Should I take Hormone Replacement Therapy (HRT)?
(updated 10 August 2003)More recent studies 2003 on the use of HRT confirmed the small but definite risks of breast cancer. In separate studies at Cancer Research UK’s Epidemiology Unit in Oxford (reported in Lancet 2003, Aug 9 Issue) and also at Fred Hutchinson Cancer Research Centre (reported in Jama 2003, June 25 Issue), the combination estrogen/progestin HRT poses significant increase in breast cancer risk compared to the estrogen only HRT. The UK study was one of the largest ever study involving 1 million women. The study also showed HRT increases the risk of dying from breast cancer. In the Fred Hutchinson centre, the additional information was that regardless of the pattern of the progestin use in the combination HRT, the risk of breast cancer was increased and the magnitude of the risk increased the longer the woman has been on HRT. In 2002, the balance of risks and benefits for HRT use in healthy postmenopausal women was observed for an average of 5.2 years in the Women’s Health Initiative trial. The study recommended that combined post menopausal hormones of estrogen and progestin in healthy, post menopausal women with an intact uterus, should not be initiated or continued for the primary prevention of Coronary Heart Disease. They found that the health risks exceeded health benefits over an average follow up of 5.2 years for this particular combination of HRT. The study population was about 16,000 women. (JAMA 2002; 299:49-57)
In the New England Journal Of Medicine (N Engl J Med 2003 Vol 348 No. 19), Jennifer Hays and colleagues in her study found that hormone therapy does not result in better quality of life among older women without menopausal symptoms. The differences between the group with and those without hormone therapy were not significant. This was different from previous trials for younger women with hot flashes that have shown that hormone (estrogen) therapy was highly effective in relieving their symptoms and improving the quality of life. How does all the new information impact me and HRT?
The new information will help in the understanding of the hormones, including progesterone, in breast cancer development. This will have implications in the development of new chemotherapeutic agents against breast cancer. In addition, women should be able to make better informed choices about taking HRT. HRT treatment has to be “individualized” for each woman. In other words, your risk profile, the benefits of HRT will be weighed against the potential risks. Your age (whether pre-menopausal or post menopausal) and your symptoms and other factors will come into play when your doctor considers HRT and what type of HRT for you. It may be prudent to consider discussing with your doctor about the duration of the HRT and that it should be just long enough to deal with the medical problems brought about by menopause. Recommended health screening tests a woman should undergo before considering HRT include full physical examination, blood pressure test, breast examination, PAP smear, pelvic examination with or without ultrasound, mammograms and a baseline bone mineral densitometry. Biochemical screening would include blood count, fasting glucose and lipid profile. All these have to be taken together with a woman’s health history, her current state of health and of course, symptoms related to menopause.
Post menopausal women on HRT should be screened for breast cancer every year regardless of symptoms or signs. In any case, even in the absence of HRT, women above the age of 40 years are recommended to go for regular mammograms for screening purposes. The Effect of HRT on the Breast
HRT given to women in the perimenopausal (around the age of menopause) period increases breast pain and nodularity, increases frequency of benign cysts and fibroadenomas in the breast and also results in the growth of some established benign lesions. Breast density (the proportion of glandular tissue to fat in the breast) increases in 17-73% of women who use HRT. This appears to be related to the type of HRT the lady is on. Estrogen-progestogen combinations appears to increase the density more. This increase in density affects (reduces) the ability of screening mammography to pick up cancers. There is increased risk of breast cancer, especially for those who have used HRT more than 5 years. Combined analysis shows the increased risk to be about 1.023 for each year of use and this rises up to an average of 1.35 after 5 years of continued use. HRT and Osteoporosis
HRT is known to help prevent osteoporosis or at least maintain bone density during HRT. Prevention of osteoporosis is important to reduce the risk of fractures, especially hip and spine (vertebral) fractures which affect the quality of life and may entail surgery (with reference to hip fractures). Other Cancer Risks?
Estrogen-progestogen combinations may have less risk of endometrial cancer, although with higher risks for breast cancer. HRT (especially estrogen only types) has been reported to increase risk of endometrial cancer by a factor ranging from 1.6 to 8.0 while tamoxifen has been reported to increase risk by 3.3-fold. There is also a small risk of increased ovarian cancer with HRT. Alternative HRT agents
Alternative agents to control menopausal symptoms, such as tibolone are available to maximise the benefits of the hormone and minimise risks. This may be offered to women with no residual cyclical hormonal production. (This means, there is no more significant hormonal production in the woman concerned). However, the UK study (Lancet, Aug 9 issue) also states that there is an increased risk for breast cancer with tibolone.
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