Snighdha Basu came to see me at a stage when she is nearing menopause. Her main concern was whether HRT could be used given the controversies surrounding it. In our daily practice we come across many such women who are either apprehended or misinformed about HRT, or who have sky high expectations about HRT as if it is some magic pill, which on popping will stop her ageing process. It is time to understand where HRT stands today vis-￠-vis the risks versus benefits and the myths and misconceptions surrounding it.
What is HRT? HRT is the use of hormones, synthetic or natural, to treat a woman who is lacking them. The ovary makes the estrogen, progesterone and testosterone and most of the controversy is related to the use of estrogen. During menopause the ovaries decrease production of the female hormone estrogen and progesterone. This decline in hormones puts a permanent end to menstruation and fertility, but it can also cause hot flushes, mood swings, vaginal dryness and urinary problems. These can also occur when a woman has both of her uterus and ovaries removed by an operation. Progesterone has a very clearly defined role and must be given to all women receiving estrogen who have a uterus. The reason being that estrogen given on its own can cause uterine cancer and is almost prevented when progesterone is given. It is seen that HRT helps in reducing the menopausal symptoms and calming down of the menopausal stress and reduces the risks of heart disease and osteoporosis. The most crucial point is the time to start HRT. In some cases it is initiated at an early age, but may be stopped after a few years while some other woman may begin it at an age of 65 years or above.
Starting HRT- One needs to take note of the following " Assess menopausal state " Check for contra indications and conditions requiring specialist advice " Check current contraception. If perimenopausal, HRT does not provide contraceptive cover. If not, HRT is combined with combined OCP " Check risk factors for coronary heart disease and osteoporosis " Take body mass index and blood pressure readings Progestin, a synthetic compound similar to progesterone is given in combination to estrogen, as taking estrogen alone increases the risk of endometrial cancer. For women who have undergone Hysterectomy only estrogen can be administered. Androgens, like methyltestosterone may be added to standard HRT in an effort to provide better control over menopausal symptoms.
Benefits V/s Risks HRT is used for two reasons- treatment of menopausal symptoms and other medical benefits. It effectively treats hot flushes, night sweats, sleep disturbances and other symptoms related to menopause. It is also effective in the management of symptoms related to degenerative changes in the vagina or urinary tract, while maintaining skin thickness and elasticity. HRT helps in the prevention and treatment of the much talked about Osteoporosis. Women who take HRT after menopause, but stop after few years, may have the same risk of fractures as those who may have never taken the treatment. Another benefit is that HRT can decrease the risk of colorectal cancer. Some data suggest that estrogen reduces the risk of heart disease when taken early in postmenopausal years. However all these benefits cannot be generalized as the outcome will depend on individual health conditions and manifestation of symptoms where the doctor will have the final call to decide whether HRT to be used at all or not and if so in what dosage. In 2002, a large clinical trail called the Women’s Health Initiative (WHI) reported that the benefits from HRT far outweigh the risks associated with it.. Despite the know benefits, some women shy away from taking HRT due to the risk of breast and uterine cancer for those who have undergone HRT for more than 10 years. There are no increased risks of breast cancer or uterine cancer when HRT is used for a shorter duration. There are certain conditions in which HRT is contraindicated and is used only after detailed discussion with the doctor on various aspects.
These conditions include: " Breast or Uterine Cancer " History of blood clots " Long term or recent liver disease " Unexplained, abnormal vaginal bleeding
Other conditions that can be safely managed with adjustments in dosage and the form of therapy are: " Migraine " Gallbladder disease " Diabetes " Uterine fibroids " Seizures
What are the side effects? There are some side effects that can occur with HRT in varying frequencies. These include bleeding, weight gain, breast tenderness, headaches, mood swings and skin irritation.
When is HRT a good idea? Scientific evidence supports the use of HRT in the following cases: " For women who have had both ovaries removed surgically at an early age leading to early menopause " For women with severe hot flushes, night sweats or vaginal dryness " As one option for maintaining bone density in cases of high risk osteoporosis
Common Myths related to HRT- " Prevent wrinkles or natural signs of aging " Cure urinary incontinence " Help moodiness or depression " Improve sexual desire or responsiveness " Prevent heart disease " Prevent Alzheimer’s disease So HRT is not a one-stop solution which will solve all the age related problems. It has its share of advantages and disadvantages. Whether to use it and in what form should be best left to your doctor.
If a woman is considering HRT, then she should- " Discuss with her doctor about the benefits and risks of the various form and dosage levels of HRT in light of her medical history. " Talk to the doctor as to how to manage menopausal symptoms and post-menopausal conditions. Who should avoid HRT? Women with breast cancer, heart disease or a history of blood clots should not take HRT for relief of menopausal symptoms. The bottom line: HRT has not lived up to its billing as a panacea for age-related disease. But the news is not all doom and gloom either. HRT is not a scare word. This is some comfort considering the alarm raised a couple of years ago about HRT’s role in increasing the risk of cancer and heart disease. The dire conclusions of the Womens’ Health Initiative (WHI) in 2004 had resulted in women giving up their HRT doses overnight. What was considered the fountain of youth in early nineties was immediately discarded as a health hazard. The only way to determine if HRT is the best treatment for you to is to talk to your doctor about individual symptoms and health risks. The use of HRT is never absolute. The final decision to opt for HRT will be on the doctor after detailed assessment of the patients’ symptoms and health conditions.