke.
Between the ages of 45 – 60 a woman has a window of opportunity to benefit from the long-term cardio and neurological effects of early oestrogen therapy. The risks in women in this age group are low.
The Risks associated with taking HRT
Professor Klim McPherson is one of those epidemiologists whom Professor Rymer accuses of causing hysteria and having his head in the sand. While he agrees there is no question that HRT treats menopausal symptoms effectively, improves quality of life and prevents osteoporosis he stresses that the risk of breast cancer and heart disease is significant.
Professor McPherson is adamant that women must know the risks associated with taking HRT and is fed up with the media misleading women and downplaying the risks.
He quoted The Million Women Study which found that taking HRT for 5 years or more doubles the risk of breast cancer and the tumours of those women taking HRT were bigger than those who weren’t.
Professor McPherson also questioned whether it is worth taking HRT as a means to prevent osteoporosis when the risk of osteoporosis is greater at age 70 than age 50. ‘Is it worth taking HRT for 20 years given the risks?’
‘Taking HRT for a long time is truly dangerous,’ he said, ‘and in order for the benefits to outweigh the risks, women need to take HRT for a short time and have serious menopausal symptoms.’
Menopause is Not a Disease!
Marilyn Glenville PhD, also in the No camp, presented an alternative approach to the menopause. She described the menopause as a natural process in a woman’s life, not a disease that has to be treated and stressed that HRT should be the last resort not the first line of treatment.
Around the world there are cultural differences in how women experience menopause as well as the risk of osteoporosis. This could be due to cultural attitudes as well as diet. In the West the menopause is seen as a negative experience and women tend to suffer more.
She traced the medicalisation of menopause back to the publication in 1966 of Feminine Forever by Robert A Wilson M.D. In it Wilson wrote, “Many physicians simply refuse to recognize menopause for what it is — a serious, painful and often crippling disease.”
He also wrote, “All post-menopausal women are castrates. But, with HRT, a woman’s “breasts and genital organs will not shrivel. She will be much more pleasant to live with and will not become dull and unattractive.”
‘The risks of taking HRT are too great for what is a natural stage of a woman’s life,’ Glenville said. If HRT is used, it should be short term use to treat symptoms.
She also believes that HRT fuels tumours rather than causes them. At her clinic she works closely with a gynaecologist and patients are tested first to see if they are at risk of developing cancer before being prescribed HRT.
Marilyn Glenville was the only expert who mentioned bio-identical hormones which are molecularly similar to the human body and usually have fewer side-effects. ‘But,’ she stressed, ‘you are still replacing hormones.’
She worried that many women were opting to buy natural progesterone creams over the internet without realising that progesterone increases the risk of breast cancer and does not prevent osteoporosis.
Glenville spoke about the introduction of a versatile new group of drugs called SERMs (selective estrogen receptor modulators). SERMs act like oestrogen in some parts of the body and have an anti-oestrogenic effect in other parts. They can be used to treat osteoporosis, hormone responsive cancers, and infertility.
Soya, beans and lentils contain phyto-oestrogens or plant-derived oestrogens which are in fact naturally occurring SERMs and have been shown to reduce the risk of breast cancer.
Stress is another important factor to consider as elevated cortisol levels increase menopausal symptoms. The adrenal glands are a major source of oestrogen and too much stress can leave them depleted. Women may need to change their lifestyle and their expectations during the menopausal years, by decreasing their caffeine and alcohol intake for example and eating a Mediterranean diet.
It is possible to live for 30 – 50 years after the menopause and still have a good quality of life.
Other Points of Note:
In the case of women who experience Premature Ovarian Failure (i.e. early menopause before the age of 40) the medical experts agreed the risks of HRT do not apply. It is far more beneficial for these women to take HRT than to endanger their health by not taking it.
HRT is not meant to be a long-term therapy. It is best to take it for 2 – 3 years and then reappraise your situation before weaning yourself off the treatment.
The official recommendations from The North American Menopause Society and NICE in the UK is to take the lowest dose of HRT for the shortest amount of time and for not more than 5 years.
The issue of GP training was brought up. Many GPs and gynaecologists need more training and information about the menopause. In the wake of the WHI results there is a whole generation of doctors and gynaecologists who know nothing about the menopause as they’ve received no education on it. Since 2002 there has been a huge reduction in the prescribing of HRT because of the climate of fear that has existed since the WHI study.
In an evening dedicated to the subject of HRT there was not a single mention of testosterone which is a vital part of many menopausal women’s hormone treatment.
Is HRT right for You?
HRT is not appropriate for every woman. When it comes to deciding whether or not HRT is right for you it is important to look at how your quality of life is being affected by your menopausal symptoms and also to carefully assess your risk factors such as family history of breast cancer, stroke, heart disease and blood clots as well as your age.
Time to Vote – HRT: Yes or No?
Now that you know all the risks and benefits associated with HRT how would you vote? The vote on the night was:
- Yes – 14 votes
- No – 12 votes
- Don’t Know – 10 votes.
For the record, I voted Yes. There is no doubt that HRT has improved the quality of my life, both physically and mentally. Starting HRT at the age of 47 means that I am in the age group of women who stand to benefit most. There is no history of breast cancer in my family and I feel I am receiving good quality care and advice from my consultant.
I have to admit there were times during the debate when I felt confused and uncertain that my choice to take HRT was the right one. But looking at the quality of my life now, the advantages of taking HRT far outweigh the disadvantages.
What is important is that women are enabled to make informed choices about their health and treatment during the menopause.
Findings of the Nurses’ Health Study
The British Menopause Society on The Women’s Health Initiative Study
DOPS study into the effect of HRT on cardiovascular events in recently postmenopausal women
Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement (2010)