Menopause news

Practical recommendations on HRT

February 2004

A recent report from a meeting of experts held in February 2004 and reported in Climacteric, Volume 7, Supplement 1, has highlighted some important further information from recent studies and provides some practical recommendations on HRT.

Regarding the Women's Health Initiative (WHI) trial and the Heart and Estrogen/progestin Replacement Studies (HERS), emphasis was made on the fact that women in the studies were generally much older than women who usually use HRT in the UK and that the risks of HRT demonstrated are lower for younger women.

Coronary heart disease.
Further analysis of results of the WHI trial showed no increased coronary heart disease (CHD) risk in women taking combined HRT who were less than 10 years postmenopausal and hysterectomised women taking oestrogen only had no increased risk after 7 years of use. It was also stressed that the overall CHD risk shown with HRT use was not statistically significant but accepts that many trials have shown that HRT does not offer CHD benefit for women who already have disease. HRT may still be beneficial for primary prevention if started early enough but there is also evidence that different doses, types and routes of both oestrogen and progestogen may be critical in achieving beneficial effect, particularly on metabolic effects.

Breast cancer.

Breast cancer risk was not significantly increased for women taking HRT in the HERS trial. In the WHI trial for women taking combined HRT, there was no significant increased risk for the first 4 years of use in women who had not previously taken HRT, and women taking oestrogen only had no increased risk after 7 years of use. The Million Women Study (MWS) showed an increased risk of breast cancer for both oestrogen only and combined therapy but the way in which the information was collected precluded any definite conclusions about relationship between dose and duration of use and risk. Information from the Cancer Prevention Study showed that women with breast cancer who had taken HRT had a better survival rate than those with breast cancer who had never taken HRT suggesting that HRT may accelerate cancer tumours already present rather than causing new cancers. Many other studies have confirmed lower mortality rates from breast cancer in women who have used HRT compared to non-users.

Menopausal symptom control.

It was accepted that hormone therapy has proven benefits for symptom relief and that the lowest effective dose should be used. Gradual withdrawal of treatment should be offered every 2-4 years but in up to ¼ of women, symptoms may recur and treatment may be required for >5 years. Women taking systemic therapy should be reviewed annually and therapy should be individualized, considering the risk/benefit balance. Alternative menopausal treatments, used by 50% of women, have questionable efficacy and no long-term safety data are available. Other treatments being used for menopausal symptoms are selective serotonin receptor inhibitors (SSRIs) and gabapentin for which reductions in flushes have been shown but because side effects are common, they should be used with caution.

Vaginal atrophy, which can considerably affect quality of life, is often neglected and under-treated. It is said to affect 15-20% of premenopausal women and 40% of women in the postmenopause. Although systemic HRT can help, additional vaginal oestrogen is required for 10-25% of women on oral HRT due to continuing vaginal atrophy and very low doses of oestrogen provided by vaginal tablets is very effective and of minimal risk.

Osteoporosis.

It was concluded that low-dose HRT is effective in prevention of osteoporosis in early postmenopausal women. Although other treatments such as bisphosphonates and raloxifene have proven effect in treating osteoporosis, it was felt that the treatment of choice for postmenopausal osteoporosis prevention is still HRT.

Finally, the concern expressed over results from the WHI trial should be considered in context: symptomatic peri- and early postmenopausal women are not likely to be at the same risk from HRT as the population in the WHI trial and current guidelines still recommend using HRT for 3-5 years for women with menopausal symptoms and for those at increased risk of osteoporosis.

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