Ups and downs of HRT

Not that long ago Hormone Replacement Therapy (HRT) was seen as a panacea for all things menopausal. As an intern I recall my bosses giving it out almost like lolly water (ok – well not quite that indiscriminately) as if it was a cure-all for women who had passed beyond the days of normally functioning ovaries. “Take this – it will stop your internal thermostat from being set at the upper limit of normal (read Hot as Hades), it will stop your bones from crumbling, it will prevent you from having heart attacks, it will make you feel younger and more vigorous and less tired and will almost certainly give you a better chance of winning the Lotto.” – okay, so I made that last one up.

The hormonal shakeup of the 60’s which led to the invention of the oral contraceptive pill (“The Pill”) had been preceded by decades by the use of HRT. The first recorded use of “ovarian extracts” (sounds interesting doesn’t it) to treat menopausal symptoms was in the late 1890’s. The first commercially available HRT “Emminem” (no, not Eminem the rapper) was available in the 1930’s. In 1942 Premarin became available and was within a short period of time widely prescribed for the alleviation of menopausal symptoms. An excerpt from an advertisement of the time makes it sound so appealing. Why wouldn’t you want to take it?

“The physician who puts a woman on “Premarin” when she is suffering from the menopause

usually makes her pleasant to live with once again. It is not easy thing for a man to take the stings and barbs of business life, then to come home to the turmoil of a woman “going through the change of life”. If she is not on “Premarin”, that is.”

……. And people try to make out that the medical climate of that time was paternalistic. Pfft!

Dodgy advertising aside, the use of HRT was extremely helpful for those women suffering from menopausal symptoms. Due partly to the effect of afore-mentioned dodgy advertising the use of HRT for the treatment of all things unpleasant for menopausal women became widespread. In 1975, it was then discovered that the use of estrogen alone led to an increase in endometrial cancer (cancer of the lining of the womb). This didn’t really slow down the use of HRT as within a short period of time it was found that progesterone “protected” the endometrium and the HRT juggernaut plowed on relatively unhindered. Until 2002…….

In 2002, The Women’s Health Initiative (WHI) Study was published in the Journal of the American Medical Association. It was a massive study looking at women taking combined HRT (estrogen and progesterone) with approximately 16,000 women involved. It was the largest randomized controlled trial (this is a particularly good type of study) ever undertaken on HRT. However, most women enrolled in the WHI study were overweight, 80% were between 60 and 79 years old, half had smoked and some had hypertension and increased cholesterol. Regardless of the limitations of the study – the results were catastrophic to the HRT industry. It showed that HRT gave you an increased risk of breast cancer, stroke and blood clots. It showed that HRT did NOT decrease your chances of a heart attack – it actually increased them (although further statistical analysis showed there was no change). More reassuringly, the study also showed that HRT decreased your risk of bowel cancer and fractures of the hip and spine. Remember, this was with combined HRT – estrogen AND progesterone. If you’d had a hysterectomy in the past and didn’t need the progesterone to protect the lining of the womb then the outlook was better. The only statistically significant increased risk for those women was for stroke. The outlook for women who start HRT before the age of 60 is even better when compared to their older counterparts. This is true for combined HRT and for estrogen only HRT.

So what did this teach us and what was the effect of this study on clinical practice. It taught us that HRT was NOT a panacea. It taught us that HRT should NOT be used as a preventative medication. The effect that this has had on clinical practice is that HRT is now used for control of moderate-severe menopausal symptoms. HRT use is a quality of life issue not a preventative medicine issue. This distinction is highlighted by a case which I had experience with before the WHI study and before I did O&G. I was working as a GP in western Queensland and one of my patients was on combined HRT. It was the late 1990’s and even then we knew that women on combined HRT had a significantly increased risk of breast cancer. Almost every one of her female relatives had been diagnosed with and treated for breast cancer. Every time I saw her we had a to and fro about her being prescribed HRT and the risks of breast cancer. I would play the concerned GP. She would play the obstinate patient. Then one day she said to me, “Look doc, I know you’re trying to do the right thing and all but if I don’t have my HRT then my hot flushes are so bad and my depression is so deep and my life is so crap I feel like I may as well throw myself under a truck. I know I have an increased risk of breast cancer and that’s why every month I examine myself, every year I get my mammogram, every year I come and get examined by you. I’d rather get breast cancer than have to live the way I do without HRT.” We never had a stand- off after that rather one-sided discussion.

A brief note should be made about the use of bioidentical HRT preparations. These are formulated as creams or troaches (to be used in the mouth). The preparations are touted as being “natural” when in fact all hormonal preparations are manufactured. The strength and makeup of these preparations are often based on salivary hormone tests which are very expensive. There is no good evidence that salivary hormone levels relate to either blood hormone levels or menopausal symptoms. There is also no good evidence that this “tailoring” of the preparation has any benefit over standard HRT. There is no good scientific evidence (unlike the WHI trial) comparing these preparations to standard HRT or investigating their potential interactions with other medications. In short, I’m not a fan of bioidentical HRT treatments. It’s expensive, unproven and inadequately studied.

So – should you use HRT? For some women – YES! For some women – NO! For some women – MAYBE! Am I fence sitting – ABSOLUTELY! There is no doubt that for some menopausal symptoms – eg. hot flushes – estrogen is by far and away the most effective treatment. However, each womans individual medical history has to be taken into account before a decision can be jointly made between herself and her doctor as to whether she should try HRT. It is very much a quality of life decision. Once the decision is made it’s best to try the lowest dose of HRT for the shortest possible time to get you through the worst of it. Some women never get to the point where they can stop their HRT (like my friend in Queensland) because the symptoms are so overwhelming that life becomes unbearable if they go off it. If they are aware of the potential risks I have no problems with prescribing HRT for them. There is also the option of non-hormonal medications although for severe symptoms they often come up short. The option is always there to just “ride it out” although this option is limited by how long and how bumpy the road is.

There is lots of information out there on this topic. One of the best places you can go to is the Australian Menopause Society’s website. They have a great page with information sheets and another with videos. Or you can head over to the menopause page on my website.

Get informed and if necessary see a gynae.