- For many women suffering moderate to severe symptoms of menopause, the benefits of HRT are likely to outweigh the risks.
- Of the alternatives to HRT, black cohosh appears to be the most effective option, and is also among the cheapest.
- Health authorities have warned women to avoid using bio-identical or 'natural' hormones.
- Clinical trials in China have found that Chinese herbal medicines are effective at reducing the symptoms of menopause, but there's no "one-size-fits-all" remedy.
In 2002, a major American study involving hormone replacement therapy – the Women’s Health Initiative (WHI) trial – was stopped early because researchers were concerned about the increased incidence of breast cancer, heart disease and blood clots among women taking the hormones.
The ensuing media frenzy prompted many women to abandon the treatment, instead either putting up with the discomfort caused by menopause symptoms, or perhaps turning to alternatives.
CHOICE re-examines the WHI study and its implications in light of new analyses of the research, and weighs up the various alternatives.
Please note: this information was current as of January 2009 but is still a useful guide today.
Pros and cons of HRT
One of the main criticisms of the 2002 Women’s Health Initiative (WHI) study is that the subject women ranged in age from 50-79, with an average age of 63, yet the average age at which women experience menopause is 51, so the majority had no symptoms and were taking HRT many years after menopause.
With this in mind, the results have been reanalysed, taking the age of women into account. In particular, the reanalysis focused on women under 60 – those most likely to use HRT to reduce symptoms at or near the time of menopause.
That HRT increases the risk of breast cancer isn’t denied. However, that increased risk is small in absolute terms. Analysis of the WHI study found that among women in their 50s who took HRT for the first time, there was no increase in the risk of getting breast cancer.
After more than five years, the risk appears to increase, and is comparable with the increased risk of that of women who:
- Had their first pregnancy after the age of 35.
- Drink more than two alcoholic drinks a day.
- Are overweight (have a body mass index of 25-30)
Within five years of stopping HRT, the risk returns to normal levels. Some epidemiological studies have reported that rates of breast cancer have decreased among women over 50, coinciding with decreased use of HRT since the WHI uproar.
There is concern about HRT and the increased risk of blood clots either in the lungs or presenting as deep vein thrombosis, especially among women who are obese or have other risk factors for clotting – something for which women should ideally be screened before commencing therapy.
Among the younger group, it was concluded that HRT doesn’t increase the risk of cardiovascular disease, and may in fact reduce it. However, there’s evidence that if HRT is started when women are older and already have cardiovascular disease, it can increase the risk of cardiac events.
Reducing the risks
There are ways of reducing the risks of side-effects, including lowering HRT doses, using oestrogen-only therapy (only women who’ve undergone hysterectomy) and starting HRT near menopause. There’s some evidence that using skin patches, rather than tablets, can reduce the risk of clots.
Apart from reducing the severity of symptoms associated with menopause, the benefits of HRT include a reduced rate of fractures related to osteoporosis, although the risk returns to normal after HRT is stopped, and reduced rates of colorectal cancer.
Essentially, it’s up to individual women, in consultation with their doctor, to weigh up their personal risks versus the potential benefits of taking HRT, the most significant of which being a reduction (not necessarily elimination) of menopause symptoms.
What about 'natural' hormones?
Uncomfortable with taking so-called synthetic hormones in HRT, many women prefer the idea of 'natural' or bio-identical hormones. Some swear by them, finding they’re very effective at relieving menopause symptoms. A doctor tests your blood or saliva for hormone levels and tops them up to so-called natural levels by having a compounding pharmacist tailor-make a preparation for you.
They’re more expensive than HRT, partly because they’re not subsidised by the government. And some medical authorities, including the Jean Hailes Foundation for Women’s Health warn against them.
The main risk with bio-identical hormones is that they’re not regulated in the same way as other hormonal treatments, and the pharmacists making the preparations aren’t required to abide by the conduct codes of Medicines Australia (the peak body for pharmaceutical companies). They could be ineffective, or worse, dangerous. One major concern is uterine cancer, due to the ineffectiveness of progesterone in opposing the effects of oestrogen on the endometrium. Several such cases have been reported.
Legal loopholes mean they may also contain hormones that aren’t approved by the Therapeutic Goods Administration (TGA) for use in Australia. Critics also point out that just because the hormones come from natural sources such as yam or soy, by the time the active hormone is extracted it’s chemically no different from the equivalent so-called synthetic hormone in HRT, which also happens to be extracted from natural sources – yam, soy or horse urine.
The TGA is considering regulating compounding pharmacists, and hormones that are not approved by the regulator would be banned.