Controversies in Management: Hormone replacement therapy for all? Universal prescription is desirableBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7053.350 (Published 10 August 1996) Cite this as: BMJ 1996;313:350
- a Urogynaecology Unit, Department of Obstetrics and Gynaecology, King's College School of Medicine and Dentistry, London SE5 8RX
- Correspondence to: Professor L Cardozo, Department of Obstetrics and Gynaecology, 9th floor, Ruskin Wing, King's College Hospital, London SE5 9RS.
At a recent European consensus development conference on the menopause (Montreux, Switzerland, September 1995) it was concluded that hormone replacement therapy improves the quality of life, increases collagen, reduces urinary symptoms, and improves cognitive function. Although hormone replacement therapy has become an everyday part of the lives of millions of women, there are three main reasons why many who would benefit do not take oestrogen supplementation.
Why some women reject therapy MISCONCEPTION ABOUT THE MENOPAUSE
Some women believe that the menopause is a natural event and that taking medication (hormones) should be avoided. These women are wrong: oestrogen deficiency is the unnatural state. In developed countries the menopause occurs at around 51 years of age, although in women who have had a hysterectomy it may occur slightly earlier. During this century life expectancy has increased from 62 to 80 years.1 Thus women now live more than one third of their lives after the menopause.
Premenopausal women are protected against cardiovascular disease by circulating oestrogen. This advantage is lost after the menopause. In the United States prescribing hormone replacement therapy is estimated to save the health budget $60m a year.2 Osteoporosis is common in elderly women and causes appreciable morbidity through fractures of the vertebrae, wrist, and neck of femur. These may not be seen for years after the menopause but early treatment could save a further $10bn of the American health budget.
Women are worried about the risk of cancer,3 particularly of the breast and endometrium. Several factors must be considered when assessing the association between hormone replacement therapy and cancer. The likelihood of strokes and ischaemic heart disease is around five times greater in terms of lifetime risk than endometrial and breast cancer.4 Long term treatment with a natural oestrogen halves the risk of ischaemic heart disease and gives a 60% reduction in oesteoporotic fractures.5 6 Against this is the possibility of doubling the risk of endometrial cancer from unopposed oestrogen (which is rarely used systemically except in hysterectomised women) and a 1.1-1.3 relative risk of breast cancer.7 8 9 10 The possible increased incidence of cancer may be reduced by improved techniques of medical surveillance such as transvaginal ultrasound assessment of endometrial thickness and regular mammographic screening for women over 50. In addition, increasing evidence of significant differences in the breast cancers being identified by mammography indicates less risk of metastasis and lower grade cancers,11 12 suggesting that we are picking up a new population or detecting previously undetected disease.
INCONVENIENCE OF MENSTRUATION
Women do not like the return of monthly bleeds. This is the largest single cited reason why women either never start hormone replacement therapy or stop within the first three months.13 14 However, over the past 10 years much research has been invested in the development of non-bleeding preparations such as tibolone and continuous combined oestrogen and progestogen regimens.15 16 Also within the past year the levonorgestrel intrauterine system has become available, which offers an alternative to oral progestogens by working at the appropriate site to maintain an atrophic endometrium.
Weight of evidence favours therapy
There is now a wide variety of preparations and routes of administration of oestrogen that allow local treatment for urogenital atrophic complaints—for example, patches, implants, and creams to avoid the first pass effect—and thereby reduce the dosage required and the side effects.
There is increasing evidence to suggest that hormone replacement therapy can be important in improving the quality of life by reducing urinary symptoms17 and improving psychological wellbeing.18 Recent publications also suggest a protective effect against Alzheimer's disease,19 20 which is leading to increasing interest in the role of hormone replacement therapy in preventing this condition through increasing cerebral blood flow, antidepressive effects, and neuronal stimulation. The weight of evidence must now be in favour of using hormone replacement therapy as widely as possible.
Often, however, despite preconceived ideas a woman seeks advice from her doctor, and it is interesting to note that in 1994 only 64% of gynaecologists and 56% of general practitioners thought that all women should be offered hormone replacement therapy.21 Perhaps now many would change their opinion in the light of increased awareness of the benefits and realisation that many of the earlier fears of cancer are unfounded. Current health trends emphasise the importance of improved quality of life. This should include the widespread use of hormone replacement therapy to enable women to remain healthy into old age.