Intended for healthcare professionals

Rapid response to:


Looking at HRT in perspective

BMJ 2022; 377 doi: (Published 15 June 2022) Cite this as: BMJ 2022;377:o1425

Rapid Response:

Re: Consider the possible underlying biochemical causes of menopausal symptoms

Dear Editor

Possible underlying biochemical reasons for the symptoms suffered by some menopausal women should be considered. At the menopause sex steroid levels fall. This is likely to result in the unmasking of previously hidden nutrient deficiencies and other biochemical perturbations. In particular, deficiencies have been reported to follow past use of hormonal contraceptives or other hormone treatments and include deficiencies of zinc, magnesium and B vitamins.[1-4] Like previous generations, many menopausal women may not need extra hormones if deficiencies are corrected (and other relevant factors such as alcohol and smoking avoided). While temporarily re-masking symptoms, giving more hormones in the form of HRT could increase nutritional deficiencies and make it more difficult for patients to stop HRT in the future.

Menopausal women also need to be aware that HRT is not risk free. [5 -8] They should consider the expert reports on breast cancer risk and mortality from the Collaborative Group on Hormonal Factors in Breast Cancer. [5, 6] It is also of note that reduced use of HRT in the past was followed by significant falls in breast cancer incidence in many Western countries. [9, 10]

1. Palmery M, Saraceno A, Vaiarelli A, Carlomagno G. Oral contraceptives and changes in nutritional requirements Eur Rev Med Pharmacol Sci .2013 Jul;17(13):1804-13. PMID: 23852908

2. Wilson SMC, Bivins BN, Russell KA, Bailey LB. Oral contraceptive use: impact on folate, vitamin B6 and vitamin B12 status. Nutr Rev 2011 Oct;69(10): 572-83 doi: 10.1111/j.1753-4887.2011.00419.x

3. Adebayo TO, Oguntibeju OO, Oparinde DP, Ogunyemi EO. Effects of contraceptives on serum trace elements, calcium and phosphorus levels. West Indian Med J 2011 Jun;60(3):308-15 PMID: 22224344

4. Grant ECG. The pill, hormone replacement therapy, vascular and mood over-reactivity and mineral imbalance. J Nutr Envir Med 1998;8:105-116

5. Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019;394(10204):1159-1168. doi:10.1016/S0140-6736(19)31709-X

6. Beral V, Peto R, Pirie K, Reeves G. Menopausal hormone therapy and 20-year breast cancer mortality Lancet . 2019 Sep 28;394(10204):1139. doi: 10.1016/S0140-6736(19)32033-1. Epub 2019 Aug 29.

7. Beral V, V, Gaitskell K, et al. Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. Lancet 2015;385(9980):1835-1842. doi:10.1016/S0140-6736(14)61687-1

8. Price EH, Little HF, Grant ECG, Steel CM. Women need to be informed about the dangers of hormone replacement therapy. Lancet 1997; 314

9. Colditz G. Decline in breast cancer incidence due to removal of promoter: combination estrogen plus progestin. Breast Cancer Research 2007;9 108.(doi:10.1186/bcr1736)

10. Grant ECG. Fall in use of hormones could have reduced breast cancer mortality. BMJ 2005; 330: 1024 doi: (Published 28 April 2005)

Competing interests: No competing interests

19 June 2022
Elizabeth H Price
Retired medical practitioner
Not applicable