Hormone Replacement Therapy (HRT) Benefits and Risks – Psychological Symptoms – Depression- Chapter 27:

Table of Contents

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around the time of my menopause?

Psychological problems including depression and anxiety are often encountered around the time of the menopause and it would certainly seem reasonable to try HRT to assess potential benefit. Psychiatrists distinguish between depressed mood and depressive disorder.

Despondency, low spirit and demoralisation are common symptoms that most of us have experienced at one time or another usually as a reaction to one of life’s stresses. Depressive disorder is more severe. “Loss symptoms” including loss of energy, appetite, interest, libido (sex drive), and the capacity to enjoy life are typical of depressed mood.

Depressed mood may respond to HRT but psychiatrists would caution that depressive disorder is generally outside hormonal influence.

Hormone replacement therapy can reduce sleep disturbance, insomnia, increase energy and restore that feeling of well-being. The balance may be redressed so that a woman comes out of despair into a world where she can cope and begin to enjoy her life again. hormone replacement therapy, however, cannot cure all the stresses and strains of life. One study found that a significant number of women had unrealistic expectations from HRT. In practice, it may be difficult to predict who will respond to HRT and who will not. There are times when one is sufficiently anxious about a patient’s mental state that it seems appropriate to request early psychiatric assessment.

However, there is little to be lost by a “trial” of HRT and perhaps much to be gained. Any improvement is to be welcomed. Adjustment of dosage may provide further benefit.

A double-blind (Q33.26) study found that with oestrogen replacement adaptation to life improved and depression showed signs of lifting and another study concluded that psychological well-being is improved by HRT.

A controlled study (Q33.26) evaluating HRT for its effect on psychological symptoms found significant improvement in anxiety and depression with oestradiol or combined oestradiol and testosterone implants. This improvement only occurred in women approaching the menopause.

References:

Estrogen improves psychological function in asymptomatic postmenopausal women (1991) 27-01-799

Hormone replacement therapy, sleep quality and psychological wellbeing (1995) 27-01-726

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 2 Can HRT help my mental ability?

You may find that you are less able to cope with psychological stress after the menopause. Oestrogen replacement therapy has been shown to return this response to pre-menopause levels. A trial of oestrogen and/or androgen (Q33.26) compared to a placebo (a look-a-like preparation but without the active drug) demonstrated improved mental ability with HRT in women who have had a surgical menopause (removal of the ovaries usually in association with hysterectomy).

Tests of short-term and long-term memory and logical reasoning were better in those patients receiving oestrogen replacement when compared to those having the placebo. Headaches, anxiety and insomnia responded to oestrogen better than to a placebo and memory was also improved.

A study ten years ago reported a 50% reduction in the incidence of stroke related deaths although other studies have not confirmed this observation. There is some evidence that oestrogen deficiency is a risk factor for Alzheimer’s disease

.
In a prospective study, 8879 women in the Leisure World Laguna Hills, a retirement community in California, have been assessed regularly since 1981. For each woman participating in the study, a detailed medical history was recorded and her use of HRT was documented. Alzheimer’s disease (senile dementia) was included on the death certificate in 138 women.

The relative risk (Q33.27) of developing Alzheimer’s disease was 0.69 (30% reduction) for those who had taken HRT and the risk decreased with increasing dose and duration of HRT. Long-term HRT may improve cerebral (brain) function (mental ability) for women with mild to moderate Alzheimer’s disease.

References:

Exploration of cyclical changes in memory and mood in postmenopausal women taking sequential combined oestrogen and progestogen preparations (2001) 27-02-3342

Long-term estrogen replacement therapy in female patients with dementia of the Alzheimer type: 7 case reports (1995) 27-02-835

Behavioral stress responses in premenopausal and postmenopausal women and the effects of estrogen (1992) 27-02-832

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 3 Can HRT reduce my chance of developing heart disease?

Women have relatively few problems attributable to coronary heart disease before the menopause because oestrogen during reproductive years confers protection (Q26.23). The majority of heart attacks before the age of sixty occur in men. After the menopause nature’s protection (oestrogen) is withdrawn. One study found that by the age of seventy, women are as likely to suffer a heart attack as men.

When the ovaries are surgically removed (oophorectomy) before the menopause the oestrogen protection of the coronary arteries is suddenly lost and without hormone replacement therapy the likelihood of heart problems is increased.

To assess the potential benefits of HRT, we have to look at evidence from large on-going studies. In 1976, The American Nurses Health Study recruited 121,700 female registered nurses aged 30-55 years. These women are now aged 54 – 79 years. The latest reports from this study shows reduced incidence of heart problems and deaths from coronary heart disease in association with HRT.

One review of the literature found twenty studies all consistently demonstrating cardioprotection (cardio – heart) associated with HRT following oophorectomy. When considering evidence from large studies, we are always concerned that there may have been some hidden bias.

It has been suggested, for example, that those nurses thought to be at particular risk of heart disease might have been advised not to take HRT – twenty years ago heart disease was thought to be a contraindication (should not be prescribed).

A study specifically designed to exclude such possible bias investigated a case-control analysis of 858 women presenting aged 45-69 between 1986 and 1990 with their first heart attack. The results again showed that oestrogen replacement reduced the risk of heart attack.

Two recently published controlled studies, however, have failed to confirm a beneficial effect of HRT on cardiovascular disease.

The Heart and Estrogen/progestin Replacement Study (HERS – 2001) was designed to test the hypothesis that treatment with conjugated equine estrogen 0.625 mg/d with MPA 2.5 mg/d would reduce the combined incidence of nonfatal myocardial infarction (MI) and coronary heart disease (CHD) death compared with placebo in women with prior history of MI, coronary revascularization, or angiographic evidence of CHD.

This was the first large-scale randomized clinical-outcome trial of HRT for prevention of CHD in postmenopausal women. After an average of 4.1 years of follow-up, there was no difference in the primary outcome of nonfatal MI and coronary death between the hormone and placebo arms.

Numerous explanations have been proposed for the overall null effect of HRT in HERS. These include inadequate duration of follow-up, adverse effects of MPA, bidirectional effects of estrogen (early risk and late benefit), a population of women too old to benefit from therapy (average age was 66.7 years), a preparation of HRT that was not ideal, chance, or that HRT is ineffective in preventing recurrent cardiovascular events in women with established disease.

Similarly, The Women’s Health Initiative (WHI) (2002) have reported no benefit with HRT on progression of cardiovascular disease.

References:

Pre-existing risk factor profiles in users and non-users of hormone replacement therapy: Prospective cohort study in Gothenburg, Sweden. (1999) 27-03-2824

Impact of postmenopausal hormone therapy on cardiovascular events and cancer: Pooled data from clinical trials (1997) 27-03-2002

Association between increased estrogen status and increased fibrinolytic potential in the Framingham Offspring Study (1995) 27-03-817

Cardioprotection by hormone replacement therapy (1995) 27-03-624

A case-control study of myocardial infarction in relation to use of estrogen supplements (1993) 27-03-808

The risk of acute myocardial infarction after oestrogen and oestrogen-progestogen replacement (1992) 27-03-558

The risk of acute myocardial infarction after oestrogen and oestrogen-progestogen replacement (1992) 27-03-558

Postmenopausal estrogen therapy and cardiovascular disease – Ten-year follow-up from the Nurses’ Health Study (1991) 27-03-809

Evaluating the benefits and risks of postmenopausal hormone therapy (1991) 27-03-647

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 4 How does HRT protect against coronary heart disease?

We know that elevated blood cholesterol increases the risk of coronary heart disease. There are two different types of cholesterol (low and high density). High levels of low density (LDL) cholesterol is a risk factor for heart disease whereas high density cholesterol (HDL) provides protection.

Women during their reproductive years have higher HDL-cholesterol and lower LDL-cholesterol than men. Following themenopause, the balance between HDL- and LDL- cholesterol becomes similar to that seen in men and hence the protection to the heart is lost. It was shown, as early as 1952, that following the menopause HRT will restore the balance between HDL- and LDL-cholesterol and total cholesterol is also reduced.

Hormone replacement therapy may reduce heart problems by additional mechanisms to its beneficial effect on cholesterol chemistry. Platelets (Q24.10) may become less sticky reducing the risks of clotting in the arteries (thrombosis), and fibrinolytic activity (Q24.17C) may be increased in the blood so that very tiny clots in the arteries are more quickly dispersed. HRT also has a tendency to dilate blood vessels.

References:

Menopause: refining benefits and risks of hormone replacement therapy (1995) 27-04-660

Q 27. 5 If I am at increased risk of heart disease, can HRT still help?

Those women at particular risk of heart attacks because of family history, high blood pressure, smoking or raised cholesterol levels receive even greater benefit from HRT than those without these risk factors. One researcher found that in an “at-risk” group, HRT reduced the risk of a heart attack to one fifth when compared to those who did not take HRT.

Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?

If you are on oestrogen replacement therapy and you have not had a hysterectomy (hysterectomy), progestogen must also be taken (Q28.9). Medroxyprogesterone acetate (Provera) and dydrogesterone (Duphaston) do not seem to have any detrimental action on cholesterol chemistry. Other progestogens, particularly norethisterone and levonorgestrel, may partly offset the benefits of the oestrogen. One paper, however, published in 1996 from data obtained from the American Nurses’ Health Study suggests that the progestogen component of combined hormone replacement therapy may actually enhance the benefits of oestrogen on the coronary arteries.

References:

A double-blind randomised controlled trial of the effects of medroxyprogesterone acetate on bone density of women taking oestrogen replacement therapy (1997) 27-05-1635

Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?

So far there is insufficient information in the literature to answer this question precisely. The presumption is that the longer it is taken the greater the benefit. HRT may protect against heart attacks and angina before damage is done and most gynaecologists and heart specialists recognise these benefits. There is however recent evidence that suggests that HRT does not protect against heart disease.

Q 27. 8 Is there any evidence that HRT will protect my bones?

The density of bones can be measured accurately by special scans. Serial bone density scans can be used to follow progress of treatment.

A 50-year old patient was found to have a polyp on her cervix and was referred to me by her general practitioner. Her periods had stopped ten years earlier and she had never considered HRT. Bone density scans of her spine and left hip showed that she was at risk of fractures.

She was commenced on HRT and remains happily on her regimen. Serial bone density scans have demonstrated the benefit of her treatment (Figure 27.1). In the Framingham Study, the relative risk (Q33.27) of hip fracture was 0.65 for those who had taken HRT at some time and dropped further to 0.34 for those who had been taking HRT within the last two years.

The earlier HRT is commenced the better and it should be continued for at least ten years. There is evidence that bone density remains higher for some years after HRT has been discontinued but the benefit may not be sustained indefinitely.

References:

Menopause: refining benefits and risks of hormone replacement therapy (1995) 27-08-660

Increase in bone mass of older postmenopausal women with low mineral bone density after one year of percutaneous oestradiol implants (1995) 27-08-824

Magnitude and pattern of skeletal response to long term continuous and cyclic sequential oestrogen/progestin treatment (1994) 27-08-363

The effect of 25-mg percutaneous estradiol implants on the bone mass of postmenopausal women (1994) 27-08-639

The effect of postmenopausal estrogen therapy on bone density in elderly women (1993) 27-08-816

Increase in bone mass after one year of percutaneous oestradiol and testosterone implants in post-menopausal women who have previously received long-term oral oestrogens (1992) 27-08-825

Smoking eliminates the protective effect of oral estrogens on the risk for hip fracture among women (1992) 27-08-818

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?

In a randomised study, 45 postmenopausal women were given a 25mg, 50mg or 75mg oestradiol implant. There was a correlation between the strength of implant, blood levels of oestrogen and effect on bone density.

Implants seem to be more effective at increasing bone density than oral oestrogen. In one investigation, ten out of twenty postmenopausal women on long-term oral (tablet) oestrogen therapy were given implants instead. Those changing onto implants increased their bone density by more than 5% whereas those maintained on oral oestrogen did not further improve their bone density.

References:

Combined oral oestradiol valerate-norethisterone treatment over three years in postmenopausal women: Correlation between oestrogen levels and bone mineral density sites (2001) 27-09-3406

Effects on bone mass after eight years of hormonal replacement therapy (1997) 27-09-1753

The dose-response of percutaneous oestradiol implants on the skeletons of postmenopausal women (1994) 27-09-638

Q 27. 10 Are there other treatments apart from HRT for osteoporosis?

Bone density improves with physical activity and diminishes with inactivity. Exercise strengthens your bones. There are other medications notably the biphosphonates but HRT remains the first-line medical treatment.

Q 27. 11 Would HRT help my skin?

Dryness of the skin is a frequent observation following the menopause. The skin texture may improve within a few months of commencing HRT.

Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?

The objectives of hormone replacement therapy are to alleviate or minimise the morbidity (illness) and mortality (death) associated with the reduced levels of reproductive hormones associated with the menopause.

Certainly if your symptoms are solely related to oestrogen deficiency they should respond to hormone replacement therapy. However symptoms typical of the menopause may have a variety of other causes. Lack of energy, soreness of the vagina, and depression are commonly found in association with themenopause, but lack of energy may be related to lifestyle (overdoing it) or anaemia, soreness of the vagina could be due to infection, and depression can have many explanations including the stresses of life.

During reproductive years, the ovaries secrete oestrogens, progestogen and androgens. Following themenopause, there is a significant reduction in production of each of these hormones. Hormone replacement therapy is the term most frequently employed for oestrogen replacement. We should also consider progesterone and androgen deficiency and possible replacement of these (Q28.16 and Q28.17).

Unfortunately, many patients or their families, inappropriately assume that there must be a perfect HRT that will provide a complete panacea for all their difficulties; some of their problems may be unrelated to hormone changes. HRT can only reduce symptoms attributable to hormone deficiency.

Q 27. 13 How common is cancer of the breast?

Sadly, breast cancer is a relatively common condition; 1 woman in 12 will develop breast cancer at some time during her life (7.5% by the age of 75 years – Figure 27.2).

Q 27. 14 What factors influence the chance of breast cancer developing?

It has been shown that natural events can influence the risk of breast cancer. In particular the amount of exposure to the body’s own oestrogen is important. Women who have never had children or who had their first child relatively late seem to be more at risk.

A girl reaching her menarche (first period) before the age of thirteen has twice the risk of developing breast cancer later in life. There is a doubling of the risk of breast cancer occurring in women who have their last period at age 55 or more compared to those who have a natural menopause before their forty-fifth birthday; the relative risk is greatest beyond the age of seventy. The affect of an early menarche on the risk of later breast cancer development is greater than the effect of a late menopause.

Women who have had an early first pregnancy, those with several children and those who have breast fed seem to be at reduced risk. There has been a suggestion that termination of pregnancy may increase the risk of breast cancer later in life.

Surgical menopause (removing the ovaries) before the age of 35 reduces the risk of breast cancer occurring thirty or more years later by more than 60%. These associations would all suggest a plausible link between exposure to oestrogen and breast cancer.

Exposure to oestrogen may increase the risk of breast cancer, but it is exposure in the early years that influences the outcome far more than oestrogen in later life. In developed countries including Europe and North America, the trend has been for the menarche (first period) to occur earlier.

Even when considering natural risk factors for breast cancer, there is a lack of consistency between studies. One group, for example, found no correlation between early menarche (first period) or late menopause and the risk of the disease.

There has been dispute as to whether a family history of breast cancer increases the risk of developing the disease. Furthermore, we do not have sufficient information to know whether a combination of a family history of breast cancer and HRT significantly increase your risk of developing the disease. Some studies show no difference and others have found an increased risk.

References:

Risk factors in breast carcinoma (1991) 27-14-645

Q 27. 15 What is the relationship between HRT and breast cancer?

For many years there has been debate about the relationship between HRT and Breast Cancer. Until 2003 the risk seemed to be relatively small unless the HRT was taken for more than 10 years.

The “Breast cancer and hormone-replacement therapy in the Million Women Study” has provided strong evidence that the risk is greater for those women taking oestrogen and progestogen regimens than had been previously believed. Progestogens must be prescribed for those women taking HRT who have not had a hysterectomy.

For women who have taken oestrogen only HRT for 10 years there is an additional 0.5% risk of breast cancer by age 65 and for those who have taken oestrogen-progestogen the additional risk is 2%. This compares to an underlying risk of breast cancer developing for never users of HRT of 4.8%.

Even a small additional risk of breast cancer would potentially affect a large number of women. There have been many studies comparing the incidence of breast cancer in women who have taken HRT and those who never have. Some studies suggest a decreased incidence of breast cancer with HRT and others show an increase.

Many of the studies have not been controlled (Q33.26) for factors already known to influence the chance of breast carcinoma developing (Q27.14). Consideration should also be given to the age of commencing HRT, duration of therapy, type of therapy and dosage.

Many patients wish to take HRT for just a short time to overcome the acute symptoms of the menopause. There is virtually universal agreement that if HRT is taken for less than five years, there does not appear to be any additional risk.

A progestogen is required for women taking oestrogen unless they have had a hysterectomy (Q28.9). In an early report, there seemed to be reduced incidence of breast cancer for women taking progestogen.

A study reported in The Lancet in 1991 showed an apparent better outcome for premenopausal women with breast cancer if surgery was performed during the luteal phase (Q2.13) of their menstrual cycle:

It is during this phase that the ovaries are releasing progesterone (Figure 2.3). The authors conjectured that progestogen therapy may be beneficial before the menopause to counteract the prolonged unopposed oestrogen secretion that is common at that time (Q24.17B).

From a theoretical point of view, however, it is believed that progestogens are unlikely to reduce the risks of breast cancer. The latest evidence from the Nurses Health Study (Q27.25) indicates no benefit from progestogen in relation to breast malignancy among postmenopausal women.

Recent evidence is tending to indicate a small increased incidence of breast cancer for women currently taking HRT for more than 10 years but not for women who have stopped it after ten years. A meta-analysis (Q33.23) of 51 investigations was published in The Lancet in October 1997.

The results were based on data from 160,000 women. More than 900 of these women had been on HRT for at least 15 years. Figures 27.2 and 27.3 show the estimated cumulative percentage of women who will develop breast cancer to be expected in those who do not use HRT and for those taking it for 5, 10 or 15 years commencing age 50 or 55.

The meta-analysis confirmed that there is a slightly increased incidence of breast cancer related to duration of use.

It should be emphasised that if there is a link between prolonged use of HRT and breast cancer it relates to the chance of the disease occurring rather than to the risk of death from the disease.

Women who have been found to have breast cancer whilst on HRT tend to have the diagnosis made at a relatively early stage (Q32.02) probably because of increased surveillance from those prescribing it. This should confer a better long-term prognosis.

Death rates from breast cancer in patients taking HRT is lower with risk ratios (Q33.27) quoted between 0.5 and 0.8. Current users of HRT who have been on treatment for more than 15 years have a 40% reduction in overall death rate from all cancers including breast cancer and from arterial disease.

Cancer of the ovaries and body of the womb occur less frequently in HRT patients. We must carefully scrutinise all new data but at the moment the evidence is reassuring.

The recommendation by the data and safety monitoring board to stop the trial by the Women’s Health Initiative Investigators (WHI) because the risk of invasive breast cancer with oestrogen plus progestin was slightly increased has led to inappropriate anxieties for many women currently taking HRT and for those who have been considering it.

There are four fundamental difficulties encountered when interpreting the report. Firstly, the age range of the women in the study was 50 to 79 with a mean of 63.3 years. Only 33% of the women were in the age range 50 to 59 and this is the group who are most likely to consider hormone replacement therapy. Secondly, 20% of the women had taken HRT, for an unspecified duration, before entering the study.

Previous HRT may have reduced some of the risks in the placebo arm of the trial. Furthermore, HRT taken for more than 10 years increases the risk of breast cancer by 1.5%. Is it possible that some of the increased breast cancer seen in the HRT arm of the study (38 vs 30 per 10,000 person-years) could be associated with the HRT being taken for several years before entry into the study in addition to a maximum of 8.5 years during the study?

The third problem relates to a 40% overall drop out rate but these do not appear to have been excluded from the analysis. Finally, during the study, 10.7% of women in the placebo group started HRT.

It would be beneficial if the WHI could look at outcomes for women in their three age groups (50-59 [33%], 60-69 [45%] and 70-79 [21%] years). It may be that for the younger age groups the risks of HRT are insignificant and for them the trial has been brought to an inappropriate premature conclusion.

We must learn from history. In the 1990s many women stopped taking third-generation combined oral contraceptive pills on the advice that the second generation were safer. The result was an increase in pregnancy termination . The third-generation pills were reinstated to first line status as the outcome differences were extremely low.

The majority of perimenopausal women take HRT for symptom relief only. Older women commence HRT predominantly to prevent osteoporosis rather than cardiovascular complications. For the majority of HRT users, the WHI trial confirms that the risks of HRT are low and the benefits are likely to be greater.

The “Breast cancer and hormone-replacement therapy in the million Women Study” must be seen as strong evidence that there is a significant increased risk of breast cancer developing in current HRT users. More than a million women aged 50-64 years were recruited between 1996 and 2001.

Half the women had used HRT. Current users of HRT were more likely than never users to develop breast cancer. Past users of HRT were not at increased risk. The incidence of breast cancer was significantly increased in preparations containing oestrogen only.

The magnitude of the associated risk was substantially greater for oestrogen-progestagen combinations and for tibolone than for other types of HRT. In current users of HRT the risk of breast cancer with increasing duration of HRT use. Ten years of HRT use is estimated to result in five additional breast cancer per 1000 users (0.5% increase).

References:

Breast cancer and hormone-replacement therapy in the Million Women Study. (2003)

Breast cancer and hormone replacement therapy: Collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer (1997) 27-15-1916

Menopausal estrogen and estrogen-progestin replacement therapy and risk of breast cancer (United States) (1994) 27-15-826

Prognosis after breast cancer diagnosis in women exposed to estrogen and estrogen-progestogen replacement therapy (1989) 27-15-658

Estrogen replacement therapy and breast cancer risk (1993) 27-15-646

Hormone replacement therapy and risk of breast cancer: Results from epidemiologic studies (1993) 27-15-830

A meta-analysis of the effect of estrogen replacement therapy on the risk of breast cancer (1991) 27-15-675

Prognosis after breast cancer diagnosis in women exposed to estrogen and estrogen-progestogen replacement therapy (1989) 27-15-658

Decreased incidence of breast cancer in postmenopausal estrogen-progestogen users (1983) 27-15-648

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 16 I have benign breast disease. Can I take HRT?

There is no evidence that benign breast disease increases your risk of breast cancer if you decide to take HRT. If you have had cyclical mastalgia (breast pain) during your reproductive years a sequential HRT (Q28.9) may result in cyclical breast pain again. However, if you are beyond themenopause, a continuous combined preparation (Q28.12) will not cause cyclical symptoms. Mastalgia has been reported in 8% of women commencing HRT.

Paradoxically, postmenopausal women troubled by mastalgia report improvement after HRT is commenced. We have observed that mastalgia is a particular problem when HRT is started several years after the menopause. In these circumstances, we often introduce the HRT slowly and gradually increase the dose.

A 40-year old lady presented to us with reduced energy and other menopausal symptoms ten years after hysterectomy and removal of her right ovary and Fallopian tube.

She was reluctant to start HRT as she had been prone to severe cyclical mastalgia before her hysterectomy. Oestradiol valerate 1mg on alternate days for two weeks increasing to the usual daily regimen was prescribed and she had no problems.

References:

Paradoxical effects of hormone replacement therapy on breast tenderness in postmenopausal women (1994) 27-16-676

Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?

It is generally believed that for women who have had breast cancer, HRT is contraindicated. We now recognise that the question of the safety of HRT for women treated for breast cancer requires urgent attention.

There are millions of women in the world who have had breast cancer successfully treated. In 1997 180,000 women were diagnosed and treated for the condition in the USA and it has been estimated that 97,000 of these have only a very small chance of recurrence.

One must always consider risks and benefits. There is a trend for oncologists (cancer specialists) to recognise that the risks of HRT for those with a history of breast malignancy has been overstated although there is likely to be a small, but so far unquantified, risk.

There is certainly some early reassuring data indicating that continuous combined HRT carries a lower risk of tumour recurrence than had previously been anticipated. It would, therefore, be inappropriate to rule out HRT for a woman with distressing symptoms adversely affecting the quality of her life.

Many women are successfully treated for breast cancer and later on suffer debilitating oestrogen deficiency symptoms or risk premature heart problems or hip fractures from osteoporosis. Recent studies provide encouraging findings and prospective studies have commenced to evaluate the benefits and risks.

A history of breast cancer can no longer be considered as an absolute contraindication for HRT although there continues to be some controversy. It is our routine policy when counselling such a patient to liaise with other clinicians involved in her care before commencing treatment. This ensures that the patient receives consistent advice.

References:

Hormone replacement therapy for women after breast carcinoma (1996) 27-17-1902

The use of hormone replacement therapy in women previously treated for breast cancer (1995) 27-17-493

Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?

This is a key issue for many women who start HRT early either because they have had an early menopause (Q26.8) or they developed menopausal symptoms before the menopause.

There is no information in the literature to provide us with a precise answer probably because there have been too few women in this group to study adequately. We must, therefore, extrapolate from the facts that are available:-

• A woman who has a premature menopause and does not receive HRT has reduced risk of developing breast cancer.

• A woman who has a late menopause has a slightly increased risk (Q27.14).

• If a woman has her menopause at the age of fifty and then takes HRT for 15 years, her risks of breast cancer are increased by 1.5% above the underlying risk (Q27.15).

Let me illustrate this by inventing identical twins. One, Anne, has her ovaries removed at the age of thirty-five and the other, Brenda, has a natural menopause at the age of fifty.

If Anne never took HRT she would be less likely to develop breast cancer than Brenda but if Anne commenced HRT at the time her ovaries were removed and continued with it to the age of fifty, we suspect that their risks of developing the disease would be the same. The HRT is essentially replacing her natural oestrogens.

If Anne started HRT at the age of thirty five and Brenda took HRT from the age of fifty and they both continued with it to the age of sixty-five each would increase their risk by 1.5%. We do not have any evidence to suggest that Anne would be more at risk than Brenda.

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?

The two most common types of cancer of the womb arise from the cervix or endometrium. HRT is not a risk factor for cancer of the cervix. Cancer of the lining of the womb (endometrial cancer – Q32.20) tends to present with irregular bleeding and at examination the neck of the womb appears healthy.

Before cancer develops in the endometrium there are pre-malignant changes and these may occur in association with prolonged episodes of unopposed oestrogen (eggs are not being released in a lady who has not reached her menopause).

Irregular bleeding and heavy periods, particularly in women over the age of forty require investigation to exclude pre-malignant changes, usually by hysteroscopy and D & C (Q24.12).

We now know that for women who have not had a hysterectomy (hysterectomy), it is essential to provide progestogen to prevent the risks associated with unopposed oestrogen. The combination of oestrogen with progestogen, as currently recommended, has been shown to reduce the chance of endometrial cancer developing to below the risk for women who never received HRT. Sadly,

when HRT was first used about forty years ago, many women were given oestrogen alone and their chance of developing endometrial cancer was increased eight-fold.

Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?

Officially endometrial cancer is a contraindication for HRT although the risks have probably been overstated. The traditional advice that HRT is contraindicated is based on the knowledge that unopposed oestrogen predisposes to the cancer developing (Q32.20).

The majority of women found to have endometrial cancer present at an early stage and are likely to be cured by hysterectomy. Following successful surgery, many women subsequently develop debilitating menopausal symptoms which may not always respond to non-hormonal treatment. There are reports of such women receiving HRT and the results have been reassuring. One study reported a better outcome for such women receiving HRT than the controls who did not.

If a woman with a history of endometrial cancer develops symptoms that warrant HRT, the team of doctors responsible for the treatment of the cancer, including the gynaecologist and radiotherapist (doctor specialising in radiation treatment), should liaise to ensure consistency of advice. If HRT is to be prescribed it would seem appropriate to administer progestogen as well as oestrogen.

A nurse had a total abdominal hysterectomy (hysterectomy) and removal of both ovaries for endometrial cancer. When hot flushes became intolerable she elected to start HRT and she has continued to take it without problems for the last twelve years.

References:

Hormone replacement therapy and gynecological cancer (1997) 27-20-2102

Q 27. 21 Does HRT have a relationship to ovarian cancer?

We know that the combined oral contraceptive pill undoubtedly reduces the risk of ovarian cancer but the evidence with HRT is not quite so conclusive. For those patients who have had cancer of the ovary, HRT does not seem to cause any adverse effects.

Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).

Until just a few years ago hormone replacemtn therapy – HRT – was contraindicated for women who had a history of a clot in a leg vein or the pelvis (deep venous thrombosis) or a blood clot that had travelled to the lungs (pulmonary embolism): A pulmonary embolism can be fatal.

It was known that the combined oral contraceptive pill increased the risks (Q15.14) and as HRT also contained oestrogen it was assumed that the risks would be too high. The changes in the blood clotting mechanism seen with the combined oral contraceptive pill, however, have been shown to be absent with HRT and for the last ten years HRT has no longer been contraindicated.

Soon after my appointment as a consultant, I was asked to see a lady of seventy who was a piano teacher. She had been taking HRT for ten years and she was certain that this maintained her mental ability and dexterity. Sadly, she sustained a DVT and required Warfarin to thin her blood.

The physicians had appropriately stopped her HRT but some months later she wanted to recommence it. We were reluctant to go against the rules although the evidence about the risks in this situation was quite reassuring.

The lady explained that without her HRT she could not play the piano never mind teach it. She promised me that, even if she died from her HRT she would not consult her lawyers! My legal advisers assured me that provided the patient was fully aware of the implications, I was entitled to prescribe HRT for her from a medico-legal point of view. Happily, she attended my clinics for many more years and no doubt played and taught beautiful music.

A history of DVT is no longer considered to contraindicate HRT and the books and information leaflets have been appropriately amended. The HRT should, however, be discontinued during an acute thrombosis. If a patient has a strong history of “clot” problems or if such problems are common in close relatives, a special set of blood tests (thrombophilia screening) may be indicated.

A 50-year old lady, who’s last period had occurred 7 years earlier, was referred to me for consideration of hormone replacement therapy. Before the age of 40 she had five episodes of deep venous thrombosis. A “thrombophilia screen” demonstrated a predisposition to thrombosis. Our haematologists (specialists in disorders of the blood) commenced her on Warfarin which reduces blood clotting and she was then started on HRT without problems.

In 1996, three papers appeared in “The Lancet” indicating a small increased risk of thromboembolism in current HRT users. We know that the risk of thromboembolism is 1 person in 10,000 per year and the risk of dying from a thromboembolism is 1 in a million. HRT increases these risks three-fold that is to say that the risk of dying from a blood clot as a result of the HRT is 3 in a million per year.

This risk should be seen in the context of other causes of mortality (Figure 27.4). The risks of dying from an accident are not high but your risk of dying from an accident are greater than your risk of dying from pulmonary embolism. The Committee on Safety of Medicines has commented that this new data does not change the overall positive balance between the benefits and risks of treatment for most women.

Q 27. 23 I have varicose veins. Can I take HRT?

Varicose veins are a common problem. Provided they are not causing pain, there is no reason to withhold HRT. If the veins are causing pain medical assessment is indicated.

Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?

One of the potential complications following an operation is a blood clot in one of the veins in the legs or pelvis (Q4.21) and we surgeons try to reduce this risk as far as possible. Whereas the advice for those on the combined oral contraceptive pill is that they should stop taking it four weeks before surgery, the advice with HRT is less defined. Many gynaecologists frequently introduce an oestradiol implant at the time of hysterectomy (hysterectomy). You should let your surgeon know that you are taking HRT so that you can receive the appropriate advice.

Q 27. 25 Does HRT increase life-expectancy?

The balance of evidence, in my opinion, suggests that HRT increases life-expectancy. In the Leisure World Laguna Hills study, there had been 1447 deaths after 7.5 years follow-up. Mortality was reduced by 20% in those who had taken HRT at some time in their lives. For current users who had been taking HRT for more than 15 years there was a 40% reduction in overall mortality.

There were less cancer-related deaths in the HRT group. In a meta-analysis (Q33.23) of the literature published in 1992, it was calculated that in general there would be a net gain of one year for a woman starting HRT at the age of fifty. For those women most at risk of coronary heart disease, HRT would provide a net gain of two years. For women at particular risk of developing breast cancer, HRT would still provide a net gain of one year.

The American Nurses Health Study has followed 121,700 female nurses from 1976. Their latest report (1997) has continued to show lower death rates at a given age in HRT users.

References:

Postmenopausal hormone therapy and mortality. (1997) 27-25-3065

Decreased mortality in users of estrogen replacement therapy (1991) 27-25-836

Postmenopausal oestrogen treatment and stroke: A prospective study (1988) 27-25-819

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?

It is possible that you may have menopausal symptoms such as hot flushes (hot flashes), night sweats, sleeping problems or mood changes associated with the menopause even before your periods have stopped. You may well reap the benefits of HRT and there is really nothing to lose by giving it a trial.

Q 27. 27 I have been told that I have fibroids. Can I take HRT?

Fibroids (Q23.14) may be present in up to 50% of women although most are small and of no clinical significance. All fibroids are initially small but a few can grow to be quite large (exceptionally reaching the size of a large melon).

At one time, the only way that we could diagnose fibroids, other than at surgery, was to feel enlargement and irregularity of the uterus during pelvic examination. Unless you are less than average weight, it is unlikely that your doctor would be aware of a fibroid during examination if it is smaller than four centimetres.

Ultrasound has revolutionised our ability to diagnose fibroids. It would seem that about 50% of women having ultrasound have evidence of small fibroids and most of these would not have been detected by routine clinical examination. These small fibroids should not be considered as reason to withhold HRT.

We have been rather cautious about prescribing HRT when there are larger fibroids. We know that fibroids tend to shrink after the menopause suggesting a hormone link. There are times when gynaecologists temporarily suppress oestrogen to menopausal levels. An example would be before removing a large fibroid.

The temporary reduction of oestrogen reduces the size of the fibroid and simplifies surgery. This temporary suppression of oestrogen may be for several months and many younger women find this difficult to cope with. In these circumstances, we would also provide HRT (add-back therapy) to control the oestrogen deficiency symptoms: this does not adversely affect the fibroids probably because the amount of hormone in the HRT is less than that in natural cycles. This suggests that our previous anxiety about HRT with regard to fibroids was overstated.

If you have fibroids, you can take HRT but the size of the fibroids should be monitored regularly.

References:

The role of hormone replacement therapy in women with a current or past history of endometriosis. (2000) 27-27-3077

The effects of hormone replacement therapy on uterine fibroids in postmenopausal women (1996) 27-27-1175

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 28 What happens if I decide not to take HRT?

The final decision is yours. Many women go through the menopause with little or no difficulty and choose not to take HRT. As a doctor who is a keen advocate of HRT, it always seems appropriate to bring up the subject of HRT with my patients whenever the opportunity arises. However, if you have decided that HRT is not for you, there is absolutely no reason for you to be pressurised in any way.

Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?

The media seem to highlight anxieties about HRT but the majority of doctors believe that the benefits of HRT are greater than the risks. Usually it is a matter of presentation. The media, for example, point out that HRT increases the risk of breast cancer. This is true, although the increase is small.

When you reach your menopause your ovaries will have run out of eggs. Menopausal symptoms are side-effects resulting from nature preventing babies being delivered to women beyond middle age (Q26.2). If any other gland stops working doctors recommend replacing the missing hormones.

This is true for diabetics who require insulin or those with hypothyroidism (underactive thyroid gland) who require thyroxin. Hormone replacement therapy can be seen as replacing hormones that the ovaries are no longer capable of producing. This may be interfering with nature but surely all medical treatment is helping nature when ill health or premature death would otherwise be the result.

Let us look at the Lancet data of 1997 again (Figure 27.3). The media stated that there is a 25% increase in the incidence of breast cancer in HRT users. Many women heard “25%” and said “1 in 4 risk – no thank you. Count me out!” The 25% was the increase compared to the underlying risk. By the age of 75 years, 7.5% of women who had never taken HRT will have developed breast cancer. If HRT had been taken for fifteen years, by the age of 75, 9% would have developed the disease.

The majority of these 90 women per thousand would have developed the disease anyway. The additional risk is actually 1.5%! When compared to the 7.5%, 1.5% represents about a 25% increase. The facts are the same – the presentation is different.

Sadly, the media appear to believe that only controversy rather than harmony can improve their ratings. They tend to highlight anxieties in their efforts to achieve sensationalism and any reassuring information seems to be hidden or withheld.

Thus evidence that women found to have breast cancer whilst taking HRT are diagnosed at an early stage of the disease when cure is more likely receives little media attention. Persuasive evidence that HRT is associated with lower overall incidence of cancer and reduced death rates never seems to make headline news.

It is not difficult to identify a lady who has developed breast cancer whilst taking HRT but the chances are it would have happened even without the treatment. Doctors, however, cannot identify specific individuals and state that they are alive and healthy as a result of HRT. We can only prove the point by statistics that appear to us to be conclusive.

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
Women’s Health – Home Page

Q 27. 30 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:

Q 27. 1 Can HRT help me with the psychological difficulties that I am experiencing around
the time of my menopause?
Q 27. 2 Can HRT help my mental ability?
Q 27. 3 Can HRT reduce my chance of developing heart disease?
Q 27. 4 How does HRT protect against coronary heart disease?
Q 27. 5 If I am at particular risk of heart disease, can HRT still help?
Q 27. 6 Do progestogens taken in combination with oestrogen replacement therapy have an adverse effect on heart protection?
Q 27. 7 How long should HRT be taken to reduce the risk of heart disease?
Q 27. 8 Is there any evidence that HRT will protect my bones?
Q 27. 9 Would the dose (strength) of my HRT influence its ability to protect my bones?
Q 27. 10 Are there other treatments apart from HRT for osteoporosis?
Q 27. 11 Would HRT help my skin?
Q 27. 12 Can hormone replacement therapy cure all my menopausal symptoms?
Q 27. 13 How common is cancer of the breast?
Q 27. 14 What factors influence the chance of breast cancer developing?
Q 27. 15 What is the relationship between HRT and breast cancer?
Q 27. 16 I have benign breast disease. Can I take HRT?
Q 27. 17 Does a history of breast cancer mean that HRT is absolutely contraindicated?
Q 27. 18 If I started HRT early (aged 30 to 45), does this influence my chance of developing breast cancer?
Q 27. 19 Does hormone replacement therapy increase the risks of cancer of the womb?
Q 27. 20 I have had endometrial cancer and now have menopausal problems. Can I take HRT?
Q 27. 21 Does HRT have a relationship to ovarian cancer?
Q 27. 22 Can I take HRT if I have had a blood clot (DVT – deep venous thrombosis or pulmonary embolism).
Q 27. 23 I have varicose veins. Can I take HRT?
Q 27. 24 Should HRT be discontinued before I have a major operation or leg surgery?
Q 27. 25 Does HRT increase life-expectancy?
Q 27. 26 I am still seeing periods. Could HRT have any benefits for me?
Q 27. 27 I have been told that I have fibroids. Can I take HRT?
Q 27. 28 What happens if I decide not to take HRT?
Q 27. 29 Doctors seem to promote HRT but the media cause me anxiety. Who is right?
Q 27. 30 Could I have some useful Web sites?
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