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Last Updated: Tuesday, 3 July 2007, 11:54 GMT 12:54 UK
Health scares take their toll on HRT
Woman discusses HRT with doctor
Risks and benefits have to be weighed up in any HRT decision
Figures out this month are expected to show that take-up of hormone replacement therapy (HRT) has continued to slump amid a series of health scares.

Many GPs, according to some experts, simply aren't offering the drug anymore.

The wonder-drug that could stop hot flushes at the same time as restoring libido and making hair and nails gleam has been the subject of a barrage of negative headlines in the past five years.

Two large studies - one in the US and the other in the UK, produced some frightening results.

The drug was linked to a host of cancers including breast, ovarian and womb, as well as an increased risk of stroke and heart attack.

And while the methodology and conclusions of both have been challenged within the international medical community, the impression that HRT is a dangerous drug persists.

"The good news about HRT has had a hard time getting past the bad," says Patrick Shervington of Women's Health Concern. "So it's not surprising if many busy GPs don't hear it."

What happened

It was a major study backed by the US government which sparked the crisis of confidence in a drug which millions of women across the world were using.

The benefits
Tackles menopause symptoms
Prevents osteoporosis

The 2002 Women's Health Initiative, which looked at more than 27,000 women - was set up to find out whether HRT prevented heart disease.

The risks
Increases breast cancer rate but may improve survival
Heart risk for women 60+

It fact, it found the opposite to be true. Those taking HRT were not just found to be at an increased risk of heart attack - breast cancer rates among the group were also higher.

Jury out
Protects against/increases dementia risk
May prevent colorectal cancer
May protect the heart

The study did find that the drug offered protection against osteoporosis - and also appeared to reduce the rate of colorectal cancer.

But researchers nonetheless pulled the plug on the study, declaring that it was putting the lives of the women involved at an unacceptable level of risk.

Too old?

Then in the last year came various studies which not only suggested that the risk of heart disease was overstated, but that the findings of the study could be totally misleading.

Women are no longer being offered a choice
Anne MacGregor
St Bartholomew's Hospital

It was the average age of the woman studied which sparked the initial reservations about the findings.

At 63, she was about 10 years older than the average age at which most women start the menopause - and so begin taking HRT.

In May, American researchers published a re-evaluation of the WHI findings and concluded that while the heart risk existed for older women taking HRT, those aged between 50 and 59 might not be at risk.

In June, a new study was published which suggested that in women under the age of 60, some forms of HRT could even help maintain clearer arteries.

The group built up significantly fewer calcium deposits in their arteries - a substance seen as an early warning sign of blocked blood vessels and heart disease.

More bad news

But that still leaves the breast cancer link.

While those participants in the WHI study taking oestrogen-only HRT - a form only suitable for certain women - were at no increased risk of breast cancer, those taking the combined HRT (oestrogen and progestogen) were 1.24 times more likely to suffer from breast cancer within the study period of 5.6 years.

The study grossly over-estimated the breast cancer risk
John Stevenson
Royal Brompton Hospital

And these findings were given further credibility by a large UK study - the Million Women Study (MWS), which reported in 2003 that the risk of breast cancer among HRT users was 1.66 times higher than non-users.

This equated to an extra 1.5 cases per 1,000 users over a five year period of taking the oestrogen-only drug, and six extra cases with the combined HRT.

There were criticisms of the methodology:

The MWS was seen as self-selecting. It only involved women who accepted invitations for breast screening and was therefore seen as likely to have included more women with a family history of breast cancer.

The study "grossly over-estimated the risk", said John Stevenson, an HRT specialist at the Royal Brompton hospital, London.

He was similarly critical of more recent findings by the MWS, which suggested that the risk of ovarian cancer - a disease which is hard to detect and thus dubbed the "silent killer" climbed by 20% among HRT users.

The WHI breast cancer findings is also criticised by some UK experts, who note that the women involved were taking a high dose of only one form of combined HRT.

Hang on

No drug is risk free, and the British Menopause Society notes that, even if the breast cancer risks were to be confirmed, they would still need to be viewed in the context of other risks.

Breast screening
The MWS study looked at women called for breast screening

Drinking two to three units of alcohol a day, being obese in the post-menopausal period, or having a first pregnancy at a late-age individually all increase the chances of breast cancer more than taking HRT, and even these risk factors contribute to less than half of breast cancer cases.

The WHI survey also showed that within five years from stopping HRT, the breast cancer risk returns to normal.

On top of this, other research suggests that even if women taking HRT are at an increased risk of breast cancer, their survival rates once contracting the disease seem to be better.

But taking into account the studies of recent years, government guidelines urge that "the minimum effective dose should be used for the shortest duration".

They also state that HRT should not be the first treatment of choice for the long-term prevention of osteoporosis in women over the age of 50, despite the success of the drug in treating the condition.

Dr Anne MacGregor, who runs the menopause clinic at St Bartholomew's Hospital in London, feels women are not being given the option of weighing up the risk-benefit ratio themselves.

"A woman suffering menopausal symptoms with a risk of osteoporosis is an ideal candidate for the treatment," says the author of Is HRT right for me?

"That doesn't mean it's right for everyone - for instance those with a history of breast cancer should avoid it - but that doesn't mean everyone should miss out or feel terribly anxious if they do decide to go on it, and even to stay on it for up to 10 years."

But if the days of HRT as a catch-all wonder-drug that could cure all problems are over, that may have its own benefits.

"The bubble was always going to burst," says Dr MacGregor.

"You can't use HRT to solve everything, and if women now also think more carefully what's about really wrong with them and try making simple lifestyle changes to help them feel better - well that's no bad thing."


SEE ALSO
HRT linked to breast cancer
10 Jul 02 |  Health

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