Hormone replacement therapy for menopause is back from exile

by Nicky Pellegrino / 16 August, 2017
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It’s not all bad news for midlife women with menopause, as health guidelines for hormone replacement therapy are revised.

Yes, the shifting state of female hormones in menopause can mean anything from hot flushes and night sweats to dramatic mood swings, loss of libido, lack of sleep and dry, thinning skin. But on the plus side, hormone replacement therapy (HRT) is back as an option for many menopausal women.

The North American Menopause Society is the latest to revise its guidelines, saying that the previous advice – that HRT should be prescribed “for the lowest dose for the shortest period of time” – may be inadequate or even harmful for some women.

“That line has become ingrained,” says Christchurch endocrinologist Anna Fenton. “But it was never something that was based on science. It came out of regulatory bodies.”

The use of oestrogen and progesterone to treat the symptoms of menopause fell dramatically from favour as a result of a research project called the Women’s Health Initiative (WHI). The WHI trial was halted in 2002 after the treatment was linked with an increased risk of stroke, heart attack, blood clots and cancer.

Subsequent analysis of the study data has narrowed down who is at risk from oestrogen and progesterone treatment and when. But the regulatory bodies have been slow to react and Fenton describes New Zealand’s guidelines as “heavily out of date and not appropriate”.

So who should be considering HRT (or, as we’re now supposed to call it, menopausal hormone therapy)?

“Any woman whose quality of life has taken a significant turn for the worse,” says Fenton, which can include “sleep disorders, changes in mood, things that influence her ability to work and go about a normal life. Everyone has a different threshold in terms of what she’s prepared to put up with.”

Endocrinologist Anna Fenton.

One in four women will go through menopause without problems, about half will have symptoms they are prepared to put up with and a quarter will suffer more serious issues that affect their quality of life.

“Given that this goes on for an average of four to eight years at a time when women are busy with children and jobs, it’s quite significant,” says Fenton.

HRT may be effective at improving quality of life, but what about the risks? It’s now clear that these differ depending on the types of hormones used and when a woman embarks on the treatment, as well as variables such as dose and duration.

For women over 60 or those who start HRT 10 years after the onset of menopause, there is an increased risk of heart attack, clots and stroke, although Fenton says this can be reduced by using oestrogen patches or gel rather than a pill.

Meanwhile, an increase in breast cancer appears to be linked primarily to synthetic progesterone when used in combination with oestrogen for more than seven years. One additional woman in 1000 will develop breast cancer, which is lower than the risk associated with alcohol consumption, family history and age but is still a risk.

Numerous studies have shown that plant-based micronised progesterone doesn’t carry the same increased risk, but New Zealand women have to pay for this as Pharmac doesn’t fund it.

Progesterone is necessary as a protective against endometrial cancer, which means post-hysterectomy women are able to take oestrogen-only therapy, which won’t increase their chances of developing breast cancer.

As for continuing to take hormones beyond the age of 65, the North American Menopause Society’s new position is that it should be considered if the benefits of preventing things such as persistent hot flushes and the bone-weakening disease osteoporosis are seen to outweigh a woman’s individual risks.

Of course, HRT isn’t for all women. Fenton says those with a history of breast cancer should consider other options, ranging from alternative therapies through to antidepressants from the SSRI (selective serotonin reuptake inhibitor) family to manage hot flushes.

There is no one-size-fits-all approach, and midlife women need to balance their individual benefits and risks.

“Giving them a choice is what is important. The problem is they have been subjected to so much misinformation and confusion it’s hard for them to make a decision.”

One thing should not be an option. “Don’t just grit your teeth and try to keep going,” says Fenton. “Menopause symptoms are only one part of what happens to a woman at this age. It’s also time to consider risk factors for things such as cardiovascular disease and bone fracture.

“Look at yourself as an entire package rather just focusing on the symptoms.”

This article was first published in the July 29, 2017 issue of the New Zealand Listener.

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