To take or not to take – the truth about HRT

Women welcome new find­ings but pa­tients still left with tough de­ci­sion

The Guardian - - NATIONAL - Sarah Bose­ley Health ed­i­tor

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

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