"Most women who use HRT for short-term treatment of symptoms of menopause find the benefits outweigh the risks."
Women who are considering taking Hormone Replacement Therapy (HRT), or wondering if they should stop it, or go back to HRT, should be aware that there continues to be a debate about the safety of its use. While there have been concerns raised about HRT and the potential risks to different aspects of a woman’s health, more recently published findings reveal that although HRT is not entirely risk-free, it does remain the most effective solution for the relief of menopausal symptoms. Hormone replacement therapy is also effective for the prevention of osteoporosis. HRT might, in certain age groups, provide protection against heart disease.
Some History of Concerns Over HRT
Hormone replacement therapy (HRT) first became available in the 1940’s, although it became more widely used in the 1960’s. It created a revolution in the management of menopause. HRT was prescribed to menopausal women for the relief of symptoms such as:
In the 1990’s, two of the biggest studies of HRT users were pursued – one clinical randomized trial in America, ‘Women’s Health Initiative (WHI), and one observational questionnaire study in the United Kingdom, ‘The Million Women Study (MWS). The results published from these two studies during 2002 and 2003 raised concerns about the safety of HRT. The safety concerns revolved around two main issues:
The results of the studies gained a wide amount of publicity and created panic among some users, as well as new guidance for doctors related to the prescribing of HRT. Once the results were published, the United Kingdom’s regulatory authorities issued an urgent safety restriction concerning HRT, recommending that doctors should prescribe the lowest effective dosages for relief of symptoms. The safety restriction stated HRT should only be used as a second-line form of treatment for the prevention of osteoporosis, advising against its use in asymptomatic post-menopausal women.
Widespread uncertainty and confusion among both HRT users and doctors remain. A number of doctors stopped prescribing HRT and many women dropped HRT use immediately, with a return of their symptoms of menopause. The number of women taking HRT dropped by a whopping 66%, which has not changed. After more than ten years, there has been almost a generation of women who have mostly been denied the chance to improve their quality of life during menopause. The women involved in the WHI were North American women in their mid-sixties, often times overweight and therefore unrepresentative of women in the United Kingdom for whom HRT may be considered suitable. The women were around the age of menopause.
It should be noted that, in a surprising turnaround, subsequent publication of the full WHI results revealed the apparent risk for breast cancer was only found in women who had been on HRT prior to entering the study. Whereas the authors initially claimed there was no difference in effects with age, additional analysis from both the combined HRT and oestrogen alone WHI studies have shown no increase in heart disease in women beginning HRT within ten years of the start of menopause.
The turnaround and retraction of some of the prior findings has received little publicity in mainstream media. In addition, a large controlled trial from Denmark reported in 2012 has shown that healthy women taking combined HRT for ten years immediately following menopause experienced a reduced risk of heart disease and of dying from heart disease. The report supports the concept of a window of opportunity when HRT is started soon after menopause. The WHI study confirmed that beginning HRT after the age of sixty might increase a woman’s risk of heart disease.
Modern Hormone Replacement Therapy
The balance of benefit to harm must always be assessed, yet appears to have shifted in favor of HRT. Women who use HRT can be assured if women who use HRT:
If women begin HRT around the time of menopause, the risk is very small. Still, there is only limited data for continued use after the age of sixty. It is not usually appropriate for women over sixty to start HRT according to the WHI study. The risks are increased, although this does not mean that women who started HRT earlier should have to stop taking it after reaching the age of sixty.
A number of women ask for advice regarding the effects of HRT on desire and sexual activity. While there is no definitive answer, case studies indicate the oestrogen in HRT may help to maintain or even return sex drive. Still, it will definitely help other symptoms of menopause such as painful intercourse or vaginal dryness. If vaginal symptoms are the only issue, the use of local vaginal oestrogen might be preferable.
Bio-identical hormones are hormone preparations that have identical molecules to those produced by a woman’s body. In practice; however, the term is used for preparations made by compounding chemists which are claimed to be, ‘safer than traditional hormones,’ used in hormone replacement therapy (HRT). The fact is – some traditional HRT preparations are actually bio-identical and use oestradiol 17-beta, which is the natural human oestrogen or use, ‘micronized progesterone capsules,’ which is the natural human progesterone.
It should be clear that any product that is a, ‘bio-identical,’ hormone will have the same benefits and risks as the HRT products created by pharmaceutical corporations and licensed for use. There is no evidence that the bio-identical hormones are any safer than ones used in traditional HRT. They may be less safe because their production is not monitored by government drug regulatory authorities and therefore the dosage might be inconsistent or inaccurate. Their purity is not guaranteed and their safety is not tested as it is with traditional HRT formulations.
Bio-identical hormones are often times compounded after salivary hormone measurements and are supposedly, ‘customized.’ The accuracy and usefulness of these tests are questionable. Bio-identical hormones are not recommended in the United Kingdom and caution against these products is suggested.
Available HRT Types
More than fifty types of HRT are available to women. HRT may be administered orally, subcutaneously, transdermally, or vaginally. The subcutaneous type is a long-lasting implant. Types of HRT can include the following:
Tibolone: Tibolone is a synthetic form of period-free HRT that might have similar benefits to CCT. Tibolone is taken on a continuing basis in tablet form.
Oestrogen-Alone HRT: Oestrogen-alone HRT is usually prescribed for women who have had their womb removed. The benefits of all HRT’s are derived from oestrogen – progestogen is only needed to protect the woman’s womb lining.
Local Oestrogen: Local oestrogen such as creams, vaginal tablets or rings is used for the treatment of local uro-genital issues such as irritations, dry vagina or infections. Progestogen may also be administered locally to protect the lining of a woman’s womb.
Continuous Combined Therapy HRT: Continuous combined therapy HRT or, ‘CCT,’ combinations of an oestrogen and progestogen are prescribed continuously in order to achieve period-free HRT. Women commonly start on cyclical HRT and then change to CCT later on.
Long Cycle HRT: Long cycle HRT uses a formulation that causes withdrawal bleeds every three months instead of each month. It is best for women who experience side-effects when taking a progestogen. Its safety in long-term use in regards to the lining of a woman’s womb remains questionable.
Cyclical HRT: Cyclical HRT mimics the usual menstrual cycle. Oestrogen is taken by the woman each day and progestogen for twelve to fourteen days. At the end of each course of progestogen there is some bleeding as the woman’s body withdraws from the hormone and her womb lining or, ‘endometrium,’ is shed. Progestogen regulates bleeding and protects the woman’s endometrium from harmful pre-cancerous changes.
Women who are thinking of starting HRT should carefully discuss the risks and benefits of treatment with their doctor to find what is right for them. They should take into account their:
Most women who use HRT for short-term treatment of symptoms of menopause find the benefits outweigh the risks. The lowest effective HRT dose should be taken with duration of use depending on the clinical reasons the woman is using it. HRT remains licensed for osteoporosis prevention and may be considered the treatment of choice for women beginning treatment younger than age sixty; particularly for women with a premature menopause. Women on HRT should be re-assessed by their doctor at least once per year. For some women, long-term use of HRT might be necessary for continued relief of symptoms and their quality of life.
A number of health centers and practices have a doctor with a special interest in post-menopausal health. The specialists are aware of the up-to-date recommendations for prescribing HRT. If your general practitioner does not have enough knowledge of the current situation regarding the risks and benefits of HRT, or has lost confidence in prescribing it because of, ‘scares,’ it is right to request advice from a local menopause clinic or a specialist who is aware of menopausal health.
The original rainbow flag, called the Freedom Flag, was devised by Gilbert Baker in 1978. The design has undergone several revisions since its debut with 8 colored stripes, and today the most common variant consists of 6 stripes: red, orange, yellow, green, blue, and violet.
Picture of Gilbert Baker's original Freedom Flag showing the meaning of the 8 colors.