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  Current Thoughts on The Safety of HRT            - Page 1

The history of clinical medicine is strewn with fashionable treatments supported by experts, the unscrupulous or the downright eccentric that have subsequently been discredited to become an odd footnote of medical history. The many biochemical placental function tests and the surgical ventrosuspension for all cases of infertility are examples in my specialty. We must not forget that bleeding for anaemia was fashionable for centuries. Will this be the fate of HRT for problems related to the menopause?

Over the last 20 years it has been believed that HRT had a hugely beneficial effect on  post-menopausal women without being complicated by many major side-effects.

There was some anxiety that there could be a very small increase in breast cancer but, as the survival was very much greater in women receiving HRT, it was easy to believe that it was not a major problem and that possibly the apparent increase was the result of over-stimulation of breast cancer with oestrogens rather than a malignancy. It was believed that oestrogens not only treated the hot flushes, insomnia, vaginal dryness and depression that occurred around the time of the menopause, but that it also prevented many heart attacks, strokes, colon cancer, Alzheimer's disease and osteoporotic fractures of the spine and the hip. There was also good evidence that women on HRT lived longer probably about 2.5 years longer hopefully in a state of less dependency, with less dementia or Alzheimer's disease.

There was always a little doubt that these optimistic observational studies were biased because physicians would tend to give oestrogens to healthy, thin, non-diabetic, non-hypertensive, non-smoking women. But the enthusiasm was such that in some countries, particularly the United States, oestrogens were given out to as many as 50% of the aged population in order to prevent strokes and dementia. It is for this reason that a huge randomised trial - the Women's Health Initiative (WHI) was set up in order to test the hypothesis that oestrogen therapy prevented these cardiovascular complications.

Almost 20,000 women were recruited from the age of 50-79 with the average age of 63 and 23% over the age of 70. Note that in the UK 96% of our patients start HRT below the age of 60. They used conjugated equine oestrogens (Premarin) which is the major oestrogen used in the USA but much less frequently used in Europe where the natural human oestradiol by tablet, patch, gel, intra-nasal spray or implant is used. The patients in the WHI study were overweight, more hypertensive with 40% receiving either statins or anti-hypertensive drugs. 7.7% had suffered a previous heart attack. Thus, they were not a healthy population and not at all comparable with the patients usually treated with HRT in this country. They were unbelievably selected for the study only if they had no symptoms.

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Professor of Gynaecology

18th January 2005 


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