There are many myths surrounding the menopause so let’s start with the big one!
HRT and Breast Cancer
The lifetime risk of developing breast cancer for women in the UK, is 1 in 8. Certain factors increase your risk of developing breast cancer. These include getting older, smoking, being overweight, not exercising regularly, drinking alcohol and having young close relatives who have had breast cancer. However, many women develop breast cancer without any of these risk factors.
Women are often scared of taking HRT, because of the risk of breast cancer. For women who have had a hysterectomy, on oestrogen only HRT, the risk of breast cancer seems slightly less than the normal matched population. For those women who have not had a hysterectomy and need to take both oestrogen and a progestogen the risk appears slightly increased. Risk is dependent on duration of therapy and does not increase significantly for the first five years. It also appears to depend on which progestogen is used. Many of the studies used older types of progestogen which are rarely used first line today. Newer formulations such as micronised progesterone and dydrogesterone are thought to carry lower risk.
Interestingly, it is the risk of getting breast cancer, rather than the risk of dying from it, which increases with HRT use and overall mortality rates are lower.
HRT and Migraine
You will have been told not to take the combined oral contraceptive pill. Quite right! HRT is not the same. It contains much lower doses of natural hormones.
Fluctuating hormone levels around the time of the menopause can cause an exacerbation of migraine. Women often find that by using HRT, delivering the oestrogen in patch form, levels stabilise and their symptoms improve.
HRT and Heart Disease
Observational studies and randomised controlled trials show a reduction in heart disease when HRT is initiated before the age of 60 or within 10 years of the menopause. Beyond this, the effect seems to be neutral.
The protection against heart disease is really important as 24,000 women die of heart disease each year in the UK (British Heart Foundation data) compared with 11,400 deaths from breast cancer last year (Cancer Research UK) This goes some way to explaining why the mortality rate from all causes is lower in HRT users.
Does HRT just put off the inevitable flushes?
Not really! On average, a woman might have flushes for up to nine years. This means some may have no flushes, or flushes for a minimal duration whereas some unlucky women flush for years and may still be symptomatic in their seventies and beyond. Unsurprisingly when they stop HRT they experience a resurgence of their symptoms.
There is limited research on when and how best to stop HRT. Symptoms one year after cessation appear the same whether the dose is tapered down or therapy is ceased abruptly.
You do not have to stop HRT after five years of therapy
NICE suggested that women should discontinue HRT after 2-5 years of treatment or at the age of 60, however it was noted that the evidence for this is uncertain. American guidance suggests that for women aged over 60 to 65 years, the decision may be taken to continue HRT for control of flushes, genitourinary symptoms or Quality of Life (QOL) issues or protection against osteoporosis after careful evaluation and counselling regarding risks versus benefits. Annual reassessment is recommended to do this along with possible trials of reducing dose, switching to lower risk transdermal medication or discontinuation of therapy. It is also important to consider what non hormonal interventions might help.
What about Bioequivalent Compounded HRT?
Some specialist pharmacies and providers offer compounded bioidentical preparations of HRT (cBHRT) This differs from regulated bioidentical HRT (rBHRT).
‘Bioidentical hormones’ are precise duplicates of hormones found in the body. As such, when they are prescribed as regulated medicines they have been subject to a rigorous regulatory pathway of development, evaluation and quality control. Unfortunately, ‘bioidentical’ is often used as a marketing term by private clinics extolling the benefits of cBHRT. It is often supplied as creams, gels or lozenges which have not been subject to the same levels of control and evaluation, raising issues about purity, safety and efficacy.
Furthermore, prescribers of cBHRT often offer complex serum and saliva tests to determine the individual’s requirements. This is expensive, has not been validated and is usually unnecessary.
HRT and DVT
A past history of DVT puts you at risk of further DVTs, as does smoking, obesity and advancing age. A recent large UK study has shown that transdermal HRT does not increase the risk of DVT above a woman’s established background risk, increasing therapeutic options