To take or not to take – the truth about HRT
Women welcome new findings but patients still left with tough decision
Hormone replacement therapy, possibly the most controversial medicine ever invented, will not kill you. That was the conclusion this week of a big study in the US that was one of the first to flag up the risk of breast cancer. Women who took the tablets to alleviate hot flushes and night sweats were no more likely to be dead 18 years later than those who did not.
That’s good news and it was loudly celebrated. The risks are low. Women must be told about them, but they should not be deterred by any thought that HRT could shorten their life.
Yet in one way, the long-term results from the Women’s Health Initiative (WHI) study don’t change a thing, because they are about mortality. HRT still increases the chance that a woman will get breast cancer and ovarian cancer and possibly heart disease and stroke in those over 60 – she just won’t die as a result because treatment is better now. It can still be difficult to decide whether to take HRT.
But HRT works. Mariella Frostrup, the presenter and Observer agony aunt, said she got her life back and hit out at “the shroud of secrecy and shame” around the menopause that prevents women getting the relief of HRT. In contrast, the Woman’s Hour presenter Jenni Murray, however, who developed breast cancer after 10 years of HRT following an early menopause, said she would never have taken it if she had known then what she knows now.
An estimated 1.5 million women in the UK – 85% of all those going through menopause – suffer common symptoms such as hot flushes and night sweats. The menopause usually takes place between the ages of 45 and 55, although for some women it happens prematurely and others are thrown into it by cancer treatment.
The first oestrogen pill was introduced in 1942. HRT became available to women in the UK in 1965, without the sort of trials that would be done today. The rationale was clear – the pills replaced the oestrogen women were losing. The sales pitch played on fears of ageing. Without any evidence, the suggestion was planted that HRT would restore both vigour and beauty.
“When a woman develops hot flashes, sweats, wrinkles on her face, she is quite concerned that she is losing her youth – that she may indeed be losing her husband,” said a drugmaker’s promotional film in 1972. A New York gynaecologist, Robert Wilson, who had links to the manufacturers, published a book called Feminine Forever, calling women who did not take hormones “castrates”.
The science came later and caused dismay. The Women’s Health Initiative was a huge study of nearly 162,000 women launched in 1991. The UK-based Million Women Study began in 1996. Both found an increased rate of breast and ovarian cancer. Thousands of women stopped taking HRT; thousands more were anxious about starting it.
The pendulum has swung back the other way, with guidance from the National Institute for Health and Care Excellence in November 2015. Nice said that millions of women should no longer have to suffer in silence and that HRT worked and should be considered. And now the WHI study has published its long-term findings showing women do not die from taking it.
“Data showing that mortality overall is not increased in all age groups is a very reassuring finding,” said Haitham Hamoda, a consultant gynaecologist at King’s College hospital in London and spokesman for the Royal College of Obstetricians and Gynaecologists.
Hamoda says the breast cancer risk is not high. The WHI study puts it at one more case in 1,000, which Hamoda says “in medical and statistical terms is a small number. It is similar to the [breast cancer] risk of drinking a glass of wine a night.” The risk of breast cancer from being overweight is four times higher.
A more recent study on the causes on breast cancer, from the Institute of Cancer Research in London last year, found that among the 100,000 women taking part, those on HRT had a 2.7 times higher risk of contracting the cancer than those not taking hormones. “We found risks that were slightly higher than other people had been reporting,” said Dr Michael Jones of the ICR’s genetics and epidemiology unit. “Part of that is because we have good quality data and were able to tell when women started and stopped HRT.”
The risk is higher for woman taking the combined oestrogen and progesterone pill and lower for those on the oestrogen-only pill – but women need progesterone to protect against womb cancer unless they have had a hysterectomy.
Hamoda said: “We see 2,000 patients a year. The number who come in saying it [the menopause] is affecting my relationship, I go to a meeting and my brain goes blank. It affects women’s lives. The average duration of symptoms is seven years but one in three go beyond that. There are no markers to show who will have the symptoms for six months and who is going to have them for 20 years.”
Jeanette Winterson sought treatment with “bio-identical” hormones rather than those the NHS provides, which their supporters claim are natural. The author wrote of the “impossible choice” women have to make, between mental and physical wreckage and flooding their bodies with synthetic hormones.
But conventional doctors say there is no difference. Women are given oestrogen in the form of estradiol on the NHS, which Hamoda says is bio-identical – identical to that made in the female body. The progesterone that most women get is synthetic, but bio-identical micronised progesterone, made from plants, is also available on the NHS.
NHS advice is that each woman should talk through the options with her GP. Those at high risk of breast or ovarian cancer or those who have had them will not be advised to take HRT. For everyone else it is something of a guessing game. The odds of cancer are low and reduced if a woman takes the pills for a shorter length of time.
There is a glimmer of hope though. In April, the results of a drug trial involving women who were having seven or more hot flushes a day were published by Imperial College London. The drug cut the number of flushes by 73% by blocking a chemical called neurokinin B, which appears to be linked to oestrogen deficiency in the brain.
It will be a couple of years before the new drug is on the market, but if the results of further trials continue to be good, it is going to do very well indeed.
Mariella Frostrup, centre, said HRT gave her back her life, while Jeanette Winterson, left, sought bio-identicals as a ‘natural’ alternative. Jenni Murray, right, developed breast cancer after 10 years on HRT
A dispenser containing hormone replacement therapy tablets