Pros and cons of Hormone Replacement Therapy (HRT) in women – facilitated by Associated Professor Jane Smith

Main menopause symptoms

  • Irregular light, heavy or prolonged periods
  • hot flushes/sweats
  • disturbed sleep
  • dry vagina, and uncomfortable sex
  • loss of libido
  • more frequent and urgent need to pass urine
  • joint and muscle pain
  • headaches, migraine
  • crawling sensation on skin
  • tiredness, irritability
  • memory loss, difficulty concentrating
  • depression/moodiness

HRT relieves menopausal symptoms – HRT use can be oral, transdermal, implants, or vaginal.  Vaginal and transdermal are the safest options.

Women with severe symptoms (approx 20%) can benfit from use of HRT.

We mainly discussed 2 papers in the clinical discussion on the use of HRT and the harms and benefits, but also referred to a cochrane review.

The original Womens Health Initiative RCT of  16,000 postmenopausal women put on oestrogen and progesterone at an average age of 63 years. They were followed up for about 5 years at which time the number of breast cancers reached the threshold to halt the trial.  Hormones used were conjugated equine estrogens and medroxyprogesterone.

It found that use of HRT in this cohort of women increased the relative risk of stroke, heart disease and breast cancer by between 25-40%  after 5 years of use. It also reduced the risk of colorectal cancer and hip fracture by 34-36%. The risk of pulmonary embolism and VTE was more than doubled from start of use.(1)

The second paper was an RCT of 1000 women randomised to start on HRT from the age of menopause, an average age of 50 years and they were followed up for 10 years, with very different findings, namely reduced risk of death, heart failure, and myocardial infarction, without any apparent increase in risk of cancer, venous thromboembolism, or stroke. The hormones used were 17B oestrodiol and norethisterone.(2)

These results being so different have created debate about their veracity and a Cochrane review on the long term safety of HRT did not include the study as there was no placebo in the control group. The Cochrane review found harms started from 1 year after taking HRT of a similar nature to WHI results.

Summary

HRT works to relieve symptoms, and reduced fractue risk, but is not without harms, which increase with duration of use, so any long term continuation needs to be carefully reviewed on an individual basis with short term use the safest option if and when HRT is required.

References

  1. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33. Epub 2002/07/19.
  2. Schierbeck LL, Rejnmark L, Tofteng CL, Stilgren L, Eiken P, Mosekilde L, et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ. 2012;345:e6409. Epub 2012/10/11