Variations on HRT.

Summary and conclusions

The principles of hormone therapy for the menopausal or perimenopausal woman can be summarized thus. These items are not entirely consistent with the current advice of regulatory bodies but they do reflect a studied analysis of the available data as well as a long clinical and academic interest in the subject. Medical practitioners of all levels require guidance for the hormonal treatment of middle aged women. These views should be considered, discussed and criticised as a fresh clinical approach is urgently needed.  Currently many women suffering severe hormonal disorders are being needlessly denied appropriate safe hormone therapy

1. estrogens are safe when started below the age of 60 particularly if progestogen   is not required and are positively indicated in women with a premature menopause It should be used for treatment of specific climacteric symptoms and low bone density and the advice that estrogens should not be first option for the prevention or treatment of osteoporosis in this age group is questioned .The dose and route will depend upon the symptoms and the age of the patient.
   
   
2. Women with a uterus need endometrial protection with progestogen. The usual duration is 14 days but if the extra risk to the breasts from progestogen is confirmed it would be sensible to reduce the duration to 7 days each calendar month.  This shortened course is also useful in women with progestogen intolerance and is adequate for endometrial protection. Alternatively a Mirena IUS can be inserted. The long term value and safety of low dose unopposed estrogen is unproven.
   
   
3. Oestrogen only therapy commenced before age of 60 is associated with a considerable but non significant decrease in coronary heart diseases, osteoporotic fractures, colon cancer and deaths. These results are consistent with the previous case control studies. There may also be a decrease in breast cancer in women receiving oestrogens without progestogen.
   
   
4. Oestrogens appear to have no place for the secondary prevention of cardiovascular disease but there may be a window of opportunity in 45-60 year old symptomatic women who may show long term cardiovascular and neurological benefits from early oestrogen therapy. Oestrogens commenced in older 69-79 women may do “early harm” before any benefit can be achieved and should be avoided if possible or started on very low dose oestrogens.
   
   
5. A moderately high dose of transdermal oestrogens is useful for perimenopausal depression as well as premenstrual depression.  Progestogen is necessary for endometrial protection and cycle control even though these patients may be intolerant to small doses and short duration of any gestogen.
   
   
6. Patients may wish to avoid bleeding by using low dose oestrogen and progestogen, Tibolone or have a Mirena IUS inserted.
   
    
7. If loss of libido and loss of energy remain a problem the addition of testosterone to estrogen should be considered. Androgen as well as oestrogen is often necessary after hysterectomy and bilateral oophorectomy.  Hysterectomized women do not need progestogen.
   
   
8. A 5 year duration has been recommended but in reality women remain on HRT if they are feeling well with relief of symptoms.  It is difficult to persuade these women to stop even after 10 or more years. (41) The need for oestrogens should be reviewed each year for long term users with clear discussion of current views on safety.
   
   
9. In spite of the reassuring data from estrogen only studies the possible increase in breast cancer remains a problem. Until the controversy concerning breast cancer risk is clarified it is probably advisable that regular mammograms should be performed each year and breast examination every 6 months although it is correct to recognise that many oncologists would doubt the value of these frequent examinations.
   
   The optimistic recommendations in this paper are now supported by the latest publication from the WHI reporting the results of starting Prempro before age 60 which results in 24% fewer cases of  CHD and 30% decrease in total mortality.(42) Age is the most critical factor whether estrogen only or estrogen plus progestogens was used . Both the North American Menopause Society (43) and the International Menopause Society (44) have now changed their guidelines recognising the efficacy for many indications for HRT outlined in this review and long term safety of such therapy. This belated conversion to the clinical realities of HRT have been warmly welcomed. (45)