It is time to undo the damage caused by fear that was engendered by the reports of American studies.

Since 2002, when results from the American studies WHI and HERS caused headlines in our newspapers, many women and their doctors have avoided using or prescribing HRT. It is now becoming clear that this may be to their detriment and based on wrong interpretation of the data.

The fourth Asia Pacific Menopause Federation Scientific Meeting and 14th Australasian Menopause Society Congress were held in conjunction in Sydney recently. The issues of possible increased incidence of breast cancer, heart attack and stroke with the use of HT were re-examined and found to be misleading. The take home message from this meeting was that HT used appropriately in women at menopause has more advantages than disadvantages.

Data were given to show that breast cancer incidence is not increased with oestrogen alone up to 15 years of study.
With combined HRT oestrogen and progestagen the progestagen may be a culprit but the increase in incidence only appears after 5 years and is only 8 extra cases in 100,000 women. This has led to a sort of rule of thumb that HT can only be prescribed for 5 years!

Women need to understand that hormones do not cause cancer but may promote the growth of a pre-existing breast cancer. They also need to be reassured that they can take it long term in many cases.

The American study HERS which pointed the finger at HT as a cause of stroke or other cardiovascular problems was done in older women who already had risk factors for heart attack and stroke - such as smoking, hypertension and raised cholesterol These women were not suffering the acute symptoms of menopause. Wrong studies on the wrong women at the wrong age produced wrong results which do not refer to healthy younger women who take HT to control acute menopause symptoms such as hot flushes, sweats and sleep disturbance.

Dr Howard Hodis from the Atherosclerosis Research Unit at the University of California (a world expert in this field) stated, "The totality of data indicate that the window of opportunity for reducing overall mortality and coronary heart disease (CHD) is initiation of HT within 6 years of menopause or on or before 60 years of age. Hormone use for 5 to 30 years in postmenopausal women who initiate HT in their 50s substantially increase quality-adjusted life -years and is highly cost effective". When initiated later as in the HERS study it has no such beneficial effect.

Professor Peter Collins from National Heart and Lung Institute London stated, "Most women do not perceive cardiovascular risk as an important health concern and report that they are not well informed about their risk. Cardiovascular disease is the main cause of morbidity and mortality, accounting for 50% of all deaths in westernised countries. Cardiovascular risk factors are frequently missed and often poorly managed. This despite the fact that, over the life span, women are more likely to experience cardiovascular disease and disability than men and intervention can improve morbidity and mortality. The optimal time for prevention is as early as possible. It is therefore a priority by the time a woman is menopausal. Risk factors are smoking, untreated hypertension, raised cholesterol, diabetes, unhealthy diet and lack of exercise." He then particularly focussed on hypertension, which is often ignored or left untreated. He feels that this is more of a risk factor than moderately raised cholesterol - which is often overtreated!

The route of administration is another issue. The American studies used oral therapy - Premarin and Provera. In Australia transdermal patches may be the treatment of choice. These avoid passage through the liver and are unlikely to cause an increase in blood clotting. (There have been no comparative studies done however and in the wake of the American studies it is unlikely that they will be done in the future).

Overall this conference provide assurance both to menopausal women and to their healthcare providers that HT, given appropriately, is safe and can be given long term to those who need it.

The long term consequences of deprivation of oestrogen are already becoming apparent. Dry vagina. painful intercourse and recurrent urinary tract infection are preventable with the use of oestrogens vaginally. Osteoporosis can also be prevented, in those at risk, with HT given at menopause.

So how have women been so misinformed? How can we provide assurance?

I would like the newspapers to help redress the effects of wrongly interpreted information from the American studies which has made women afraid to take HT and many doctors loath to prescribe it.

5 June 2011

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