Variations on HRT.
Summary and conclusions
The principles of hormone therapy for the menopausal or perimenopausal woman can be summarized thus. These items are not entirely consistent with the current advice of regulatory bodies but they do reflect a studied analysis of the available data as well as a long clinical and academic interest in the subject. Medical practitioners of all levels require guidance for the hormonal treatment of middle aged women. These views should be considered, discussed and criticised as a fresh clinical approach is urgently needed. Currently many women suffering severe hormonal disorders are being needlessly denied appropriate safe hormone therapy
- estrogens are safe when started below the age of 60 particularly
if progestogen is not required and are positively indicated
in women with a premature menopause It should be used for treatment
of specific climacteric symptoms and low bone density and the advice
that estrogens should not be first option for the prevention or treatment
of osteoporosis in this age group is questioned .The dose and route
will depend upon the symptoms and the age of the patient.
- Women with a uterus need endometrial protection with progestogen.
The usual duration is 14 days but if the extra risk to the breasts
from progestogen is confirmed it would be sensible to reduce the
duration to 7 days each calendar month. This shortened course
is also useful in women with progestogen intolerance and is adequate
for endometrial protection. Alternatively a Mirena IUS can be inserted.
The long term value and safety of low dose unopposed estrogen is
- Oestrogen only therapy commenced before age of 60 is associated
with a considerable but non significant decrease in coronary heart
diseases, osteoporotic fractures, colon cancer and deaths. These results
are consistent with the previous case control studies. There may also
be a decrease in breast cancer in women receiving oestrogens without
- Oestrogens appear to have no place for the secondary prevention
of cardiovascular disease but there may be a window of opportunity
in 45-60 year old symptomatic women who may show long term cardiovascular
and neurological benefits from early oestrogen therapy. Oestrogens
commenced in older 69-79 women may do “early harm” before
any benefit can be achieved and should be avoided if possible or started
on very low dose oestrogens.
- A moderately high dose of transdermal oestrogens is useful for
perimenopausal depression as well as premenstrual depression. Progestogen
is necessary for endometrial protection and cycle control even though
these patients may be intolerant to small doses and short duration
of any gestogen.
- Patients may wish to avoid bleeding by using low dose oestrogen
and progestogen, Tibolone or have a Mirena IUS inserted.
- If loss of libido and loss of energy remain a problem the addition
of testosterone to estrogen should be considered. Androgen as well
as oestrogen is often necessary after hysterectomy and bilateral oophorectomy. Hysterectomized
women do not need progestogen.
- A 5 year duration has been recommended but in reality women remain
on HRT if they are feeling well with relief of symptoms. It is
difficult to persuade these women to stop even after 10 or more years.
(41) The need for oestrogens should be reviewed each year for long
term users with clear discussion of current views on safety.
- In spite of the reassuring data from estrogen only studies the
possible increase in breast cancer remains a problem. Until the controversy
concerning breast cancer risk is clarified it is probably advisable
that regular mammograms should be performed each year and breast
examination every 6 months although it is correct to recognise that
many oncologists would doubt the value of these frequent examinations.
The optimistic recommendations in this paper are now supported by the latest publication from the WHI reporting the results of starting Prempro before age 60 which results in 24% fewer cases of CHD and 30% decrease in total mortality.(42) Age is the most critical factor whether estrogen only or estrogen plus progestogens was used . Both the North American Menopause Society (43) and the International Menopause Society (44) have now changed their guidelines recognising the efficacy for many indications for HRT outlined in this review and long term safety of such therapy. This belated conversion to the clinical realities of HRT have been warmly welcomed. (45)