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
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.