HRT issues

Hormone Replacement Therapy (HRT)

There are many issues with HRT. I will try to outline some of the issues below.

The publication of two large studies: the US Women’s Health Initiative (WHI) study in 2002 and the UK Million Women Study (WMS) in 2004 caused the dramatic reduction in prescribed HRT.

The results of these studies, which used a particular combination of oestrogens and progestogens, were then extrapolated to ALL HRT regimens.

There is little data for topical HRT or the use of intrauterine devices.

HRT Regimens

Oestrogen alone tablets vs. combined HRT

Breast cancer risk

Oestrogen-alone HRT does NOT increase the risk of breast cancer. In the WHI study the risk of breast cancer was LOWER in the HRT group than placebo, by about 5 cases per 1,000.

However in the combined HRT group there were about five per 1,000.

There is a higher risk of clotting with combined HRT.

Patches and gel.

The trans-dermal route avoids first-pass effects on the liver.

It reduces clotting risk, reduces stroke risk, and should be the preferred route in women with migraines.

Vaginal oestrogen.

Urogenital atrophy (thin, sore vaginal skin) affects 25% of post-menopausal women, even in women taking systemic HRT.

Oestrogen cream can be absorbed and cause endometrial stimulation.

Vaginal tablets (Vagifem) or oestrogen rings is not, so can be used unopposed. I tend to suggest Vagifem daily for three weeks then twice weekly for three months, but it is licensed for indefinite use.

Intrauterine progestogen (Mirena IUS).

The Mirena delivers 20mcg per day into the uterine cavity, which as well as giving contraception, allows the use of oestrogen by any route without endometrial concerns.

It is the only way to give women a true “no-bleed” form of HRT.

It does not have a increased risk of breast cancer.

Operations (full list)