Making sense of the HRT debate

 

Older women holding hands

29 March 2019

Dr Anne Connolly, RCGP Clinical Champion for Menstrual Wellbeing and Dr Louise Newson, GP and Menopause Specialist

The menopause is a normal life event for women, not an illness or medical condition. As the life expectancy of women has increased over the past century many women, on average, spend one-third of their lives being postmenopausal.  Many women suffer in silence from their menopausal symptoms and do not realise how effective hormone replacement therapy (HRT) can be at dramatically improving both their symptoms and their quality of life and future health.

The most common menopausal problems are vasomotor symptoms like hot flushes and night sweats. Other symptoms include mood changes, memory loss, vaginal dryness and soreness, reduced libido, sleep disturbances, joint pains and muscle stiffness.1,2. These symptoms can be non-existent, last for a few years, or even decades. Around 75% of menopausal women experience symptoms, with one third of these describing them as severe.3

'There are numerous potential benefits to be gained by women taking HRT'

Many women and healthcare professionals are worried about the perceived risks of HRT. Much of the negativity regarding HRT stems from the misinterpretation of the Women’s Health Initiative (WHI) study in 2002, which led to a worldwide reduction in HRT use.4 The subsequent sub-analysis of this study showed some reassuring and positive results to support the use of HRT, especially in younger women.5 

There are numerous potential benefits to be gained by women taking HRT with improvement of their menopausal symptoms, such as hot flushes, mood swings, night sweats, and reduced libido. 

Numerous studies have shown that shown that when HRT is started in women who are within 10 years of menopause onset it can to reduce future risk of development of osteoporosis, type 2 diabetes, osteoarthritis and all-cause mortality.6 

It is not just the timing of HRT that is important. The type of HRT also affects a woman’s risks and benefits. HRT containing micronised progesterone appears to be associated with a lower risk of breast cancer, cardiovascular disease, and thromboembolic events compared with androgenic progestogens.7,8 Women who have had a hysterectomy and only require oestrogen have a lower risk of breast cancer compared to women taking combination HRT.

'It is so important that women are given accurate, evidence-based information'

In addition, the mode of delivery of oestrogen is also important because, in contrast with oral oestrogen, transdermal oestrogen is not associated with an increased risk of venous thromboembolism.9

Most women and healthcare professionals are concerned about the possible risks of breast cancer in women taking HRT. However, the risk is far lower than many realise. Women who take oestrogen only HRT (women who have had a hysterectomy) do not have a greater risk of breast cancer. Women who take oestrogen and a progestogen may have a small increased risk of breast cancer. However, this increased risk is a similar magnitude to the risk of breast cancer for women who are overweight or drinking a glass or two of wine each night. Telling women this often really helps to put this risk into perspective.

Clearly HRT is only one part of the management of perimenopausal and menopausal women. Lifestyle recommendations regarding diet, exercise, smoking cessation, and safe levels of alcohol consumption should be encouraged.

It is so important that women are given accurate, evidence-based information so they can have an individualised consultation regarding their perimenopausal and menopausal symptoms. There is more information on the RCGP Menstrual Wellbeing Toolkit, The Primary Care Women's Health Forum (PCWHF) and British Menopause Society websites. An easy HRT prescribing guide has recently been written for the PCWHF.

About the authors:

  1. Dr Anne Connolly is the RCGP Clinical Champion for Menstrual Wellbeing
  2. Dr Louise Newson, is a GP and Menopause Specialist at Newson Health Menopause and Wellbeing Centre in Stratford-Upon-Avon. She also runs the My Menopause Doctor website. 

References:

  1. National Institute for Health and Care Excellence. NICE guideline NG23 – Menopause: diagnosis and management 2015 [May 2017]. Available from: https://www.nice.org.uk/guidance/ng23
  2. Baber RJ, Panay N, Fenton A, Group IMSW. 2016 IMS Recommendations on women's midlife health and menopause hormone therapy. Climacteric 2016;19:109-50
  3. Hamoda H, Panay N, Arya R, Savvas M. The British Menopause Society & Women’s Health Concern 2016 recommendations on hormone replacement therapy in menopausal women. Post Reproductive Health 2016;22:165-83
  4. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA 2002;288:321-33
  5. Manson JE, Aragaki AK, Rossouw JE et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women's Health Initiative Randomized Trials. JAMA. 2017; 318(10):927-938
  6. Boardman HM, Hartley L, Eisinga A, Main C, Roque i Figuls M, Bonfill Cosp X, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev 2015:CD002229
  7. Stute P, Wildt L, Neulen J. The impact of micronized progesterone on breast cancer risk: a systematic review. Climacteric. 2018 Apr;21(2):111-122. M.
  8. L’Hermite. Bioidentical menopausal hormone therapy: registered hormones (non-oral estradiol ± progesterone) are optimal. Climacteric 2017; 20:331-338
  9. Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ 2008;336:1227-31

 

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