A clinic dealing with gynaecological endocrinology was run at the Lister Hospital, now at The London PMS Menopause Centre, 46 Wimpole Street, London W1G 8SD, by Professor John Studd, DSc,MD,FRCOG. He was also a Consultant Gynaecologist at Chelsea & Westminster Hospital and started the first menopause clinic in Britain in 1970 and the first psycho-endocrine clinic in 1995. He is regarded internationally as an expert on menopause, osteoporosis, PMS and the hormonal aspects of depression in women. He is Vice-President of the National Osteoporosis Society.
It is generally accepted that oestrogens abolish menopausal symptoms, increase bone density, reduce the incidence of heart attacks, strokes and Alzheimer's disease and improve sexuality. Oestrogen users also live about 1.5 years longer than non-users. If that is the case acceptance of oestrogen therapy should be simple but it is not. Only about 15% of women at risk take oestrogens and the vast majority abandon HRT within a year. This lack of continuity is due to a combination of things including breast cancer, fear of weight gain, reluctance to have periods or the PMS type symptoms that occur with cyclical progestogen (Table 1). Also many women taking low does oestrogens do not feel any better and are therefore reluctant to take long-term therapy to prevent a fracture at the age of 85 which may not occur anyway. There are many new formulations with using various routes of administration, various combinations which attempt to improve the well-being of menopausal women without side-effects or problems of bleeding. Thus therapy is becoming more complicated rather than more simple as we tailor treatment to the needs and response of the individual woman. It is for this reason that selective oestrogen receptor modulators (SERMs) have been introduced to improve patient acceptability but they produce flushes and sweats and other menopausal symptoms.
Oestrogen therapy for the over 60s is a very important area as these are often neglected in the belief that older osteoporotic bones do not respond to oestrogens. They do and they respond even better than the bones of younger postmenopausal women. In fact the lower the bone density the greater the increase with hormone therapy (Fig. 1). It is these women which value low dose oestrogens and no-bleeding regimens. There is a view disputed by many, that oestrogen therapy should only be on ten years' duration. If this is so it is possible that maximum cardiovascular and skeletal benefits with least side-effects would accrue by starting aged 60 rather than aged 50, but the 50 year old usually requires symptom relief during this decade.
Similarly, HRT for the peri-menopausal woman who is still having periods but suffering from depression, tiredness and loss of libido is another neglected area. These patients often have a long past history of hormone related depression i.e. postnatal depression or pre-menstrual depression. Such patients suffer their worst depression in the one or two years before their periods stop but often need oestrogens instead of, or as well as, anti-depressant therapy.