Risks and benefits of HRT

The Women’s Health Initiative (WHI) study published in 2002 and several other randomized placebo-controlled trials of HRT fundamentally changed our understanding of its harms and benefits. They provided for the first time evidence of harmful effects of HRT on cardiovascular system and also confirmed significantly increased risk of breast cancer, particularly with combined estrogen/progestogen regimens.

However, there is a significant proportion of post-menopausal women who, in spite of all bad publicity about HRT, require it for symptom control. In the light of currently available evidence about the risks and benefits associated with HRT it is essential that we make HRT safer for those women who need it.

Harms of HRT

The WHI study showed an increase in risk of coronary heart disease, stroke, venous thrombo-embolism and breast cancer in postmenopausal women on continuous combined preparation containing Premarin and Provera. Although the absolute risk of harm to an individual woman is very small at the beginning, it would increase steadily over longer duration of treatment. It is important to be aware that different types of HRT, mode of application and most likely the dose have different risk profile. Estrogen alone does not increase risk of coronary heart disease or breast cancer. Estrogen given via trans-dermal route is not associated with an increased risk of DVT.

Benefits of HRT

It is well known that estrogen therapy is effective in 90% of women with hot flushes and is considered the gold standard treatment. Since some studies documented that low doses of estrogen (0.3 mg of Premarin or 0.5 mg of estradiol) were adequate to control even severe symptoms and effective in maintaining bone mass, it seems justifiable using the lowest estrogen dose whenever possible.

Although HRT users generally believe they have better health status and often report that quality of life is a consideration in their decision to use hormones. It appears that only women with flushes have improvement in emotional measures of quality of life.

There is no doubt that HRT is effective for prevention or treatment of osteoporosis, but it should be used for this purpose only short-term in women who also have menopausal symptoms. Consequently long-term use of HRT should be discontinued in women who do not suffer vasomotor symptoms and non-hormonal methods should be used for prevention of osteoporosis.