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