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The pros and cons of hormone replacement therapy

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The menopause may lead women to consider the use of hormone replacement therapy (HRT). Much has been written about HRT, but media reports covering recent research have left many women confused over whether HRT is likely to do them more harm than good.

Abstract

VOL: 99, ISSUE: 35, PAGE NO: 26

Kay Brennan, MBChB, BA, is on a general practice rotation in Sydney

Julie Ayres, MBChB, MRCGP, is clinical assistant in the menopause/PMS clinics at Leeds General Infirmary and St James’ Hospital, Leeds

What is HRT?

When a woman nears the menopause her ovaries produce less and less female hormones. HRT is the name given to a group of drugs, in a variety of preparations, that are a substitute for these female hormones. The most common form of HRT is a combination of oestrogen and progestogen (see Boxes 1 and 2).

Why do women take HRT?

Women use HRT around the time of the menopause and beyond, to relieve menopausal symptoms and for its protective effects. The menopause typically occurs between the ages of 45 and 55 and is simply the name given to the last menstrual period of a woman’s life. Symptoms usually last between two and five years and are due to a decrease in the amount of oestrogen in the body. Hot flushes are the most common symptom of the early menopause (Porter, 1996), usually occurring at night, but other early symptoms include:

- Irregular menstrual cycle;

- Insomnia;

- Mood swings/irritability;

- Anxiety/panic attacks;

- Poor memory/lack of concentration;

- Joint/muscle pains;

- Loss of self-esteem;

- Atrophy of the vagina;

- Urinary infections and pain on passing urine;

- Loss of libido;

- Dry hair and skin.

HRT is almost completely effective at relieving hot flushes (Greendale, 1998). It can also alleviate other early problems. The increase in oestrogen levels keeps the lining of the vagina soft and healthy, making intercourse more comfortable and protecting the bladder from infection (Hextall, 2000).

HRT is also recognised for its long-term benefits, including the prevention of osteoporosis. This is because of the important role oestrogen plays in maintaining the levels of calcium in bone. HRT has been shown to reduce the risk of colon cancer and studies suggest that the incidence and severity of Alzheimer’s disease may be reduced by up to 30 per cent in those taking long-term HRT (Zandi, 2002). HRT has also been linked to improvement in rheumatoid arthritis (©lia, 2003).

Recent evidence

HRT may not be suitable for every woman, but for many the increased risk of breast cancer is the greatest concern. Such concerns may be heightened with widespread and often alarming media coverage.

New data on the link between breast cancer and HRT appeared in The Lancet last month. The Million Women Study (Beral, 2003), which was set up by Cancer Research UK to investigate the effects of specific types of HRT on the incidence of fatal breast cancer, found that current long-term use of HRT is associated with an increased risk of breast cancer. A total of 1,084,110 women in the UK aged between 50 and 64 years were recruited to the study between 1996 and 2001. Researchers found 10 years use of a combined oestrogen/progestogen preparation of HRT resulted in an estimated five additional breast cancer cases per 1000 users.

The Committee on Safety of Medicines commented that for short-term use, the benefits of HRT outweigh the risks for many women, but for longer-term use women need to be aware of the increased risks of breast cancer.

Another large study recently undertaken in the USA, the Women’s Health Initiative (WHI), was due to run until 2005 but was terminated early as results showed that women taking combined HRT had a 26 per cent higher risk of breast cancer (Roussouw, 2002). This translates as a difference of less than one additional case of breast cancer per 100 women per year - figures comparable with the Million Women Study.

Overall, evidence shows that there is an increase in breast cancer risk when taking HRT, but this risk is small if it is used in the short term. Unfortunately, the arguably overblown perception of this risk in the media has caused many women to forego the significant benefits of HRT.

Until recently HRT was thought to prevent heart disease but recent research has cast doubt on whether HRT has any effect on either the primary or secondary prevention of heart disease. The WHI study found a 29 per cent increased risk of coronary heart disease in those taking combined HRT. Again, like breast cancer this translates as a small increase, but at present there is insufficient evidence to recommend it in either case.

High blood pressure is not a contraindication to taking HRT, but as it increases the risk of heart disease and stroke it must be controlled before starting HRT (Yorkshire Menopause Group, 2003). Other areas of concern include gallbladder and uterine cancer (Ferandez et al, 2003).

So what should the millions of women worldwide who already take HRT, or those considering doing so, be advised? The evidence base indicates that for the average woman with no significant risk factors, HRT can safely help to relieve the symptoms of the menopause in the short term, but there is no good evidence that the overall effects of oestrogen make it worth taking for more than 10 years. However, longer-term treatment may be justified for the prevention and treatment of osteoporosis (US Preventive Services Task Force, 2002).

HRT preparations

Oestrogen may be administered vaginally, orally, though the skin, nasally and via an implant. There is no evidence of increased benefit of one route over another. Patient choice is the most important factor.

Local treatments

- Creams - a plastic syringe-like applicator delivers a measured dose of oestrogen cream into the vagina for relief of local symptoms, such as vaginal dryness. Such creams are usually used on a short-term basis. If used for longer periods progestogen tablets may be needed.

- Vaginal tablets/pessaries, like vaginal creams, are indicated for system-specific problems.

- Vaginal ring - a synthetic ring impregnated with oestrogen is inserted into the upper third of the vagina and worn for three months at a time. The ring can be uncomfortable and other local treatments may be needed.

Oral preparations

- Tablets come as either oestrogen alone, if the patient has had a hysterectomy, or oestrogen and progestogen. Oestrogen alone increases the risk of uterine cancer up to six-fold (Ferandez, 2003). HRT tablets are available as monthly bleed, quarterly bleed or period-free preparations (from a year postmenopause).

Non-oral preparations

- Topical oestrogen is available as an adhesive patch or as a gel that is rubbed on to the skin. More recently a nasal spray containing oestrogen has become available. Skin or local reactions may occur with any of the topical agents.

- Subcutaneous implants supply oestrogen for six months. They are usually inserted under the skin of the abdomen. As with any invasive procedure there is a small risk of skin infection and some women find the implants uncomfortable/unsightly. Progestogen tablets may also be needed.

Non-oral preparations avoid having to be broken down by the liver, a process known as first pass metabolism. This is preferred if there is a history of hypertension, gallstones, thromboembolic disease, epilepsy, liver disease, malabsorption or diabetes.

Alternatives to HRT

Medical, dietary and lifestyle alternatives to HRT include:

- Clonidine, usually prescribed for high blood pressure, can reduce hot flushes but has side-effects such as dry mouth, dizziness, nausea and insomnia;

- Tibolone can improve hot flushes, increase libido and vaginal lubrication;

- Beta-blockers, such as propanolol, may be used to reduce anxiety and panic attacks;

- Some phytoestrogens contained in soy-rich food such as tofu can help to relieve menopausal symptoms, as may a diet rich in vitamin E (Porter et al, 1996);

- A newer class of drugs called selective estrogen receptor modulators (SERMs), such as raloxifene, help to prevent osteoporosis, but they do not relieve menopausal symptoms. Bisphosphonates, calcium and vitamin D are also used to prevent and treat osteoporosis;

- Regular weight-bearing exercise will also reduce the risk of developing osteoporosis;

- Dietary advice includes avoiding caffeine, alcohol and spicy food (Yorkshire Menopause Group, 2003).

Discussion

All women approaching the menopause or going through it should be aware of the potential benefits and risks of HRT. The media can affect a woman’s decision to accept or reject hormone replacement and health professionals should be able to address the highlighted risks and give a balanced view. This is difficult with new findings and research data frequently being released in the press.

HRT is a prescription-only medicine and any decision to take it needs to be made by a woman in consultation with her GP. Nurses play an important role in discussing the risks and benefits of HRT with women and helping them consider their individual needs, concerns and risks.

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