By Dr Jane Dickson, Consultant, Sexual and Reproductive Healthcare
Is HRT safe or not to be trusted after all?
We invited menopause specialist, Dr Jane Dickson, to give us her view.
I have run a menopause clinic in South East London for the last twelve years. The initial scare stories related to hormone replacement therapy really began in about 2002. At this point, many GP’s put a ‘blanket ban’ on prescribing HRT so when I started my clinic it was the norm to see totally desperate women whose lives were being severely disrupted by menopausal symptoms.
Many women are lucky and glide through menopause but the two hundred new women that I see each year do not. In short, women have been so terrified by what they might do to themselves by taking Hormone Replacement Therapy, that they only request to see a menopause specialist if they are totally desperate.
Women I see broadly fall into three groups:
Firstly, women who are suffering symptoms whilst in the early throes of perimenopause. These include hot sweats, hot flushes, poor sleep, and mood disturbance. These symptoms affect energy, confidence, relationships, and self-esteem.
Next are the group of women, who are often older and may have been post-menopausal for several years – these women may or may not have taken HRT at some point, but now they come to see me because of symptoms related to their genitourinary tract, mainly their vagina or bladder. It is very common to develop vaginal dryness and bladder weakness because muscles become weak and the tissues thin. This may lead to sexual problems in previously sexually satisfying relationships.
Finally, there is the group of women who have had early menopause which has either occurred naturally or because of surgery. These women are often battling with many additional issues such as the loss of their fertility. All of these women would benefit from HRT.
HRT-related panic set in in 2003/2003 when the findings of two big scientific studies suggested that there were major risks associated with HRT. These studies were the Women’s Health Initiative and the Million Women Study and they both followed women over time who had used HRT.
These studies showed an increased risk of breast cancer, an increased risk of venous thrombosis (blood clots in legs and lungs), and an increased risk of stroke and heart disease. However, the studies had many limitations, including the fact that the group of women that they studied were far older than the age at which women usually use HRT and had a higher than average body weight.
After years of scrutiny, it is now known that the risk of breast cancer is related to how long HRT is used and goes back to normal after stopping. It is also known that the risk of stroke and heart disease is only really relevant to women who start HRT over the age of 60 (the average age of menopause is 51 so the majority of women will use it much earlier) and there is an increased risk of blood clots but this relates to tablets and not other forms e.g, patches and also other risk factors.
To put this into a totally anecdotal context, I have seen more than a thousand new menopause patients since I started my clinic. None have developed breast cancer that I am aware of and one woman had a blood clot in her lung following a long-distance flight and a blood clot in her leg.
NICE (The National Institute for Health and Clinical Excellence) published its guidance on menopause in November 2015. This guidance states that for symptomatic women, the benefits of HRT generally outweigh the risks. This refers to the clinical risks, but what can’t be forgotten is the enormous benefit that HRT can have on life in general. If sleep, mood, and sex life are improved this can have an enormous benefit on quality of life as well as physical well-being.
Recently, yet again more controversy has been unleashed as the “Breast Cancer Now Generations Study’ has shown a higher risk of breast cancer in HRT users compared to non-users -‘up to threefold depending on how long HRT has been used’. Once again it has been shown that the longer HRT is used is associated with increased risk. A ‘three-fold increase’ has also been reported as a ‘300% increase’ – numbers which sound extremely alarming.
In reality, about 14 women in a thousand will develop breast cancer in this age group and this may go as high as 34 in a thousand HRT users – However, short-term use has negligible risk, and also HRT which only contains estrogen hormone does not have increased risk. The group of women who have had an early menopause does not have any additional risk related to HRT until they reach the age of the ‘natural menopause’ because they have lost their own internal hormones.
Finally, I’d like to reassure that group of women who have vaginal dryness and painful sex. This group of women can use ‘local’ hormones i.e estrogen creams or tablets that are put into the vagina. There is no risk related to these products and I have even given them to women who have actually had breast cancer. Using these preparations for one whole year is only the same as taking one single HRT tablet.
There are no guarantees about anything in medicine and there are no guarantees about HRT. But there is no doubt that if women are suffering from considerable symptoms, HRT can help.
Dr Jane Dickson is a Consultant in Sexual and Reproductive Healthcare in South East London. She runs gynaecology clinics with a particular interest in helping women manage hormonal problems. She is a menopause specialist who regularly teaches and trains other doctors so that they can also help to support women with symptoms.