There are thousands of women around Australia presently reaching menopause and peri menopause who need good information and proper prescription of HRT.

The American studies, WHI and HERS, reported in headlines in the media in 2002, were alarming. They suggested increased breast cancer and cardiovascular risks for women taking hormone replacement therapy (HRT). Women everywhere went off HRT or refused to start it. Most doctors also became alarmed and some refused to prescribe it.
Recent evidence negating the previous American findings has not been given a public hearing.

The American Society for Reproductive Medicine (ASRM) this year convened a multidisciplinary group of healthcare providers to discuss the efficacy and risks of hormone therapy for symptomatic women and to determine whether it is appropriate to treat women at the onset of menopause who are complaining of menopausal symptoms - particularly the vasomotor symptoms of hot flushes and sweating which give rise to distress in the day and sleep disturbance at night.

This group included many highly regarded experts in the field of women's hormones, in particular Rogerio Lobo and Morris Notelovitz whom I have met and whose opinions are based on good scientific research.

Their consensus, reported on the website Medscape, is that healthy symptomatic women should be offered the option of hormone therapy for menopausal symptoms. They say that symptom relief with hormone therapy for women at the onset of menopause with menopausal symptoms outweighs the risks and may provide an overall improvement in the quality of life. They also suggest that hormone therapy be individualised for symptomatic women.

The use of hormone therapy changed dramatically when the results of the Heart and Estrogen /progestin Replacement Study (HERS) and The Women's Health Initiative (WHI) were published in major American medical journals in 2002.
In the United States approximately 42%of women between 50 and 74 were taking hormone therapy. This declined to 28%.

In Australia there has been a similar decline and many doctors remain unsure about prescribing hormone therapy for the very women who have most need of it.

A postal survey in March 2004 of 600 primary care physicians in Florida about their understanding of risks and benefits of HRT found that most overestimated the magnitude of risks and benefits 67% of the time.

I suggest that this effect may be likened to the American invasion of Iraq based on information about hidden weapons of mass destruction, which was found to be false and has led to great disruption and distress.

The fear of HRT has led to an upsurge in prescription of alternative approaches to the management of menopausal symptoms. These include much that is unregulated, in the form of herbs, vitamins and so called bio-identical hormones.

The latter were front page news in the Sunday Age a few weekends ago and have cause a further upsurge in fear especially among women who thought - or were told -that these were natural hormones and thus were not dangerous like the "synthetic" hormones in commercially produced HRT. In fact they come from the same laboratories and therefore carry the same possible risks. But are these risks as great as the American studies would have us believe? Are alternative methods useful?

There is little scientific evidence that complementary and alternative therapies can help menopausal symptoms yet many women use them, believing them to be safe and "more natural" The choice of treatments is confusing and, unlike conventional medicines, not much is known about their active ingredients, safety, or adverse effects and interactions with other therapies.

Over 200 alternatives exist but only about 20 of these have had trials done. None of them were significantly effective as compared to HRT in the relief of hot flushes etc.

Lifestyle measures such as increased exercise, good diet, avoidance of alcohol and caffeine, and cessation of smoking can reduce severity of vasomotor symptoms. Such measures can also reduce cardiovascular risk so should be advised for all women at this time and not just suggested as an alternative to HRT.

Professor Henry Burger, who with Dr Jean Hailes, founded the first menopause clinic in Australia in Melbourne in 1971 and is widely regarded as an expert in the field of menopause has recently reviewed HERS and WHI. His review published in the Australian and New Zealand Journal of Obstetrics and Gynaecology in April this year is encouraging and in accord with the findings of the ASRM.

He says "The announcement in July 2002 in the media of the results of the combined continuous treatment arm of the WHI had a profound effect on perceptions about hormone therapy among the lay public and the medical profession.
Careful scrutiny of the announcement and the subsequent publications leads to the conclusion that the widespread fear of hormone therapy that was generated was not supported by the facts.

WHI was not designed to be, nor can it be interpreted as a randomised controlled trial of HRT, rather it was a trial of chronic disease prevention particularly aimed at the possible cardiovascular benefits of a specific combination HRT in postmenopausal women.

The results which were consistent with existing data did not, and do not, warrant any major change to the previously established guidelines for the use of hormone therapy."

Women need to be told clearly that oestrogens do not cause breast cancer but can cause growth of cancer cells already in existence. Throughout reproductive life oestrogens make breast cells grow - that is their main task. The risk of cancer increases with age. Women who do not take hormones have the same risk on developing breast cancer as users of HT but cancers will grow more rapidly with added oestrogen.

The final arm of the HERS study showed that there was no increase in breast cancer occurrence in women using oestrogen alone after 10 years. They speculate that the addition of progestagen may alter the rate of growth.
Unfortunately the worldwide WISDOM study, which was designed to clarify all the confusion, was ceased because of the negative impact of the American studies so we will never have the answers that we need to reassure women!

There is a further point to be made which has been lost in all the confusion.

Is Premarin the best oestrogen to use? It is extracted from the urine of pregnant mares and is oestrone, the so-called postmenopausal hormone in women. It is truly natural - in that it is produced in the body of an animal - whereas all other oestrogens including the "bio-identicals" are made in the laboratory.

Oestradiol is the main hormone in premenopausal women. It can be given as a transdermal patch rather than as an oral tablet. This route may decrease the cardiovascular risk.

American studies have been focussed on Premarin. In addition there has been the concept that one size fits all. Women need doses that relieve symptoms with minimal side effects.

We must not be led astray by American studies using different hormones in older women and getting results which do not apply to younger, healthy, symptomatic women. I want to assure women that proper use of hormone therapy (HT) is both beneficial and safe and suggest that we call it HT (hormone therapy) not HRT (hormone replacement therapy) as it is never true replacement.

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