IS HRT SAFE?

Rosol HamidConsultant O&G

NO

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

BenefitsRe 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