IS HRT SAFE?
Rosol Hamid
Consultant O&G
What is safe?
• Driving
• Swimming
• Crossing the street
• Cycling
• Riding a motor bike
• Parachute jumping
• Flying
Evolution & controversy
Over 20 years
HRT changed
from being the
elixir of youth
to being
considered
extremely risky
British Menopause society&
Women Health Concern recommendations
2013
• Informed choice
• Annual evaluation
• HRT before 60 has a favourable
benefit/ risk profile
• Premature menopause encourage
HRT until natural age of menopause
• Over 60 use low dose /transdermal
Effects of HRT
~Estrogen is most effective for
vaso motor symptoms
~improve mood in early
menopause
~ improve sexual function
~ improve vaginal dryness and
dyspareunia
~ help relief bladder symptoms
and reduce risk of recurrent UTI
Other effects
• Protective effect against connective tissue loss
• Bone protection
• Mirena can be used to reduce progesterone effects
Long term effects of HRT
• Preserve bone density
• Significant reduction in heart
disease
• Improvement in cognition
• Reduction in long term risk of
Alzheimer's and all cause
dementia
What about breast cancer?
• WHI... Small increase in
breast cancer risk. 1 extra
case/1000 women / year.
• In same WHI Estrogen
alone significant decrease
in breast cancer risk
• Recent critique of both
WHI and MWS revealed
flaws which limit the ability
of the trials to establish
causation
Other cancers
• Conflicting evidence on ovarian cancer risk
• Reduced risk for endometrial on continuous
combined preparations.
• Reduce risk of colorectal cancer
Summary practice points
• Individualised decision for
each woman
• Dosage and duration
individualised
• Annual evaluation of pros
and cons
• With time increased
sophistication of hormonal
preparations will reduce side
effects
Key recommendations
• Main indication is relief of vaso
motor symptoms
• Duration should not be subject to
arbitrary limits
• Routine advise on diet and life
style
• Phytoestrogens offer some
benefits on symptoms and on
skeletal and cardiovascular
systems
• Don't start HRT 10 years after
menopause
Issues
• MPA is associated with higher risk of breast
cancer than other progestogens ( American
association of cancer research)
• Moderate increased risk of VTE may only relate
to oral and not transdermal preparations
(RCOG)
Does HRT cause breast cancer
• Recent decrease in incidence of breast cancer
• The decline occurred immediately as HRT use declined
• No duration lag to support the association
• The evidence neither supports nor refutes the theory of
possible causation
• The associated risk of breast cancer is lower than that
associated with obesity and alcohol and later
reproduction
Benefits
Re examining the evidence
• Reduction in
cardiovascular problems
• Fewer risks than initially
reported
• Neuroprotective with
preservation of cognitive
ability and verbal
memory
Parkinson disease
• Younger age of onset in males
• Oestrogen has direct effect on dopaminergic
functioning
• PD more common in women after surgical
menopause
• May be protective from PD or has ameliorative
effects on symptoms
Reviewing the evidence Dec 2014
• HRT is the most effective
treatment for menopausal
symptoms
• In particular for younger
women at the onset of
menopause
• Hot flushes and night sweats
affect 70% of women for up to
5 yrs
• 10% may continue for many
years
The evidence
• Symptoms vary. In some can be
debilitating and can affect quality of
life
• HRT is the treatment for the
menopause.
• WHI 2003 reported increased risk of
breast cancer, VTE and stroke
• The re-analysis of the Women Health
Initiative study in 2007 demonstrated
that giving HRT for up to 10 years had
fewer risks! And reduction in
cardiovascular problems.
The evidence
• The Million women study
2001 suggested
increased risk of breast
cancer
• But failed to address
short use to relief
symptoms
• Women can gain the
advantage and tailor
treatment to reduce risk
Conclusion
• Women live long beyond the
age of menopause
• Future….Improved formula
with better long term benefits
and reduced risks
• Quality of life
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Is HRT safe – Lecture 2015 ( Miss R Hamid)