There are so many HRT myths out there, and most of them are incorrect, or greatly exaggerated. So let’s go through the most common and explain why these myths, are just that: myths.
1. HRT is associated with an increased risk of breast cancer in women undergoing premature menopause.
POI (Premature Ovarian Insufficiency) is when the menopause occurs in women under the age of 40 years. The incidence is about one in a hundred women under the age of 40 and around one in a thousand women under 30 in the UK. It is still under-diagnosed and under-treated.
Women with POI should be given replacement hormones either in the form of hormone replacement therapy (HRT) or the combined oral contraceptive pill (COCP) until at least the average age of the menopause (51 years). This is not just for symptom control, but also to maintain their long-term health and reduce their increased risk of osteoporosis, cardiovascular, psychological and cognitive diseases.
Any risks of HRT (for example, breast cancer risk) do not apply to younger women with POI which take HRT. The risks and benefits of HRT for women with POI is completely different from those of women using HRT for their menopause who are older than 51 years of age.
2. Menopause lasts for a year, so women should learn how to cope with it.
Myths like this are silly and cause a lot of pain. Symptoms of the menopause last a lot longer than most women usually anticipate. The average length of time described is usually four years and many women reported still have some symptoms for longer than 10 years, so there is great variability. On average, women spend nearly a third of their life being postmenopausal especially now that we live longer.
Retirement age is increasing year by year and elderly people are more active, both physically and mentally than they were in the past. All these factors mean it is increasingly important that women are given choices regarding how to manage their menopause to reduce the detrimental impact it may have on their home and work lives.
3. All women having menopausal symptoms need to have their FSH level tested
NICE have very clear guidelines regarding the diagnosis of the menopause. In women over 45 with menopausal symptoms or who present with amenorrhea (no periods) for over 12 months, investigations are now no longer necessary.
In those women aged under 45 years, FSH testing may be used to diagnose the menopause. Other tests are largely unnecessary. This means that in practice women can start treatment sooner. This will have advantages for many women, especially those experiencing more severe symptoms. There are plenty of studies demonstrating that starting HRT treatment earlier has more advantages.
4. Women with a history of VTE cannot take HRT
There is an increased risk of Venous Thromboembolic Disease (VTE) in those women taking oral oestrogen; the risk is approximately double. To put that in context, we need to remember that this increased risk is far lower than the one experienced when taking the combined oral contraceptive pill. We should also be aware that the background risk of VTE increases as we get older.
However, transdermally administered oestrogen (patches or gel) is not associated with an increased risk of a clot. This is due to oral preparations undergoing first-pass hepatic metabolism. They, therefore, have a greater effect on clotting factors produced by the liver than transdermal preparations, which avoid hepatic metabolism.
Women with an increased risk of VTE should be offered HRT either as a gel or patch. NICE recommends that transdermal preparations should be considered for those women with a higher risk of VTE, including those with a BMI >30 kg/m2.
5. Women with cardiovascular disease should not take HRT
The controversial Women’s Health Initiative (WHI) study started women on HRT when they were over 60 years of age. Some subjects were given high doses of oral HRT. More recent studies have looked at the timing of starting HRT after the menopause; this seems to be pivotal regarding CVD risk. There is a lower incidence of CVD in women who start HRT within 10 years of their menopause starting. The CVD benefit of taking HRT is greater the earlier a woman starts HRT.
A recent Finnish study has shown that using HRT for at least 10 years is associated with fewer CVD and stroke deaths per 1,000 women. NICE states that women should be informed that. “HRT with oestrogen alone is associated with reduced or no risk of coronary heart disease”. And “HRT with oestrogen and progestogen is associated with little or no increase in the risk of coronary heart disease. Taking HRT for under 60 years does not increase a woman’s risk of CVD”.
The presence of cardiovascular risk factors is not a contraindication to HRT. It is then essential to manage any other underlying cardiovascular risk factors (eg blood pressure, cholesterol).
6. The maximum length of time women can take HRT is 5 years.
As a general rule, women should be prescribed the lowest effective dose of HRT for the shortest length of time. However, as the menopause can last for many years and everyone is different, some women will end up taking HRT for longer than five years.
When discussing menopause with women, it is so important that they receive individualised care. Women are not numbers. All women should receive appropriate and up to date information. This will enable them to make informed choices regarding the treatment they receive. Women need to be made aware that the HRT benefits and risks vary by dosage, regimen and timing of initiation. They need to be informed that, for example, vaginal bleeding may occur in the first three months of treatment.
Any woman taking HRT should be reviewed annually. This is the same as with the contraception pill. Women who elect to stop HRT can either have their HRT gradually reduced or stopped immediately. Many prefer to reduce slowly. This allows them to determine if they have any background menopausal symptoms with a lower dose.
7. Topical oestrogen to treat symptoms of vaginitis should not be used in the longer term.
Many women present during or after their menopause with symptoms of urogenital atrophy (muscle weakness in the vagina and bladder) One of the most common symptoms is recurrent urinary tract infections. These symptoms are often effectively managed giving women topical vaginal oestrogen in the form of pessaries, creams or rings. The NICE guidance states that vaginal oestrogen should be offered to women (including those on systemic HRT) with symptoms of urogenital atrophy and then continued for as long as needed to relieve those symptoms.
The only real contraindication to these preparations is active breast cancer. However, for the sake of context, a year’s dosage of topical oestrogen is roughly equivalent to one oral HRT tablet. This gives reassurance that vaginal oestrogens can be safely given as a repeat prescription. Vaginal lubricants and moisturisers (that help with vaginal dryness – another very common symptom of menopause) can be used with vaginal oestrogen and the combination of treatments is often effective for many women. Numerous women taking HRT still need to use topical oestrogen.
8. A recent study in the British Journal of Cancer demonstrates a correlation between HRT and breast cancer.
This study used information taken from serial questionnaires from the UK Generations Study. It estimates hazard ratios for breast cancer risk among postmenopausal women with known menopausal age. Their results showed a 2.74-times increased risk of developing breast cancer for women using combined HRT for five years.
This risk seems to increase around threefold with prolonged treatment – over 15 years. As shown with other studies, there was no increased risk of breast cancer seen for users of oestrogen-only therapy. This increased risk returned to normal within two years after stopping HRT.
A negative point of this study is that it has not differentiated between the various combined HRT products. This is a shame. There is considerable evidence to suggest that certain synthetic progestogens, for example, medroxyprogesterone acetate, may increase breast cancer risk if used in combined HRT and when compared, for example, to using micronised progesterone. Progesterone is micronized by reducing it to tiny particles, and mixing with oil to ensure better absorption.
This risk should be presented in context. Women should be made aware that the increased risk of developing breast cancer through HRT is less than the risk from being overweight or having a glass or two of wine each night.
9. Antidepressants should be used as the first line for women with depression symptoms.
The NICE guidelines clearly state that HRT should be considered to alleviate low mood arising as a result of the menopause. There is evidence that women receiving oestradiol have a significantly greater improvement in mood compared to those receiving a placebo. Moreover, cognitive behavioural therapy (CBT) might also be beneficial for some women.
It is very important that women who present with symptoms of depression are asked about the date of their last period. There is no clear evidence that antidepressants work to improve low mood in menopausal women who do not have depression.
10. HRT is not effective in reducing osteoporosis risk.
The incidence of fragility fractures increase in women at the onset of menopause, coinciding with lower oestrogen levels, a decrease in bone mineral density (BMD) and higher rates of bone turnover. Oestrogens currently remain the most effective way of increasing bone mineral density and preventing osteoporotic fractures in women. There is good evidence from randomised and cohort studies which demonstrates that the risk of fragility fractures and non-vertebral fractures is significantly lower for women taking HRT from the onset of menopause (either oestrogen alone or the combination of oestrogen plus progestogen) compared with non-users.
NICE recommends that women should be informed that their risk of fragility fracture is decreased while taking HRT. This benefit is maintained during treatment but decreases once treatment stops. It’s important for woman to understand that these are just myths and looks for scientific proof for their decisions.