October 2, 2008
Your Life: Dear Miriam – Why HRT Scare Stories Are Wide of the Mark ; HEALTH
By DR. MIRIAM STOPPARD
A million women in the UK have stopped taking hormone replacement therapy (HRT) thanks to scare stories based on flawed medical studies.
In 2001, doctors wrote just over six million HRT prescriptions, but experts estimate the number has now dropped to just 2.5m a year.
I'm a great believer in HRT and, providing there aren't any medical reasons why you shouldn't take it, I think it's a very good medicine indeed. I was one of the very first HRT researchers in this country and worked with many eminent scientists to find a form that was safe and effective in the lowest possible dose.
But when studies that blackened the name of HRT were published - including the US-based Women's Health Initiative study in 2002 and the UK's Million Women Study in 2003 - I found the findings disturbing because, in my opinion and that of many experts, they contained serious errors. And because the negative findings were widely publicised, they did untold harm, with many women unnecessarily stopping HRT.
One of the problems in some of these studies was that the findings were based on women who, on average, were in their 60s.
And that's when the health risks in question start to become more common - whether you take HRT or not.
Looking closely at the numbers the studies produced, the increase in risk for HRT-related problems is very small in real terms.
Many experts also now think that not taking HRT could do more harm than good. First, there's no other treatment for menopausal symptoms that comes anywhere close to the effectiveness of HRT.
But it also has a positive effect on bone and heart health and, as a result of so many women not taking HRT today, there could be many suffering fractures and heart attacks in the future. Here's what the scares really mean and how to make that decision.
The truth behind the tales
The scare: Taking HRT increases the risk of heart disease.
What experts think now: The latest study published this week found that overall there was no increased risk of heart attack with HRT compared to taking nothing. In fact, taken cyclically, HRT can even reduce the risk of heart disease.
The scare: HRT causes an extra six cases of breast cancer in every 1,000 who take it for five years.
What experts think now: HRT causes just two extra cases in every 1,000 who take it for five years, increasing to six per thousand who take it for 10 years.
Most recently, HRT has been shown to cut the chance of breast cancer in women with the BRCA1 gene (which predisposes women to a high risk of breast cancer) by a half.
The scare: HRT raises risk of ovarian and endometrial cancer by 20 per cent.
What experts think now: Fewer than one in 1,000 who take combined HRT (oestrogen and progestogen) for five years will develop ovarian cancer. There's also no evidence that taking combined HRT increases risk of endometrial cancer as long as you take it correctly.
The scare: For every 10,000 taking HRT, 29 a year have a stroke (compared to 21 in women not taking HRT).
What experts think now: Doctors accept that stroke is one risk of taking HRT. But if you're under 60, you don't smoke, drink heavily or have high blood pressure, experts now say the risk is small - just one in 1,000 in women who have been on HRT for five years.
The scare: The combined form of HRT increases risk of blood clots by an extra four cases per 1,000 after five years.
What experts think now: If you're under 60 the risk is minimal.
Why take HRT?
HRT treats every symptom of the menopause, including:
Urinary problems (cystitis-like symptoms)
Loss of sex drive
Back and joint pain
What are the treatments?
HRT isn't just available in tablets any more. There's a type to suit every woman.
It's just a case of finding what's right for you.
Discuss the various types of HRT with your doctor or, if you're having problems, ask for a referral to a gynaecologist.
Patches and gels: They deliver HRT through your skin and are the types that I personally favour since, unlike tablets, the hormones don't pass through your liver so you need a much smaller dose.
With a gel, you can also match your dose to your day-to-day symptoms.
Vaginal creams and pessaries: They treat vaginal dryness and urinary symptoms very well as the treatment goes directly to where it's needed.
Progestogen: Unless you've had a hysterectomy, you must take progestogen as well as oestrogen to protect against cancer of the womb.
You can take it on its own in tablet form, or as a combined pill with oestrogen.
You can also have a device called Mirena, which is a progestogen intra-uterine system (IUS) inserted in your womb.
You'd still need to take oestrogen separately.
The benefit of the IUS is that you don't have periods and you're also less likely to get any of the possible side effects of progestogen.
How long can you take HRT?
There's no exact starting age for HRT as it should be used when menopausal symptoms start.
However, most experts agree that if it's used on a short-term basis - that is for five years or fewer - the benefits greatly outweigh the risks, especially if you're under 60.
If you and your doctor decide you should take it for longer, review the situation together on a regular basis.
When it's a no no
If you have a personal or family history of any of the following, you may not be a suitable candidate for HRT:
Breast, ovarian or endometrial cancer
Blood clots or thrombosis
If you have high blood pressure, HRT is also not recommended.
However, if your blood pressure is treated and comes back into the normal range then you may then be able to start HRT.
What are the side effects?
There are possible side effects of oestrogen and progestogen.
However, just because you're having a side effect, you don't have to stop taking HRT.
Just ask your doctor to try you on a different type. Side effects also usually improve in time, so don't stop or change straight away.
If, however, the side effect continues after three months, ask your doctor for advice.
You may get:
Water retention and bloating
Additional research: CHRISTINE MORGAN
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