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How the benefits of hormone replacement therapy outweigh the risks

Written by | 23 Apr 2024 | 'In Discussion With'

The benefits of hormone replacement therapy (HRT) using transdermal devices are considerable, including a 30% reduction in all-cause mortality, according to Deborah Evans, prescribing pharmacist and Clinic Director at Remedi Health.  Furthermore, contrary to what some women have been told, age is not a contra-indication.

In the past the benefits of HRT were underplayed. Moreover, studies published in the early 2000s caused scares about possible breast cancer and this was reinforced  by irresponsible reporting in the media, says Mrs Evans.  Unfortunately, the story has stuck and many women (and some doctors) continue to worry about breast cancer with HRT. “You’re much more likely to be at risk of breast cancer if you’re overweight, obese, [or] drink more than two or three units [of alcohol] a day on a regular basis”, she says. She also emphasises the importance of referring to the latest evidence and relevant products.

“The body-identical oestrogen that we replace through the skin in the licensed transdermal preparations that we use ….. [has been] shown to not increase risk of breast cancer. There’s no increased risk of blood clotting – beyond the woman’s natural risk of blood clots – if she’s using transdermal oestrogen; there is an increased risk from taking oral oestrogens and in modern practice, unless there is a particular reason why we need to use an oral HRT product, we don’t start there – we start with the transdermal, neutral-risk-for-blood-clots oestrogen replacement – and that works very well for the majority of women”, explains Mrs Evans

“In fact, there’s evidence to show that women that get breast cancer when they’re on HRT …… have a lower death rate from their breast cancer than women who don’t. We also know that ….. women who take oestrogen only [HRT] have an equal or better breast cancer rate than women who are not on HRT at all”, she adds.

HRT replaces the hormones that women no longer make. The aim of HRT is to restore the hormone levels to where they would have been throughout their natural reproductive life. Modern HRT does this using body-identical hormones “with the same molecular structure as the molecules that they made themselves and so it makes it makes sense, actually, for there to be very little increased risk associated with HRT”, she explains.

Benefits of HRT

Current data show that HRT

  • reduces the risk of osteoporosis by between 26 and 37%
  • reduces the risk of diabetes by 30%
  • reduces the risk of coronary heart disease by 50%
  • reduces risk of dementia by between 22 and 32%
  • reduces the risk of age-related macular degeneration by a third
  • reduces the risk of depression by 50%
  • reduces the risk of all-cause mortality by 30%

“Women should be offered HRT unless there’s a good reason not to go on it, just based on the longevity and the health benefits long-term”, Mrs Evans says.

How old is too old?

Another thing that women have been told is that they are too old for HRT and various age limits have been quoted.

Mrs Evans says: “We know from the data that the long-term health benefits can be best achieved if you start HRT earlier and, actually, the sooner the better. So, any myth … that you can only have it for five years we’re going to dispel right here, right now. It’s really important to recognise that if you need hormone replacement then the earlier you start the better for your long-term health. However, there are [older] women who can benefit from being on HRT and again it’s about that individual in front of you, personalising her care, evaluating the risks versus the benefits. …But I’ve started women in their 70s on HRT and they haven’t looked back”.

She describes one case of a woman who had experienced drenching night sweats for more than 20 years and was having to change the sheets every morning. No-one had suggested HRT until she consulted Remedi Health. Now, “she says she’s never going to come off it! But she said it’s absolutely been the best decision for her health that she could have made and she’s living a normal life – not to mention the other symptoms that have gone. So, as long as we look at that individual in the same way that we would for anybody at any age, then certainly age is not a contraindication”.

Menopause clinic at Remedi Health

A cornerstone of the service at Remedi Health is to start by carefully listening to women who consult for menopause symptoms.

Mrs Evans describes a recent case of a woman in her early 60s who initially consulted for worsening irritable bowel syndrome (IBS). On further questioning she described troublesome night sweats of recent onset coupled with extreme joint pain.

“It’s not unusual for someone to experience symptoms after their menopause. …. Some women go through perimenopause without too many problems but then it’s when their hormones are really low that they suffer”, says Mrs Evans.

“Looking at a woman’s health through the lens of her hormones makes us perhaps make some connections that she hasn’t done already. The key aspect of our service is listening and so our initial menopause consultations will last up to an hour and during that time we go through a questionnaire process so that she has the opportunity to reflect on a wide range of symptoms”, she explains. The questionnaire is used again at each follow up consultation to check on progress. The interview involves a full gynaecological and obstetric history as well as previous medical history, including prescribed medicines and supplements.  Remedi Health can also offer blood tests for hormones, if required.

The initial consultation usually results in prescribing and supply of HRT,  in line with the guidelines. A review is offered at two to three months to check progress and adjust treatment if necessary. This is important because there is considerable inter-individual variation in oestrogen absorption and handling, explains Mrs Evans.  Thereafter, “Depending on how she’s getting on we could potentially leave her until her annual review, repeating her medicines every quarter”, she says.

About Deborah Evans

Deborah Evans is a pharmacist independent prescriber who specialises in women’s reproductive and sexual health, including the menopause. She owns and runs Remedi Health, a clinic in Winchester, Hampshire. She combines the roles of Clinic Director, Superintendent Pharmacist and hands-on practitioner.

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