IRREPLACEABLE?
Is HRT’S bad rap leading women to needlessly suffer life-altering symptoms?
What was your reaction when you read this assemblage of consonants? If it induced a sentiment of wariness, mistrust or even fear, you’re not alone. But as leading medics declare hormone replacement therapy’s PR problem one of the greatest injustices in women’s healthcare, WH hears them out
The bathroom cabinet of a magazine editor is a sight to behold. It’s stacked with the latest lotions, serums and elixirs from beauty brands, with products to brighten, tighten, nourish and soothe rotating in – and out – with regularity. But a couple of products remain a constant in
Women’s Health’s Editor-in-chief Claire Sanderson’s cabinet. The first is an oestrogen gel, a few pumps of which are applied to the outside of her upper arms each morning; the second – a lightweight white cream containing testosterone – gets rubbed along each bicep. The former allows oestrogen to sink into her body through her skin, while the latter allows testosterone to do the same. They amount to Claire – who, at 42, is going through the perimenopause – being ‘on HRT’. But while she views it as just another ingredient in her ever-evolving recipe for staying healthy and happy – alongside her give-it-all-you’ve-got Peloton workouts, a plant-based diet and early nights – she’s in the minority.
HRT is, at present, the most effective way to improve the lives of women with perimenopausal and menopausal symptoms in the short term, while enabling them to live healthier, more independent lives as they age – but it’s desperately unpopular. While there are 3.4 million women aged between 50 and 65 in the UK*, doctors believe only 10% of them use HRT. Some women who spoke to WH for this piece dabbled with short courses; others refused to touch it – and this reticence is matched by doctors. A study by the independent Nuffield Health group found that, despite 47% of women with menopausal symptoms feeling depressed and 10% considering quitting their job, doctors aren’t readily offering the treatment to their patients. One-third of women who visited a GP were not made aware of HRT, and, of those who were, many were denied it due to existing or family history of health concerns. So why did taking the reins of your hormonal health become so problematic? And what does this mean for you?
RISE AND FALL
If you’ve filed menopause away in the ‘deal with it later’ corner of your brain, here’s your primer. it occurs when a woman hasn’t had a period in 12 months, and usually between the ages of 45 and 55 – though some women go through it earlier. A drop in the production of oestrogen and progesterone by the ovaries triggers symptoms including brain fog, weight gain, vaginal dryness and unmanageable moods. This is where HRT comes in; topping up plummeting hormone levels to reduce the severity of symptoms, while mitigating long-term negative consequences of low oestrogen levels, such as osteoporosis and heart disease. For most women, taking HRT will look like a daily dose of progesterone (either a synthetic progestogen, or body-identical progesterone – more on the difference later) and oestrogen in either tablet form or in pessaries, creams and gels, applied topically. Some women are also prescribed a low dose of testosterone to improve tiredness and low libido.
The story of HRT begins in the 1940s, when the first formulations were synthesised, although it wasn’t until 1969 – when the first menopause clinic in Europe opened in London – that it began to be widely prescribed. ‘By the late 1990s, when use of HRT peaked, scientists realised it appeared to improve long-term health outcomes, such as bone density,’ says Haitham Harmoda, chair of the British Menopause Society and a consultant gynaecologist at King’s College Hospital. It was in studies aimed at quantifying HRT’S benefits that it was dealt its major blow, something that underlines much of the hesitancy around the treatment today: being linked, directly, to an increased risk of breast cancer, as well as heart disease. Findings from the Women’s Health Initiative (WHI) study, published in the US in 2002, were so widely shared – under headlines such as ‘HRT doubles breast cancer risk’ – that the number of prescriptions issued plummeted from 6 million to about 2.3 million between 2003 and 2007. Today, around 250,000 women in the UK take HRT.
The treatment has been the subject of a game of reputational snakes and ladders ever since. First, an analysis of the WHI study indicated that the alarming headlines were overstated. ‘The women studied had several risk factors for these diseases, independent of HRT; nearly half were smokers or ex-smokers, while 70% were overweight or obese,’ says Harmoda. NICE guidance in 2015 – stating that, for most women, the benefits of HRT outweigh the risks – was seen as a win by Harmoda and others in the field; as was an apology in 2016 by two of the WHI study authors for the way the results had been interpreted. Then came the publication of a meta-analysis in The Lancet, in which University of Oxford researchers reaffirmed the association between HRT and
‘There’s no prize for going through the menopause without HRT’
breast cancer. They found that, for women of average weight, taking combined oestrogen plus progestogen for five years from the age of 50 could increase their chance of developing breast cancer in their fifties and sixties by 2%, with sequential HRT (oestrogen daily, and progestogen for part of each month) upping the risk by 1.4%, and oestrogen-only HRT by 0.5%. The day after the study was published, the Medicines and Healthcare products Regulatory Agency issued an alert, calling for doctors to prescribe HRT ‘at the lowest dose for the shortest amount of time’.
‘It was totally inappropriate,’ says Professor
Dame Lesley Regan, former president of the Royal
College of Obstetricians and Gynaecologists. First, she argues, there was no context given around these statistics: context like the use of HRT not leading to more deaths from breast cancer; that the very small risk of breast cancer associated with taking combined HRT is six times lower than that resulting from being overweight or obese; and that the medication would be preventing bone loss and providing protection from cardiovascular disease. ‘Risk means different things to different women – it’s wrong to assume our priorities and concerns are all the same,’ she says. Just as one woman might prioritise mitigating her risk of developing breast cancer above all else, ‘another might feel that quality of life now – and a reduced risk of fractures and heart disease in the future – is more important than avoiding the small increase to their risk of developing breast cancer’. The most recent estimate of that risk is that for every 10,000 women who use combined HRT (the preparation associated with the most side effects) just 36 are likely to develop breast cancer as a result of the medication*.
NATURAL SELECTION
While the widely reported breast cancer risk was the biggest deterrent against taking HRT among women contacted for this piece, a desire to go through the menopause naturally came up repeatedly, too. Dr Helena Mckeown, 53, is a GP in Salisbury and chair of the British Medical Association’s Representative Body. She’s currently experiencing irregular periods, insomnia and hot flushes. But, despite offering HRT to her patients, she’s
reluctant to take it herself. ‘I want to address [my symptoms] through lifestyle, at least until my periods stop altogether,’ she says. ‘I’m part of a generation who grew up wanting more natural health experiences, like experiencing childbirth with as few interventions as possible. I think that’s why a part of me wants to go through the menopause naturally.’ She’s not alone: Google searches for ‘menopause diet’ in the UK were, in 2019, the highest since records began and, in the same year, ‘natural menopause’ was searched more than it had been in 15 years.
‘I constantly hear from women who want to find a “natural” alternative and I think that they expect me to warn them off HRT,’ explains Maisie Hill, an acupuncturist, doula and author of Perimenopause Power (£14.99, Bloomsbury). She’s ‘all for’ HRT forming part of her toolkit when her own time comes, and is frustrated by an increasingly pervasive false binary in midlife wellness circles: that you can tackle the menopause one of two ways – naturally, or by using HRT. ‘There are no prizes for going through the menopause without taking HRT – and combining strategies can work wonders. I’m currently working with a client who’s taking body-identical progesterone, and we’re addressing workplace stress, boundaries, people-pleasing, sleep hygiene, nutrition and exercise alongside.’
Also advocating for a holistic approach is Dr Louise Newson, a GP who set up a specialist clinic – and menopause support app, Balance – after becoming frustrated with limited NHS provision. (Her tips include improving gut health to better aid serotonin production, reducing cortisolspiking high-impact workouts and supplementing with vitamin D, magnesium and fish oil.) For her, they work hand in hand. ‘When I had perimenopausal symptoms, I couldn’t be bothered to cook; my yoga practice was hard because my joints were stiff and sore; I had no energy,’ she recalls. Her experience is reflected in a survey by the British Menopause Society (BMS), in which 34% of women reported being less active since experiencing menopausal symptoms. ‘Once
I’d addressed the hormonal issue,’ she says, ‘I was able to revisit those health-promoting habits.’
LIVES LOST
But it’s not simply that HRT hesitancy is reducing women’s ability to optimise their wellness in their forties and beyond. It’s bigger than that: as if, without HRT – the most effective set of tools available to tackle its short and long-term consequences – the (peri) menopause is inadvertently handed power to claim women’s jobs, relationships and identities at one of life’s most challenging stages. In the aforementioned BMS survey, 37% of respondents said the menopause had left them with low energy, and almost half felt that their menopause had a negative impact on their work. Lisa O’neill, 47, a gallery owner from
‘I’ve had no symptoms, I can exercise again and I feel like myself’
Lancashire, began her menopause at 45, following a hysterectomy to prevent the return of painful fibroids. Soon after came hot flushes that left her unable to sleep and a constant full-body ache; then perpetual brain fog that meant she was unable to concentrate in meetings, forgetfulness and anxiety so severe she couldn’t drive herself to work. ‘I must have seen 20 doctors over the past two years,’ she says. Physicians were reluctant to offer HRT, as she’d had a breast cancer scare the year before – and this wariness stood in the way of her symptoms being alleviated. The low-dose oestrogen gel they eventually offered didn’t make much difference, and the higherdose patches (which she finally got her hands on when she self-referred to an NHS menopause clinic, after a DEXA scan revealed that her bones were already thinning) eased hot flushes, but nothing else.
Doctors’ hesitancy around HRT – fuelled by the now robustly challenged increased breast cancer risk – is a common refrain among women in their forties and fifties, and a source of huge frustration for every menopause specialist WH spoke to for this piece. ‘What’s happened with HRT is one of the biggest injustices in women’s healthcare,’ adds Professor Regan. ‘It’s basically condemned two generations of women to having brittle bones unnecessarily and poorer quality of life,’ she says. Dr Newson is at pains to emphasise this isn’t just about symptom relief. ‘Women now can expect to live for 30 to 40 years longer than they had done for centuries with low levels of hormones,’ she explains. ‘If I stopped taking HRT today, I might have worked through my symptoms and feel fine. But overwhelming evidence suggests that once I stop, I’ll be more likely to develop heart disease, dementia or osteoporosis.’ These women aren’t pushing for every woman to take HRT, but for doctors to feel confident prescribing it to women who could benefit; for women to have access to accurate information and to feel empowered to make the choice for themselves, coming from a place of knowledge – not fear.
Such was the case for Claire. When she first went to her GP to ask about HRT, after her friend – a doctor – suggested that the exhaustion and catapulting moods she was experiencing at 39 might be down to the perimenopause, she was warned against the medication because of a strong history of breast cancer in her family, with no detailed questioning or blood tests to investigate whether a hormonal issue was behind her feeling so unlike herself. It was only after hearing Dr Newson speak at a government meeting that she decided to look again at the treatment. And now, after 18 months of tweaked doses and formulations – with Dr Newson’s guidance and support (see right) – she’s found a balance that works for her.
‘With access to a broad spectrum of experts, I’ve been able to educate myself on the benefits and – what I believe is – misinformation about HRT to make an informed choice,’ she says. ‘Once I got the dose correct, I felt clear-headed, energetic and so much happier.’ Lisa was offered an HRT implant, which was inserted under the layer of fat on her stomach, in a quick outpatient appointment. ‘The difference was instantaneous,’ she recalls. ‘I’ve had no menopause symptoms, I can exercise again and I feel like myself.’
In the minds of both women, the benefits of HRT – for now, and in the future – outweigh the risks. Mammograms are attended, breasts routinely checked, and they’re able to work, parent, and show up for themselves as they wish. There’s no neat roadmap to follow when it comes to optimising your health in midlife. But as you plot the right route for you, be careful you’re not writing off something that could ease your journey.