Dr Matt Pic­caver weighs the pros and cons

New ad­vice about the safety of HRT has stirred the de­bate once again. Suf­folk GP Dr Matt Pic­caver weighs the pros and cons

EADT Suffolk - - Contents -

MED­I­CAL ad­vice is of­ten con­fus­ing. One mo­ment a treat­ment is en vogue, a panacea for all ills. The next, fallen out of favour, de­nounced in the press and avoided by clin­i­cians. Then it comes back in favour, per­haps for the same con­di­tion, per­haps for some­thing else. Then be­fore you know it, out of fash­ion again.

For many women, the menopause is a mis­ery. Hot flushes are a com­mon fea­ture, and per­haps the commonest symp­tom peo­ple re­port to me. Add on top of that changes in weight, emo­tional la­bil­ity, loss of li­bido and vagi­nal dry­ness, and it is clear to see that the run up to the menopause can be far from pleas­ant.

The av­er­age age of the menopause is just un­der 52 years of age in the UK. The pe­riod run­ning up to it is known as the cli­mac­teric. This is the time when the egg sup­ply is get­ting low. A woman is born with all the po­ten­tial eggs she will ever have, be­ing made dur­ing de­vel­op­ment in the womb and start­ing to fall in num­ber in the last third of de­vel­op­ment in the womb.

In the run up to the menopause, pe­ri­ods may be­come more ir­reg­u­lar and heav­ier. Some women I meet are de­bil­i­tated by the sever­ity of their pe­ri­ods, caus­ing a se­verely neg­a­tive af­fect on their qual­ity of life.

The role of HRT is to supplement or re­place nat­u­rally oc­cur­ring hor­mones and al­le­vi­ate some of the symp­toms of the menopause. The de­ci­sion on whether to take HRT is not an easy one to make. Ear­lier in my ca­reer we were fairly re­laxed about pre­scrib­ing HRT and many women will have de­rived ben­e­fit. Some will have suf­fered breast can­cer, the risk of which was un­known in the early days of its use. Sub­se­quent stud­ies have shown an in­creased risk of breast can­cer.

There is a whole range of dif­fer­ent brands of HRT avail­able, but in gen­eral here are the main types. Oestrogen only HRT con­tains one type of hor­mone, and is given to peo­ple with­out a womb. It had been shown that oestrogen only HRT in­creased the risk of en­dome­trial can­cer (can­cer af­fect­ing the lin­ing of the womb). This is why we usu­ally re­serve this for women who have had a hys­terec­tomy. The other types of HRT con­tain oestrogen and pro­ges­terone. Con­tin­u­ous com­bined HRT con­tains hor­mones all the time, and cycli­cal HRT uses pro­ges­terone for part of the time, mim­ick­ing the menstrual cy­cle to some de­gree. Com­bined HRT has been shown to in­crease the risk of breast can­cer. This risk usu­ally drops af­ter the HRT has been stopped. Us­ing pro­ges­terone and oestrogen HRT may re­duce the risk of en­dome­trial can­cer com­pared to oestrogen alone, but there are still some un­cer­tain­ties. Ovar­ian can­cer risk is also in­creased a lit­tle with HRT of ei­ther form. Can­cer Re­search UK advises that for ev­ery 1,000 women tak­ing HRT at the age of 50 there will be two more breast can­cer cases and one more ovar­ian. The ques­tion of whether we should rec­om­mend HRT is very much down to in­di­vid­ual choice and how badly af­fected a per­son is with the symp­toms of the menopause. The risk is usu­ally greater the longer it is taken for, but the over­all risk of de­vel­op­ing breast or ovar­ian can­cer is still low for most women. The re­lief gained in tak­ing HRT must be tem­pered with the knowl­edge that there may be an in­creased risk of cer­tain can­cers. In gen­eral we should prob­a­bly take HRT for the short­est amount of time at the low­est ef­fec­tive dose. This is in com­mon with many treat­ments for a va­ri­ety of diseases. Why take more than you need? Much of the risk comes with pro­longed HRT use, of­ten over five years. Many women might only take HRT for a year or two while symp­toms are at their worst. Peo­ple tak­ing HRT for 10 years or more tend to have the higher risk of de­vel­op­ing breast can­cer. What­ever de­ci­sion you make re­gard­ing HRT has to be the right one for you. For many, the dis­tant pos­si­bil­ity of breast can­cer in the fu­ture is out-weighted by the mis­ery of symp­toms here and now. Dis­cussing your con­cerns with your GP will help you get to the right de­ci­sion for you.

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