Current Thoughts on The Safety of HRT            - Page 3 The evidence that oestrogens are safe and beneficial for women below the age of 60 who have appropriate symptoms remains convincing.    However, another major study which cast doubt on the safety of HRT was the Million Women's Study (MWS) from Oxford which claimed that there was a 30% increase in breast cancer in women taking unopposed oestrogens and a greater increase in women taking oestrogen plus progestogen. Once again this paper claimed that the risk starts at one year and disappears when HRT is stopped, has been severely criticised because its design and the many careless errors in the statistics and text. Of the 9364 patients in the Million Women Study with breast cancer, 2224 were excluded for unexplained reasons. The peak of breast cancer at one year after the mammography and questionnaire is certainly due to interval cancers missed at mammography with a well-recognised worst prognosis. This would have nothing to do with HRT. These cases were not excluded. There are many, many other objections to the design of this study. The usual numerical estimate of excess breast cancer that we give patients is 12 per 1000 after 15 years of HRT. Even if this is true (and there is some evidence of a decrease in breast cancer) this risk is no greater than alcohol, being overweight, having no children, having a late first pregnancy or having a late menopause.    The following is my current advice on HRT prescribing.    1. Oestrogen treatment should be used for the treatment of specific symptoms and low bone density. 2. Although oestrogens appear to have no place for the secondary prevention of cardiovascular disease, they may still be indicated in early symptomatic menopausal women for protection against coronary heart disease and Alzheimer's disease. 3. There is a window of opportunity in 45-60 year old symptomatic women who may show long-term cardiovascular and neurological benefits from early oestrogen therapy. 4. Oestrogens commenced in older 60-79 year old women may do "early harm" before any benefit is achieved. 5. The dose and route of oestrogens will depend upon the symptoms and the age of patient. Peri-menopausal and post-menopausal women with vasomotor symptoms should be given either oral or transdermal oestradiol with cyclical progestogen for endometrial protection. 6. The usual duration of progestogen is 14 days but if the extra risk to the breast of progestogen is confirmed it is sensible to reduce the duration to seven days. This shortened course is also useful in women with progestogen intolerance. 7. Women may wish to avoid bleeding by using low dose oestrogen and progestogen or by the use of Tibolone or they may wish to have a Mirena IUS inserted. 8. Women with hormone responsive mood disorders should have a higher dose of transdermal oestrogens by patch, gel or implant. As these women are often progestogen intolerant, 7 day cycles of progestogen are permissible rather than the orthodox 14 day cycles. 9. If loss of libido and loss of energy remain a problem, the addition of testosterone should be considered. 10. Five year duration of HRT has been recommended but in reality women remain on HRT if they are feeling well with the relief of symptoms. It is often difficult to persuade such women to discontinue treatment even after 10 or more years. 11. Women who have had an early menopause and women who have had a hysterectomy with loss of ovaries will need HRT for more than 5 years, until at least the normal age of menopause. 12. After loss of ovarian androgens, following hysterectomy and bilateral oophorectomy women normally need the addition of testosterone as well as oestrogen. 13. A mammogram should be performed each year and a breast examination every 6 months.  Page 4 >> John STUDD, DSc, MD, FRCOG Professor of Gynaecology 18th January 2005  . www.studd.co.uk Back to top