Up until a few years ago, Hormone Replacement Therapy (HRT) was considered the panacea for every woman hitting her menopause. But with long term research shedding more light on the definite benefits as well as the inherent risks involved in the therapy, HRT has changed from a prophylactic medicine guaranteed to see every woman through the hard times of the menopausal stage to a therapy that is prescribed to treat its specific symptoms.
Womenone.org takes a closer look at the therapy that has come under greater scrutiny in recent times with Dr Rosalie Sant, Specialist Obstetrician and Gynaecologist at the Welcare Hospital, Dubai, who has done a lot of research in this field.
What is Hormone Replacement Therapy? Why has it been at the centre of a lot of controversy?
Hormone Replacement Therapy (HRT) as the name implies replaces hormones that the human body normally produces but has stopped producing now as the woman has entered the menopause. It contains one or two female hormones - oestrogen and progesterone. Oestrogen is the hormone that makes you feel better and reduces the symptoms of menopause such as "hot flashes", sleep disorders, mood swings and lack of libido. What oestrogen also does is thicken the lining of the uterus as it always does in every woman every month.
However, the thickening of the lining of the uterus in a menopausal woman itself is ridden with danger as it can give rise to complications which can lead to cancer. So any woman who takes Hormone Replacement Therapy and has an uterus needs to take progesterone along with the essential hormone oestrogen to protect the uterus lining. Women who have had their uterus removed are put on oestrogen-only therapy.
Since, the hormones that we take as part of the Hormone Replacement Therapy are artificial, they can cause side effects such as headache, bloatedness etc., until we get accustomed to them.
Up until sometime ago, we used to prescribe it quite widely because it maintained a sense of well being in a woman and we believed it delayed ageing, both physiological and psychological aging. It was also thought to prevent certain types of diseases such as cardiovascular diseases, Alzheimer's disease and dementia. That type of scientific knowledge was based on smaller studies done fifteen to twenty years ago. Drug companies themselves might have sponsored some of those studies. So these issues had to be further investigated on a larger scale with independent, multi-centre, controlled, prospective studies.
Unfortunately, some of the earlier results were not confirmed by the long-term research, results of which started pouring in about five years ago. Interestingly, some of the benefits that we thought were definite as they were so logical were not proven to be so scientifically in these studies. So we do not prescribe HRT to prevent cardiovascular diseases or strokes or to maintain cholesterol levels in patients anymore.
When do you advise Hormone Replacement Therapy to patients? And what are the definite benefits of HRT?
Menopause is usually around the age of 50 or 51 years. A peri-menopausal woman who is heading towards the menopause can be plagued by severe symptoms of the menopause such as "hot flashes", depression, insomnia, inability to concentrate, irritability and lack of libido and some find it very difficult to cope. Such women obviously need help with HRT. Some others have the symptoms of menopause even before the normal age, say at 40-43 years. Such women need to be put on HRT for 5 -7 years, preferably taking them to the average age of 50 and then tapering it off.
With HRT being in the news for all the wrong reasons, some women get panicky and cut off the treatment abruptly. When the supply of oestrogen is stopped abruptly, the symptoms of menopause resurface with severity. Women, who are seriously affected by menopause, stand much to gain from going on HRT for some time, say five to seven years. Instead of stopping HRT abruptly, they should consult their doctors and decide on a way to tail if off.
One of the other definite benefits of HRT is that it prevents osteoporosis. It is indicated for women who are fifty and have predisposing factors towards or a family history of osteoporosis. In these cases, benefits of HRT far outweigh risks as osteoporosis in itself has many long-term implications and consequences. Therefore here, HRT is indicated, again for 5 - 7 years after the average age of the menopause.
What are the risks involved in HRT?
HRT puts you at a slightly increased risk of Deep Vein Thrombosis. Just like with the contraceptive pills but to a lesser extent, they affect the blood clotting system. The risk is mostly in the first year of use. We warn the patients about the aggravated risk factors such as long haul air travel or before surgery. They need to be aware of the risk and minimalise it by moving their feet to ensure smooth and continuous flowing of blood in their calf muscles. Avoiding dehydration on long distance flights also helps, if in no other way as it makes you need to go to the toilet thus getting you out of your seat frequently during a flight! Knowing the symptoms and looking out for them will also decrease the risk of complications.
Another harmful effect often cited is the increased risk of breast cancer which is still a matter of controversy. A woman of 55 years is at a higher risk of breast cancer with or without HRT than a woman of 50 years. It is difficult to decide how much of the increased risk is caused by HRT and how much of it is caused by age. Then again, if it is due to HRT, how much of it is due to oestrogen and how much of it is due to progesterone.
Anyway, the increased risk is only minimal. Now it is confirmed that if a woman develops breast cancer in the first five years of HRT, it is unlikely to be due to the therapy but only because she had predisposing characteristics for breast cancer. However, the slight increase in risk is enough to warm women about the need for regular check-ups and mammograms and to be extra cautious when prescribing in women who have a family history of breast cancer.
I do not usually mention the slightly increased risk of cardiovascular diseases and strokes to my patients. When I prescribe HRT nowadays, I make sure that patients whom I am putting on HRT do not have any predisposing factors towards coronary diseases.
There is a lot of scientific data out there, which is difficult to interpret, which you cannot be sure of. It is only after the data have been investigated extensively and conclusions drawn can I adopt it as a scientific truth. In the future, maybe I would have to tell my patients about the risk of cardiovascular diseases if this risk is shown to be significant as I do about the slight increased risk of breast cancer and DVT after these were proven to be definite and significant.
However at the moment, with the available scientific knowledge, I can safely say that the benefits of HRT outweigh the risks.
What are the different forms of HRT?
It comes in the form of tablets. It could either be oestrogen only tablets or oestrogen combined with progesterone.
Patches of oestrogen and progesterone are another form of HRT. It is usually stuck to the buttocks and the hormones are released into the blood stream. It is changed once or twice a week.
Implants contain only oestrogen and is given every six months.
As HRT is a bit addictive in nature, it is advisable to use tablets and patches more than the implants with which the chances of addiction are greater. As I said before, one feels very well on oestrogen. How much of it is physiological and how much of it is psychological, it is not completely clear. Once you are used to a certain level of oestrogen in your blood, as soon as the level starts dropping, even if it is still within the therapeutic range, you feel the symptoms of lack of oestrogen. You are wrecked by mood swings and the hot flashes. And you keep wanting more and more of the oestrogen.
The newer modes of delivery of HRT aim at reducing this dependency on high oestrogen levels.
Nasal sprays are one such form of HRT introduced three years ago, which is picking up quite fast due to the unique manner in which they interact with the body. Also it is very promising as it administers only low doses of HRT to the body.
With time, HRT has also changed in character. Though the modern HRTs have the same oestrogen, they have more natural progesterone in it which does not affect the cholesterol and triglyceride levels and which doesn't have such a bad effect on coagulation. Unfortunately, the modern HRTs are not widely available and you still come across people who have been on a preparation that has been superseded in the Western world. However, here in Dubai, we are quite lucky as we have most of the modern forms of HRT so that we can tailor our prescriptions to the needs of our patients.
What is the percentage of women who need HRT?
That is a difficult question to answer. It varies with culture and environment across the continents. But if you are to corner me and ask for a percentage then I would say probably about 30 % of the menopausal women in this time and age may benefit from HRT as against 70 % about 5 years ago. This reduction in percentage is the result of the new advances in HRT and the changes in its prescribing indications over the years.
What are the awareness and acceptance levels of HRT in the women here?
The awareness levels over here are not too high. People need to know that there are a lot of benefits to be gained from HRT, but only when indicated. Also doctors need to keep track of the rapid developments in the field so that they can give patients the latest advise on the matter.
About the acceptance levels, it is slightly less than in Europe but it is not too bad. The Arab population tends to refuse HRT and accept it only if they really need it because of osteoporosis or the like. Having said that they seem to have an easier menopause anyway so in that respect they are lucky! The Indian population usually accept it if you prescribe and explain the benefits to them. A lot of the Westerners know about it and actually come into clinic asking for it or to discuss its risks and benefits before they decide whether they want it.
Though HRT has transformed from a preventive therapy to an actual treatment over the years, it still plays an important and a beneficial role in the lives of women reaching their menopause.
