Spotlight on HRT

Since the 1960s’ hormone replacement therapy (HRT) has been the centre of much discussion and speculation. The media from time to time sensationalise risks of HRT but research suggests the benefits outweigh the risks in symptomatic women <60 or within 10 years of menopause.1 GPs should feel confident in discussing the benefits and prescribing HRT for their patients.
CV effects—benefits early after menopause
 
The cardiovascular (CV) benefits of HRT have been extensively studied in randomised controlled trials (RCTs) and observational studies. The former have shown no or negative CV effects, frequently in women who start hormone therapy 5 to 20 years after menopause, while the latter, on the whole, have shown positive effects, probably as the result of HRT starting shortly after menopause. Meta-analyses where age has been considered have found that HRT in younger women is associated with a lower risk of coronary heart disease and reduces overall mortality.2
A recent RCT demonstrated that after 10 years of randomised treatment, women receiving HRT early after menopause (on average 7 months) had a significantly reduced risk of mortality, heart failure, or myocardial infarction, without any apparent increase in risk of stroke, cancer, or VTE.2
Administration—the latest developments
 
Early forms of HRT were designed to mirror a menstruation cycle by adding progestogen for 12 days a month, known as sequential therapy. This is generally still used in perimenopausal women and during the first year or two after menopause.3
 
Continuous HRT with progestogen and oestrogen avoids bleeding altogether and is thought to reduce the risk of endometrial cancer. Women may prefer to switch to this a year after menopause has occurred; however, it’s not always easy to determine when menopause has finished.3
 
A new development tries to strike the balance by inducing a withdrawal bleeding every 3 months by adding progestogen to daily oestrogen for just 14 days every 13 weeks. This means the uterus is still protected.3
Another development is the lowering of the dose of oestrogen in combined HRT, aimed at reducing the side effects while maintaining symptom relief and bone strength.3
 

Before HRT is started4

• Consider HRT in perimenopausal or recently postmenopausal symptomatic women with low risk factors for CV or VTE disease.
• Consider the nature and severity of symptoms and their impact on function and quality of life.
• It is reasonable to advise younger, healthy postmenopausal women that HRT is unlikely to increase their risk of CVD.
• Consider therapy in women at high risk of fracture if there are no contraindications.

Note that HRT is contraindicated in patients who have had an oestrogen-related tumour in the past.
 
1. Womens Health Concern. (Accessed February 22, 2016, at www.tinyurl.com/havnolv).
2. Schierbeck LL, et al. BMJ 2012;345:e6409.
3. Women's Health Concern. (Accessed February 22, 2015, at www.womens-health-concern.org).
4. Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 2012.