Dark downside of hormone replacement therapy

Health reporter REBECCA WALSH looks at the dangers in trying to stay youthful and sexy with HRT.

It would happen about 9 o'clock most nights. Sometimes the redness would rise from her chest up her neck and over her face. At its worst, her hair would stick in a soggy mass to her head and sweat would drip off her nose.

"I used to feel like I was in the tropics," the 59-year-old woman says of her menopause symptoms.

"I was not sleeping at night. I was soaked. I was having to have showers in the night because my bedclothes were soaking wet. It was just awful."

The Mt Albert podiatrist started hormone replacement therapy about 10 years ago. Five years ago she tried to come off it, but the headaches and sweats started straight away.

At her doctor's suggestion, last year she started slowly weaning herself off the drug, and by Christmas she was off it altogether.

But the menopause symptoms refused to go away.

"I went back to the doctor and said, 'I can't cope like this', and that I would have to go back on HRT.

"It makes me feel normal. I can function. I don't have the hot flushes, the headaches, and I'm not drenched in sweat."

The Auckland woman is one of tens of thousands of New Zealand women on some form of HRT.

But HRT - once reported to be the most prescribed medication in the world - has been coming under increasing fire.

For years, it was claimed it prevented conditions such as heart disease and helped women stay youthful and sexy.

But studies now show women who take HRT increase their risk of heart disease, breast cancer, blood clots, stroke and dementia.

In September last year, the Medicines Adverse Reactions Committee and the Guidelines Group, an independent body contracted to evaluate research, advised that combined HRT should be confined to early menopause for a limited time, and only where the symptoms were disruptive to the woman's quality of life.

Women's health advocates say that is not enough. They say HRT has been "oversold" and ask why any women, apart from the about 10 per cent who suffer acute symptoms, would be on it, given the known health risks.

Some believe women should not use it at all.

Doctors say HRT helps control the symptoms of menopause and reduces women's risk of fractures.

They say women must make the best decision for them, knowing the risks and benefits.

With the mass of information available, what do women need to know about HRT?

This year, an American study reported that combined HRT doubled the risk of women 65 and older developing dementia, prompting health authorities to advise women over 64 to discuss with their GPs whether they should continue taking it.

That came hard on the heels of another American study, the Women's Health Initiative, which was abandoned mid-way though last year, years before it was due to finish, when researchers found the risks of combined HRT outweighed the benefits. The WHI study involved 16,608 post-menopausal women aged between 50 and 79 whose uteruses were intact.

It compared figures for women taking combined HRT against those using a placebo, and found that over a year, seven more in every 10,000 women taking combined HRT could be expected to have a heart attack and eight more to have a stroke.

It also found eight more were likely to develop breast cancer and 18 more to suffer blood clots.

Although it reported benefits - six fewer colorectal cancers and five fewer hip fractures for every 10,000 women - overall, women taking the combined drug might expect 19 more "events" a year per 10,000 women than women taking the placebo.

A parallel trial of oestrogen-only therapy in women who have had hysterectomies is continuing.

A British study, which involved about 100 New Zealand women, was cancelled as a result of the American findings.

Last month, a British study known as the Million Women Study found women taking combined HRT doubled their chances of developing breast cancer.

The research, published in the Lancet, found that for every 1000 women who took HRT for 10 years from the age of 50, there would be an extra 19 cases of breast cancer among those using the combined product and five more among oestrogen-only patients.

The study tracked 1,084,110 women aged between 50 and 64 over 10 years and found the risks were higher than previously thought - and began earlier than doctors had assumed.

But Professor Rod Jackson, head of epidemiology and bio-statistics at the School of Population Health at Auckland University, said the study's retrospective nature and the fact it was not a randomised study were major flaws.

He said the only thing he felt reasonably confident about was that "all combined therapies seem to have an adverse effect".

Pharmac estimates about 30,500 New Zealand women stopped taking the medication in the 12 months from June last year, reducing the number of women using it from about 82,400 to 51,900. Pharmac medical director Dr Peter Moodie expects the decline to continue, and says it is a direct result of the risks outlined in recent studies.

Christchurch endocrinologist Dr Anna Fenton says the discoveries of the past year have been a warning for women and doctors.

But she says women have been left confused and anxious and the statistics have been misunderstood.

At her clinic she outlines the risks and benefits to women but says it is up to individuals to work out what is best for them.

"We can say yes, it's going to help control menopausal symptoms, yes we know it will reduce your risk of fracture.

"On the opposite hand, in the first three to six months it may increase your risk of coronary events and that risk is an extra 7 to 8 women per 10,000 a year.

"And after five years there's an increased risk of breast cancer," she added.

While some argue women should "guts out" menopause without HRT, Dr Fenton says times have changed and women are often trying to balance a home and working life.

"I always trust women. They are innately intelligent creatures and if you give them the information they can make up their own minds."

Women's health advocate Sandra Coney believes health authorities should give women more guidance.

She wants HRT to be available only through specialist prescription and questions whether using it for three to four years, as the current guidelines recommend, is too long.

Ms Coney, who has written books on menopause and is on the New Zealand Guidelines Group for HRT, believes menopause has been "demonised" and that women have been encouraged to reach for HRT straight away "at the first hot flush".

But the WHI studies showed it made no difference to women's mental alertness or sexual satisfaction.

It increased the risk of dementia and breast cancer and had been found to make mammography less effective.

"All this adds up to, why would you be on it?

"What is the gain? There are so many downsides to HRT that to me it's almost a drug that shouldn't be on the market."

Gill Sanson, a menopause educator for Women's Health Action, says menopause is a natural event, not an illness, and should not be treated with medication.

The only benefit in taking HRT was relief from hot flushes, which were not life-threatening.

"I firmly believe we should not be offering it to women at all."

She says more women are also looking for alternative therapies.

Dr Fenton says some alternatives, such as red clover, wild yam cream and soya products appear to be no better than placebos.

Black cohosh, also known as Remifemin, has shown good results in clinical trials in helping with hot flushes.

However, it has been reported to alter liver function, so she recommends that women using it have regular checks.


Menopause

* Is when a woman stops menstruating.

* Average age 50-51, but 42-55 years is considered the normal range.

* On average menopause lasts two to five years.

Effect on the woman's body

* The ability of a woman's ovaries to make eggs and good amounts of hormones, particularly oestrogen, reduces.

* As the oestrogen levels fluctuate, the body has to adjust to the change in hormone levels. This is when symptoms such as hot flushes, experienced by about 75 per cent of women, begin. Other symptoms include headaches, trouble sleeping, mild mood swings, heavy periods or lighter periods further apart, and changes in short-term memory and the ability to concentrate.

What is HRT?

* HRT replaces naturally occurring hormones in the body with synthetic substances or hormones derived from the urine of pregnant horses.

* The most common form prescribed in New Zealand is a combination of oestrogen and progestogen.

* HRT is also available in an oestrogen-only form for women who have had hysterectomies (progestogen reduces the risk of cancer in the uterus).

* It is recommended that women who want to stop using HRT wean themselves off over six to eight weeks.

* The Medicines Adverse Reaction Committee, which advises the Ministry of Health, meets today to review the latest research and decide whether new advice on the use of HRT is needed.