I cannot think of any other medication which has been the subject of such savage and unwarranted attacks as has Hormone Replacement Therapy (HRT) in the last 10 years. HRT was introduced as replacement therapy - comparable to thyroid or insulin replacement when the body has given up producing these hormones.

Patients on thyroid replacement generally continue it long term as thyroid failure is usually not reversible. Without insulin, patients die miserably, so insulin must be replaced in measured dose and for long term. However Hormone Replacement Therapy (HRT) has now been renamed HT or hormone therapy, since the aim is not to replace oestrogen to previous premenopausal levels, but simply to give enough to reduce hot flushes without causing breast soreness and to give it for a short time only.

American studies using Premarin, an extract of pregnant mares' urine, and Provera a synthetic progestagen, have tried to convince women and their doctors that HT is potentially dangerous and can only be used short term i.e. 2 to 5 years although the deficiency lasts forever once menopause is reached. Some symptoms such as flushes may subside but other oestrogen deficiency effects on skin, brain function and bone continue long term.

It is true that many women (probably around 50%) do not have significant hormone deficiency symptoms. However these very women may suffer, later, from loss of bone density which gives rise to osteoporosis and fractures of hip and spine. Such fractures are preventable. It is sad to see old women bent over like question marks and suffering from not only the deformity but the pain which accompanies the fracture of vertebrae in the thoracic spine.

Then there is the problem of the vagina deprived of oestrogen which gives rise to shrinkage, dryness and pain on intercourse, together with recurrent urinary tract infection because the bladder and urethra are also sensitive to oestrogen deficiency.

Medscape has recently had an article proclaiming that there is an ‘epidemic of vaginal atrophy’. I am not surprised. Women have been taken off HT or have never received it and now their oestrogen deficiency is becoming evident in the vagina. It can be administered locally without any fear of altering breast cancer or cardiovascular risk.

So why has HT received such bad press and become both feared and avoided? Much of the blame must lie with the American studies which have been done using Premarin and Provera. Premarin, an extract of pregnant mares' urine, is outdated and has some hidden problems. It contains many other compounds (equine oestrogens etc) which are a said to be inactive - but are they?

In at least 10% of women taking Premarin sex hormone binding globulin is raised. Although SHBG, itself, has no harmful effects it binds both oestrogen and testosterone so that in these women their effectiveness is lost and the women may need increased doses to control hot flushes. At the same time the woman’s own testosterone is bound and she may suffer from loss both of libido and general energy.

Premarin in older women may also increase clotting - as demonstrated in the infamous American study in which women, aged 60 and over, with existent risk factors for heart attack and stroke were given Premarin and Provera for secondary prevention of cardiovascular events

At this stage they did not have hot flushes or other menopause symptoms. There was an increase in stroke incidence in the first year. This is not surprising. But those who did not have a stroke actually had less cardiovascular events over the next 5 years! The data from this study were then extrapolated to women taking HT at a much earlier age - early fifties - for treatment of menopause symptoms and women were told, and are still being told, that HT has a risk of causing heart attack and stroke. Of course women with significant lifestyle factors such as untreated hypertension, smoking, raised cholesterol and diabetes have an increased risk and these factors should be identified and treated before considering HT.

It is possible that transdermal HT may be the route of choice in such women but of course their lifestyle factors must first be reduced.

The route of administration is significant. Although no large studies have been done comparing Premarin with transdermal oestrogen it is very likely that the transdermal route may be safer in that it is less likely to increase clotting as it does not go first pass through the liver.

Many newspaper reports of the dangers of HT have been misleading and frightening to the general public. HT does not cause breast cancer but will cause growth of an existent breast cancer since most breast cancers do contain oestrogen receptors though the exact importance of these in determining outcomes is not clear.

BRCA 1 and 2 genes occur in only 5% of all breast cancers. Other family history of breast cancer is important but must be taken in context and need not be an absolute contraindication if menopause symptoms are severe and not relieved by other measures.

In truth, only oestrogens will relieve the true oestrogen deficiency symptoms, which are hot flushes, night sweats, resultant sleep disturbance and dry vagina. Only oestrogens can be taken up by oestrogen receptors and thus be effective.

The effect of all the American studies on the use of HT can be likened to what happened in Iraq. Hidden weapons of mass destruction were suspected but not found, nevertheless Iraq was invaded and much damage inflicted on the innocent as well as the villains.

Around this time HT was also suspected of having hidden dangers and the big American studies (using what I consider the wrong hormones on the wrong women at the wrong times) have led to wrong conclusions and the loss of the only appropriate treatment for women suffering significant symptoms of acute hormone deficiency as well as long term losses of bone density and sexual function.

Meanwhile women are prescribed antidepressants such as venlafaxine which may have side effects greater than any caused by HT. We have gone back 50 years to the time when women were treated with barbiturates and other heavy sedatives and then Serepax or Valium because hormone therapy was not available or even thought of. Many women suffered greatly and unnecessarily with reduced quantity as well as quality of life.

To add insult to injury, all oral HRT agents have now been removed from PBS listing without any warning to doctors who prescribe HRT. I gather that was a drug firm initiative rather than a government decision. This is an added burden for many women already struggling financially and thus a further deterrent to HRT usage.

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