You can see from these absolute risks of harm, when we look at 10,000 women taking HRT for one year, the risk to an individual woman is not great. However, if we count all the adverse health events that happened over the 5.2 years of the WHI Study, the excess number of adverse events in the women using the HRT was 1 in 100 women. This is a small risk, but shows that risks from combined oral HRT add up over time.
Although the WHI Study was set up originally to demonstrate the ability of HRT to prevent common diseases of ageing, the Study found that the opposite effect appeared to be happening. Given these results, the authors of the Study are recommending that doctors stop prescribing combined oral HRT therapy for long-term use.
Since the results of the WHI Study have caused such a furore, many people are asking questions that will take time to answer definitively – it is possible that future studies will find that the benefits outweigh the risks, perhaps thorugh the use of different combinations or formulations of more natural hormones. For example, studies are needed to determine the long-term benefits of transdermal natural hormones provided as patches or creams. I am confident that these will be shown to be safer than oral combined synthetic HRT, but only time will tell.
Professor Graham Colditz from Harvard Medical School was refreshingly candid about the results of the WHI Study: he said they are a major wake-up call to both consumers and health authorities. Since the WHI Study was abandoned, Professor Colditz and many other health experts around the world no longer recommend the use of long-term combined oral HRT to prevent disease. However, the use of combined oral HRT is still considered as generally safe when used for short-term treatment to relieve menopausal symptoms. My attitude to this is – Why would you use oral synthetic hormones when you have natural hormones that can be given in a more physiological way to relieve the symptoms of menopause?
The results of the WHI Study were based upon using 0.625 mg of Premarin (conjugated equine oestrogen) plus 2.5 mg of Provera (medroxyprogesterone acetate). Other types of oral hormone combinations may have different results. However, three studies using other oral combinations of HRT have all found an increased risk of breast cancer. An Oxford University Study in the mid-90s showed that oral HRT increased the risk of deep vein thrombosis. A long-term study of nurses found a link with breast cancer in 1995, but until now, the risk of combined oral HRT has generally been kept rather low key in mainstream medicine. Well, we have known for years that oral oestrogens such as Premarin, if taken for more than five years, will increase the risk of breast cancer by around 30 per cent. So why has the outcome of the WHI Study created such a bombshell?
It could be partly because the experts cannot seem to agree on the significance of the findings of the WHI Study –
Dr Deborah Grady, Director of the Mount Zion Women’s Health Clinical Research Center at UCLA (University of California in Los Angeles), believes that the results of the WHI Study provide compelling evidence that doctors find a way to get women off oestrogen.
Dr Maura Quinlan, an HRT specialist at the University of Chicago Hospitals, states ‘We have to stop using HRT for healthy women.’
Dr David Dammery, a GP and chairman of the Victorian College of General Practitioners in Australia, is very much against HRT for long-term prevention.
Other well-known professors world-wide believe that the design of the WHI Study was flawed, and that its results are not representative of the true value of HRT in healthy menopausal women. They criticize the sample of women chosen in the WHI Study as being unsuitable candidates for the use of HRT in the prevention of cardiovascular disease. They cite the problem that the sample of women chosen was too old and unhealthy to be used in a primary-prevention trial of the benefits of HRT.
Indeed, 66 per cent of the women in the WHI Study were 60 years or older. One-third of women in the study sample were obese, 36 per cent were being treated for high blood pressure, 12.5 per cent were being treated for high cholesterol, and 50 per cent were ex-smokers. Thus they were not representative of healthy women who had just arrived at menopause. According to these experts, the results of the WHI Study are not meaningful for healthy post-menopausal women. They also point out that there was no increased death rate among the women in the WHI Study who took HRT, compared to those who did not.
What Are the Real Issues?
As a doctor who sees thousands of peri-menopausal women, I believe that it is the quality of life now, and in the immediate future, that is most important to women. This is what women grapple with every day, and it greatly affects the enjoyment of their lives.
Just because certain types of hormones have been found to be unacceptably dangerous for long-term use, does not take away the need for, and interest in, hormone replacement therapy. Women are not so much interested in how they will feel in 20 or 30 years’ time, but rather want to be able to enjoy the still relatively young years, at least in today’s terms, that exist between the ages of 45 to 65. Also, today’s woman is smart and well educated and wants to know ALL her options. She knows that osteoporosis and heart disease have much more to do with diet and lifestyle than with hormones. The reality is this – if you have a poor diet, are overweight, smoke heavily or do not exercise, then all the HRT in the world is no guarantee that you will be saved from diabetes, fractures and heart attacks. Yes, a magic HRT pill to protect us from ageing and disease would be great – I would take it! However, we are all too smart to be duped by the drug companies.
The issues of the moment for peri-menopausal women are:
How do I feel and look today?
How does my mind function?
Do I have energy and vitality?
Do I feel sexual, sensual and feminine?
Can I have a good sexual relationship with my partner?
How can I remain healthy for the next 20 years?
To help women achieve their goals and satisfy the above expectations, doctors have to think laterally, practise holistic medicine and have empathy with every individual woman. If this is not their area of interest, they can always refer to a doctor who is interested in this sub-speciality of medicine. Clinical trials are based upon large numbers of subjects, statistics and a generalized deduction and recommendation. However, many individual women do not really relate to this academic world – it can be frightening and confusing for women trying to relate to the academic ivory tower.
First we must be honest with women – they deserve it! They depend upon doctors and we want to keep their trust.
Women would like to know that:
Very few pharmacological treatments in medicine are perfect – most are a compromise between relief and possible side-effects. We need to weigh up all the pros and cons. If we do take HRT it will have a protective effect upon our bones and usually improve our sex life, however if we use a potent oral form of HRT for more than several years, it may increase our risk of blood clots, strokes and breast cancer.
There is a great difference between individual women – some women need HRT to enjoy their lives, while others feel well and function efficiently without HRT. We should not frighten all women off HRT – some types of HRT remain a viable and safe option for many women.
Nutritional medicine can work, especially for the prevention of long-term degenerative diseases; however it cannot simulate the effect of real hormones in the way we feel. For example, homoeopathic hormones do not work at all, and herbal hormones will not achieve the exact same effect of real hormones.
There is a huge difference in the effect induced in the body by different types of hormones. For example, hormones taken orally, as in the WHI Study, are absorbed from the gut and pass straight to the liver. The liver breaks the hormones down (metabolizes them) and only a certain amount gets past the liver into the general circulation; thus we must use higher doses of more potent hormones to gain a clinical result. This increases the workload of the liver, and induces the liver enzymes to make more clotting factors; thus we become more at risk of blood