The truth about HRT

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Do the benefits of hormone replacement therapy outweigh the risks? The answer depends on your lifestyle, your family history - and even your personality. Below is a great article written by Philippa Pigache about HRT pro's and cons.

The menopause is a life-changing but not a life-threatening event, so ultimately whether you treat the short-term discomforts and the long-term health risks associated with it is a matter of personal choice. It will depend upon your priorities and your individual risk profile. It should be easy to sort these out, but in practice it is not, because really objective advice about whether or not to take HRT is hard to find. The problem is that almost everyone – GP, specialist, medical author, website – appears to be in one camp or another: HRT enthusiast or HRT hater. If you are medically qualified and an expert on statistics, you could read the clinical studies to inform your decision, but even these produce conflicting stories. The average woman hit all of a dither by a hot flush doesn't know where to start.

Hormones start (and stop) here

The menopause is caused by the falling off in the production of a particular form of the hormone oestrogen produced by the ovaries – oestradiol. This hormone, and others that are linked to it, are active not just in the ovaries, but in almost every part of the body. So, although the most dramatic consequence of the menopause is the cessation of monthly periods and the loss of fertility, knock-on effects are felt in your heart, blood vessels, bones, bladder, skin – even your brain. A fall in oestrogen causes uncomfortable short-term effects: hot flashes and night sweats, painful intercourse, disturbed digestion, bladder infections, breast tenderness, cold hands and feet, joint pain, mood swings; and also the more serious long-term effects: increased risk of heart attack, stroke, breast cancer and brittle bones (osteoporosis).

What is HRT?

Since menopausal symptoms and health problems can be tracked back to a fall in oestrogen produced in the body, it's not surprising that similar hormones, produced in the laboratory, can cure or alleviate them. Artificial oestrogens first appeared in the 1920s, at first isolated from the urine of pregnant women, and later from the urine of pregnant mares. These days other forms have been isolated and later from plant sources, though the equine type is still the most important.

To start with artificial oestrogen was used alone (unopposed) to treat the short-term symptoms of the menopause. And very successful it was too. But further down the line it was discovered that, used alone, oestrogen increased the risk of cancer of the womb lining, so the drug companies went back to the drawing board and combined artificial oestrogen with progestogen, another hormone that plays a role in the normal menstrual cycle but which also protects the womb lining. It is this combination in various formulations that we know as Hormone Replacement Therapy: HRT.

Is HRT for you?

No doubt you will start by asking your GP. But the medical profession is cautious by nature; not keen to push pills unless they are clearly needed, which means that in all probability the doctors in your life will not urge you in the direction of HRT, though they will certainly inform you about it, and very properly emphasise the risks involved. They read the literature and know that the verdict on HRT has swung violently from side to side over the past 20 years or so. But your GP is best placed to help you decide whether you are in one of the high-risk groups advised not to take HRT. For a few women the choice may be a clear: "Not for you."

But for the vast majority it will be a case of a slightly increased risk of one problem, or a slightly reduced risk of another. It comes back to a risk benefit analysis, plus how you feel about risk which only you can decide. One woman thinks a few sweaty moments are no big deal, whereas another, with a career to sustain, is desperate to avoid anything that could disrupt it. Yet another regards anything that might interfere with her sex life as anathema. For one woman adding even slightly to the risk of breast cancer is unthinkable, whereas another believes in living for the present, clings to her youth and lets risk in the distant future go hang.

Drawing up a personal health profile

Studies done of HRT show two things clearly: nothing beats HRT in treating the troublesome short-term symptoms of the menopause – the hot-flushes (also known as vasomotor symptoms), painful intercourse, urinary infections, bloating and mood swings, to name the chief culprits. Independent of the short-term symptoms, HRT increases the risk of some medical conditions for those in the high-risk groups. The most significant increased risks are from breast cancer, heart attack, stroke, and osteoporosis. Women start by having a very low incidence of heart attack and stroke compared with men before the menopause, but they reach the same risk as men within 10 years after.

Your family history

To work out your personal risk profile start by looking at your family history. Few diseases are 100 per cent hereditary. Nevertheless, some families have a higher incidence of particular conditions than others, and this seems most likely to be because they share a gene that, in certain circumstances, may make them susceptible to developing a health problem. So if female members of your family have had breast cancer, or if several have died of heart attack or stroke; or if there is a tendency for older family members to have a hip fracture or break bones easily, you also may be at risk. There are classic early-warning signs of heart risk: do you or members of your family have high blood pressure, high cholesterol, or blood that clots easily? Both the number of suffers and how closely related they are to you makes a difference to a risk profile that can be calculated by your doctor.

Your health and lifestyle

Your current state of health also affects your risk profile. Do you exercise regularly, are you overweight, over-stressed, depressed? Do you (God forbid), smoke cigarettes? Your health now and in the recent past is an indicator of how you may go on. Another thing that has only emerged recently from studies of HRT and health: if you are healthy HRT seems to improve your health, but if you are not, it can increase your risk of ill-health.

Your attitudes

After plotting your personal, statistical risk profile, you need to take a psychological inventory. What are your priorities in life and your attitude to risk? Of course, we all say we want to be healthy and are against taking risks with our health, but probe deeper. Do you want to be healthy at all costs. Would you give things up in order to be healthy – for example, flying, drinking wine, making love? Not that you need to give up any of these in order to survive the menopause; nevertheless, if you have ever said, "A short life, but a merry one," you may be among those prepared to take calculated risks rather than disrupt your lifestyle too much. Such things reveal important aspects of your personality that affect whether you choose to take a drug that may add to your quality of life now, while slightly increasing your risk of certain health problems later.

When to take HRT

One reason why you need to work this out early – before or when the menopause shows up – is that when you take HRT is as important as if you take it. Basically HRT early is good; HRT late is not. One massive US study of the health risks associated with taking HRT called the Women's Health Initiative (WHI), gave HRT to women in their 60s who hadn't taken it before. One reason the study chose older women was because some serious health conditions they wanted to assess: heart attack, stroke and osteoporosis, don't really show up until women reach this age, so starting a study from when they went through the menopause at around 50 would have been very long and expensive. In 2002 the WHI made headlines and halted the branch of the study assessing the effect of HRT upon heart attack and stroke because it emerged that there was a very small increase among those taking HRT. However, unlike most women who use it, they had not taken HRT at the time of the menopause, so it was not totally clear whether it was this lack or the HRT they had taken in their 60s that had caused the increase. Further analysis of the results of this and other studies confirms the latter: the earlier you start HRT the more beneficial its effect on the risk of heart attack and stroke, and only if you start taking it later does it increase your risk.

It's a different picture for breast cancer and osteoporosis. All other factors being equal (that is, familial risk), taking combined HRT appears to slightly increase the risk of breast cancer from the low baseline figure of 17 women in every 100. The risk increases the longer you take it: less than five years increases it very little; up to 10 years a little more; over 10 years (when you are over 60) more noticeably. Five years after you stop HRT your risk is the same as someone (of the same age) who has never taken it. On the basis of these statistics most doctors will prescribe HRT for five years starting at the menopause, while you are at a low risk of breast cancer and heart disease, but at a very high risk of nasty temporary conditions like hot flushes, painful intercourse and disturbed sleep. Some GPs may be relaxed about prescribing it for five more years if your general health is good. When you reach 60 most will ask you to stop. It will have seen you through the tough times by then.

Where osteoporosis is concerned, taking HRT reduces your risk to that of a premenopausal woman. However, five years after you stop, your risk of the condition reverts to what it would have been had you not taken HRT. So if you are in a high-risk group for this condition you will have to consider alternative, long-term treatments. There are a number of these, like bisphosphonates, raloxifene (a selective oestrogen receptor modulator) or strontium ranelate that are generally effective, though not without side-effects.

What are the alternatives?

There are also alternative prescription medicines for the risk of heart attack and stroke. However, if you decide against HRT, either because you fall in a high-risk group or because you are unsympathetic to this kind of medication, there are few alternatives that are as effective for the short-term symptoms of the menopause. You will be offered a forest of complementary and herbal cures, which include several compounds based on plant extracts that act like oestrogen. Some of these have a strong oestrogen-like effect and therefore carry the same health risks as drug-company manufactured oestrogens for those in one of the high-risk groups.

Among the most potent are motherwort leaf, saw palmetto berry, rhodiola rosea root and red clover blossom, while dong quai root, black and blue cohosh, vitex berry, hops flower, wild yam, and liquorice root have a moderate oestrogen effect. These are mostly sold in health food shops and classified as foods rather than medicines, which means that they don't have to undergo the same rigorous testing regime as prescription medicines before they can be sold. So far only black cohosh and vitamin E have been shown to be effective for vasomotor symptoms (hot-flashes) and then only for the short term (six months). While others may be effective, there is at the moment no evidence of their long-term safety. To target things like night sweats, wicking pajamas are a great natural solution as well.