Times Review Section
Sunday 18TH April 2004
Is HRT Safe?
I remember it well. Women would turn up to their GP and
explain that they were not feeling well. They were, they
explained sadly, going through their menopause and suffering
from hot flushes. Not only that, their libido had disappeared,
they could not sleep and they were exhausted. The doctor
would look the patient in the eye and explain that he or
she was terribly sorry but there was nothing that could
be done. And off the woman would go, to suffer at home in
That was in 1968. Since then
HRT has brought relief to millions of women. But recently,
the treatment has been facing crisis. In the last 15 months,
the number of British women using HRT has dropped by 30%.
In the United States, the fall has been even steeper - HRT
use is down by 50%. These figures are the result of two
studies which apparently showed links between HRT and breast
cancer, heart attacks and strokes.
Yet last week another report
was published. This one, in the Journal of the American
Medical Association, suggested that HRT is not linked with
an increase in breast cancer or heart attacks; indeed these
illnesses were less common!
Not surprisingly, women everywhere
are confused. So what is the truth about the safety of HRT?
I became interested in the
treatment when one of its pioneers, Robert Greenblatt, an
American gynaecologist, invited me to go to his clinic in
Augusta, Georgia to observe his patients. For three days
I sat and watched scores of healthy women who were all enthusiastic
takers of HRT. They took oestrogen and some testosterone,
and they all said that their lives became transformed. I
returned to England and wrote to all the heads of departments
of gynaecology in medical schools asking the advice given
on HRT. Only one of them taught that HRT was a useful treatment.
So I opened -in Birmingham - the first menopause clinic
Swiftly, the clinic became
a great success. But six months on, the British Medical
Association protested that HRT was unethical and dangerous,
and closed my clinic down. I was furious. Eventually, the
BMA was won round and six months later we reopened. Today
the Clinic is still hugely successful. These first women
said we had helped them not by just helping their hot flushes
and sweats, but something more fundamental. They said they
felt happy, confident and wanted - all the important things
in life. They also reported a domino effect; the HRT cured
their insomnia and exhaustion; which, in turn, helped cure
their loss of libido; which, in turn, helped their marriages.
There is also evidence that HRT prevents osteoporosis. All
but one of 30 papers on HRT show that oestrogen therapy
is associated with fewer heart attacks, possibly fewer strokes
and fewer incidences of Alzheimers' Disease.
For years women enjoyed the
benefits of HRT. Then, 18 months ago, the World Health Initiative
(WHI) published a study of 19,000 women which erased 30
years of careful practise and research. Probably the most
expensive and ill-conceived study that I have come across
warned that HRT increased the risk of breast cancer, heart
attacks and stroke.
The study understandably scared
women - which explains why so many have stopped taking HRT.
It ought not to have done so as it was fundamentally flawed.
There were several problems
with the research. For a start, the women in the study were
too old. In real life, women on HRT usually begin taking
it in their early 50's; and their dose varies with age.
In the WHI study, the average age of the participants was
63, and a quarter of them were over 70. Furthermore, each
was given a standard dose of HRT whether she was aged 50
or 79, whether they had bone problems or depression or simply
flushes and sweats. In the WHI study many of the women were
also overweight, or had high blood pressure. Eight percent
of them had even had had previous heart attacks before starting
on the HRT.
But the most extraordinary
thing is that the women in this study did not have any menopausal
symptoms. Indeed, the researchers specifically searched
for women who were not showing symptoms. This may sound
bizarre, but it is true. In other words, they were being
given a treatment that they did not need. The women did
not feel any better - which was hardly surprising, given
that you would not expect aspirin to cure a non-headache.
What is truly disgraceful
is that these sensational findings - that HRT causes heart
attacks and increases the risk of breast cancer - was announced
at a press conference days before publication.. It was only
later, after the story had hit the newspaper headlines,
and the report was published, that the details I have just
outlined emerged. But then it was too late.
I do not think one can blame
the press; journalists had published the information in
good faith. The problem was that the scientific community
had not been given the opportunity to analyse the study
before it was publicised.
Then came another report -
perhaps even worse. The Million Women Study (MWS), which
was published two months ago, was even more disastrous.
Full of errors and discrepancies, it claimed, for example,
that there was a huge increase of breast cancer for many
women in their first year of HRT. Yet, we all know that
breast cancer takes four, five, seven years before it's
diagnosed. So these women whose breast cancers had been
"caused" by HRT had in fact already been carrying
the cancer - which may have been missed by their previous
mammogram - when they signed up for the trial. There were
many other objections to this study - which was also first
presented at a press conference days before publication.
Menopausologists around the
world think that these papers are appalling. Many GP's are
refusing to give HRT, and actually, I understand why - even
though I believe the research on which they have based their
decision is entirely wrong.
I have absolutely no doubt
people will change their minds when the truth emerges.
I draw an important conclusion
from the mess we find ourselves in. Academic studies should
not be presented to journalists with the razzmatazz of a
press conference before fellow scientists have had a chance
to evaluate it. It is unusual to have a paper of such importance
published without it being discussed at workshops and meetings.
Andrew Wakefield, the doctor
who attempted to draw a link, rightly or wrongly, between
the MMR vaccine and autism also held a press conference
before he published his work. I cannot help wondering if
there are scientists who are using unquestioning journalists
at press conferences to beef up their message.
I have just finished a snapshot
survey of nearly 100 patients who have had HRT for ten years
asking them if they wish to come off HRT. Only three out
of a 100 agreed. The reason is simple: woman on HRT feel
better, and have more energy and self confidence. I say
to women: if you are confused by the various reports, be
reassured that the HRT is effective and safe - if properly
used and can transform your life for the better.
John STUDD, DSc, MD, FRCOG
Professor of Gynaecology
Chelsea & Westminster Hospital
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