HRT: The big picture, by Eddie Morris, Chair of the British Menopause Society and Consultant Obstetrician and Gynaecologist, Norwich University Hospital
Every woman experiences the menopause differently – it can last from a few months to several years and between 30% and 60% of women experience physical and/or emotional symptoms during this time. These can include; hot flushes and night sweats, tiredness and sleep disturbance, mood swings, forgetfulness or lack of concentration, vaginal dryness and loss of interest in having sex.
Some women choose to go through the menopause without treatment; others prefer to help to manage their symptoms either by using hormone replacement therapy (HRT) or an alternative treatment option.
Following the publication of the Women’s Health Initiative (WHI) study in 2002 the way in which society and the medical profession viewed HRT radically changed. Over a very short space of time women stopped taking HRT and in many cases women had their HRT stopped by their doctor, often this was a unilateral decision. The study appeared to offer clarity to regulatory authorities concerning the balance of longer term risks and benefits and the conclusions of this study were rapidly incorporated into many countries’ national guidance.
Perhaps the biggest concerns about the findings of this study centred on the fact that some of the findings were almost opposite to the findings of many observational and cohort studies before the WHI was published. Over the past 12 years there has been much work from both the WHI and other investigators in this area to establish what the messages really are.
At present our understanding is that overall if a woman takes HRT early in the menopause she is likely to experience an overall benefit on her health in comparison to a woman who does not take HRT. The story is however naturally more complex. Women who start HRT later in life may be exposing themselves to long-term health risk and there is also additional risks when the addition of progestogens are considered.
I believe that much of the management of the menopause depends on a clear and complete understanding of the health of women in their later years. In 2011, the RCOG discussed the concept of a life course approach to women’s health rather than the management of health in specialty based silos of healthcare.
Post-reproductive health comprises a multispecialty and multidisciplinary approach to improving women’s health and HRT is just a small component of post reproductive health. However if research demonstrates that a woman may benefit from HRT use, it is vital that she receives clear information as to how it will help her both in the short and long term.
In the UK, the British Menopause Society recently released a set of guidance about the use of HRT. This publication has been one of the most downloaded publications in the history of the society’s journal. This indirect evidence shows that there remains a thirst for understandable information in a sea of confusion.
Later in 2015, the UK looks forward to NICE’s publication of the guideline for Diagnosis and Management of the Menopause. Finally will there be some clarity for the UK regulatory authorities?
Eddie Morris has received sponsorship from Gedeon Richter, Abbott/Mylan, Besins and Novo Nordisk.