The arrival of menopause can be particularly distressing both mentally and physically. A number of conditions are associated with menopause. These include hot flashes, an increase in incidence of osteoporosis, alzheimer’s, vaginal atrophy and cardiovascular disease. At the beginning of the 20th century, the FDA approved an estrogen replacement medication called Premearin for the treatment of hot flashes.
In the 1970s, it was found that unopposed estrogen therapy was associated with an increase in endometrial cancer and HRT became unfavourable.
Subsequently however researchers found that if the dose of estrogen was reduced and combined with progesterone then the risk of endometrial cancer was reduced and once again HRT in the form of combined therapy (estrogen and progesterone) became popular again.
In 1988, the FDA approved HRT as a treatment not only for hot flashes but also for prevention of osteoporosis. As confidence and usage increased, researchers became interested in cardiovascular disease prevention.
We know that the incidence of cardiovascular events increases in post-menopausal women. This was shown nicely in the SWAN study which found that in women with hot flashes, there was a higher incidence of sub-clinical cardiovascular disease which included more calcification in the walls of the big vessels in the body (aorta) compared to women without menopausal symptoms. GIven this observation, researchers became very interested in trying to work out whether replacement of hormones by giving patients HRT could in fact prevent or arrest the sub clinical cardiovascular disease and in some way prove protective.
A bunch of observational studies did in fact suggest that this could be the case and doctors became very interested in prescribing HRT to women to reduce the risk of heart disease.
In 1998, a study was undertaken to better study the effects of HRT on the most common causes of mortality and morbidity in women such as cardiovascular disease, cancer and osteoporosis. This was called the Women’s health Initiative study.
16608 women with intact uteruses were given either a combination of oestrogen and progesterone or placebo and a further 10739 women without uteri were given oestrogen or placebo. The results were published after 5 years and claimed that in women with intact uteri, there was an increase in coronary disease and breast cancer but there was a reduction in osteoporotic fractures and colon cancer. On the basis of these results the trial was stopped prematurely and the message sent out was that HRT was a bad bad thing and there was a huge drop in HRT prescription.
In the group of women without uteri, they found that there was a small increased risk of strokes and there did not appear to be any benefit in terms of cardiovascular risk or breast cancer (but there was no increase risk either) but again there was a consistent beneficial effect on osteoporotic fractures and colon cancer. Nevertheless the overall message still remained that HRT was not such a great thing and it could be used maybe sparingly for osteoporosis and symptoms relief (from hot flashes) but should definitively not be used in asymptomatic women.
As people tried to make sense of these data, it started becoming apparent that a large number of patients in the WHI study were almost 10 years past their last menstrual period and therefore could these results really be applied to younger women who were perimenopausal or early into their menopause?
There was therefore a reanalysis of the data and other studies looking at younger women within 10 years of menopausal onset. These were younger women aged between 50-59y and in these patients it did appear that taking combined HRT for 10 years immediately after menopause was associated with a reduction in heart disease and death from heart disease. Unfortunately this was not as heavily publicised in the media and because of this many symptomatic women in the early years after menopause are still not prescribed HRT.
So currently the scientific bottom line is that HRT is highly beneficial in women who are symptomatic with hot flashes and other symptoms associated with menopause within the first 10 years of menopause. In these patients it will help with hot flashes, reduce the risk of osteoporosis and reduce the risk of heart disease.
Here is a little summary of who may benefit from HRT and in whom HRT is probably not a good choice.
- At present given all the conflicting data, HRT is no longer routinely prescribed solely for prevention of chronic conditions such as osteoporosis, cardiovascular disease, dementia etc
- However in patients with symptoms associated with menopause, HRT is a safe choice within the first 10 years after menopause or in women under the age of 60 years of age. Such symptoms include:
- Hot flashes
- Mood lability or depression (in such patients HRT combined with an SSRI antidepressant can be helpful)
- Sleep disturbances – these are common in peri/post menopausal women and HRT may help with these
- Joint aches and pains – HRT can help with these in some patients
- Volvo-vaginal atrophy
HRT is not however recommended in patients with:
- a history of breast cancer
- Known heart disease
- Previous blood clots or previous strokes
- Active liver disease
- Active endometrial cancer
- Unexplained vaginal bleeding
So I hope you found this useful. I do not have a huge amount of expertise in this subject but i was keen to educate myself and also provide my patients with a more informed opinion and this is why i chose this subject for a video. I would love to know what you think of this and once again thank you for all that you do for me.
Keywords: HRT; Hormone replacement therapy; menopause; heart disease; oestrogen; estrogen