Page 5 2012 Vol 2
HRT: 10 years on
After a decade of confusion and misinformation, the facts about hormone replacement therapy (HRT) are finally becoming clear. These facts will help women decide if they should use HRT or not.
In 2002, a report from the Women’s Health Initiative (WHI) trial of HRT concluded that the risks of taking HRT outweighed the benefits. This caused concern for many women and resulted in a dramatic drop in HRT use worldwide.
Ten years on, however, it is now clear that the results were misinterpreted. The study in fact shows HRT is an effective and safe treatment for the relief of menopausal symptoms for many healthy women up to the age of 60.
Women who have stopped taking HRT since 2002 have suffered unnecessarily, says Professor Henry Burger, a founding director of Jean Hailes and a former president of the Australasian Menopause Society (AMS) and the International Menopause Society (IMS).
“The WHI study created a high level of anxiety and fear. In parts of America there was an 80% drop in the use of hormone therapy. In Australia we saw about a 50% drop,” says Prof Burger. “At least half of those women saw their symptoms return which meant their quality of life significantly suffered.”
Correcting the picture
Two important publications have finally set the record straight. A comprehensive review of evidence was published in the official journal of the International Menopause Society, Climacteric, and an HRT update was written in the British Medical Journal by three highly respected Australian doctors and researchers.
What went wrong?
The aim of the WHI study was to look at whether HRT could prevent diseases such as cancer and heart disease. It wasn’t set up to study whether HRT provided relief from menopausal symptoms at the time women usually go through menopause – around 51 years.
The confusion was caused because:
Women in the study were on average aged 63 and many years post-menopausal. They were not the women who are usually prescribed HRT.
When risks of HRT were reported they were reported as a ‘relative’ risk not an ‘absolute’ risk.
Instead of reporting the actual likelihood a woman would be at risk of cancer, they compared older women exposed to HRT for a longer period of time directly with women not on HRT.
Using ‘relative’ risk is common but it can lead to confusion. When ‘relative risk’ was reported, women thought their risk of getting breast cancer was increased by 26% when really the ‘absolute’ increase was less than one extra breast cancer case per 1,000 women per year.
What does this mean for women?
Dr Robert Langer was the Principal Investigator at the WHI Clinical Centre at the University of California. Speaking this year to mark the 10th anniversary of the study he said lessons had been learned.
“Information that has emerged over the last decade shows that for most women starting treatment near the menopause, the benefits outweigh the risks, not just for the relief of hot flushes, night sweats and vaginal dryness, but also for reducing the risks of heart disease and fractures.”
Professor JoAnn Manson, also a WHI Principal Investigator, says it was unfortunate that initial study results were applied to newly menopausal and healthy women who can benefit from hormone therapy.
“The WHI results point the way towards treating each woman as an individual,” she says. “There is no doubt that hormone therapy is not appropriate for every woman, but it may be appropriate for many women, and each individual woman needs to talk this over with her clinician.”
So what are the risks of using HRT?
One of the features of the WHI study that scared women was HRT’s apparent link to a significantly increased risk of breast cancer. Understanding that the actual risk is smaller than the WHI report made it sound helps women to decide if HRT is right for them.
For women who use combined HRT (oestrogen plus progestogen) the actual increase is generally less than one extra breast cancer case per 1,000 women treated per year.
For women who use oestrogen only HRT (because they have had a hysterectomy and so don’t need progestogen) the risk of breast cancer does not appear to increase for up to 15 years of use. When considering breast cancer risk, each woman needs to consider whether to take HRT based on her health background and history.
The fact that the WHI study included women who were older and many years post-menopausal – not the group of women usually prescribed HRT – led to another finding that caused concern. “Before the WHI study, other studies suggested the risk of heart disease was reduced by taking HRT,” says Prof Burger.
“But the WHI found the risk of heart disease was increased and in the initial paper this was said to have occurred regardless of a woman’s age.”
Later analysis found increased risk of heart disease did depend on age, with the only significant risk occurring in women who were over 70 and taking HRT.
So the findings again caused unnecessary concerns. “It’s too early to see whether there’s going to be a consequence for heart disease because women stopped
their HRT,” Prof Burger says. Healthy women who use HRT around the time of menopause are not necessarily at increased risk of heart disease. Other causes of heart disease such as high blood pressure, high total blood cholesterol and family history of heart disease increase the risk of heart disease for women and must be considered when thinking about HRT.
What are the benefits of HRT?
Benefits include not only relief of symptoms such as hot flushes and vaginal dryness, but reduction in the risk of diabetes and various cancers such as endometrial and colorectal cancers.
“For otherwise healthy women suffering severe symptoms around the time of menopause, the benefits of HRT significantly outweigh the risks,” Prof Burger says.
For women who stopped taking HRT in the past decade there has been an increase in the rate of hip fracture and other fractures, whereas HRT has been shown to increase bone strength.
What about women with early or premature menopause?
“Untreated women with early or premature menopause are at substantially increased risks of heart disease, osteoporosis and fracture, dementia and Parkinson’s,” Prof Burger explains.
“There was no reason for them to stop HRT, but many women in those younger age groups stopped taking it.”
For those women Prof Burger says the impacts on their health will gradually be seen.
For women who have had an early or premature menopause it is important they discuss their individual risks and benefits of taking HRT. In general, HRT should be strongly recommended for them.
What if I can’t take HRT?
For women who are at risk of breast cancer, who already have breast cancer or established heart disease, HRT might not be the right option for treatment of menopausal symptoms. There are alternatives available.
Some types of antidepressants are known to reduce hot flushes; other non-hormonal medications can help, along with some psychological therapies and relaxation practises.
A discussion with your doctor about how to help with menopausal symptoms if you can’t take HRT is important.
The full picture
Summarising the chequered history of HRT during the past decade, Prof Burger is relieved that a more accurate picture has emerged.
“For a woman who is troubled by hot flushes, night sweats, poor sleep around the time of menopause or in the first five years after menopause, hormone therapy is a very safe and effective means of treatment,” he says.
“It also helps to preserve bone density and it almost certainly reduces the risk of heart disease, diabetes onset and colorectal cancer. It may also possibly reduce the risk of dementia and it improves quality of life for many women.”
Australasian Menopause Society
The International Menopause Society
The Heart Foundation
The Cancer Council
Content Updated September 2012