Hormone Replacement Therapy, also known as HRT, has evolved from the controversial synthetic oestrogen-only HRT first used in the early 60’s. Food Scientist and Nutritional Therapist Susie Debice explains why HRT’s chequered history is tainted by a flawed scientific study and reveals why perimenopausal women should be asking their doctors for safe and effective body identical forms of HRT.
HRT is effective at delivering a baseline of oestrogen and progesterone that helps keep your head above water when it comes to the types, range and severity of symptoms being experienced. So why has HRT got such a bad reputation and why are women so fearful about taking HRT?
When you look back over the history of HRT and how some of the very initial, large clinical trials where setup and reported you can start to understand where the controversy stems from.
HRT Safe and Natural
We now know that HRT is safe when taken in the right form (body identical), in the right dose (low dose similar to what the body would normally produce) and in combination (always take oestrogen with protective progesterone, never take oestrogen on its own, unless you have had a hysterectomy).
Myths and Mystery around HRT
There is so much misinformation about HRT and concerns relating to side effects and confusion over possible risk factors which may be preventing you from exploring this route of hormone support. The relatively recent development of bioidentical and body identical hormones has created even more uncertainty about what the best route forward is for obtaining a safe and authentic form of HRT. A short review of the history of HRT helps debunk some HRT myths.
Oestrogen only HRT
Premarin was the first HRT to hit the medical community in the 1960’s, readily prescribed for women experiencing hot flushes, low libido and vaginal dryness. The early forms of HRT contained a super high dose of synthetic forms of oestrogen which have a different structure to the oestrogen that’s naturally produced by the body. For women in the early stages of the menopause this new wonder pill was revolutionising how women were coping with this hormonal transition. Studies were conducted to see how this type of oestrogen helped symptoms and assess side effects and risk factors.
In the 1970’s researchers discovered that taking these high doses of conjugated (synthetic) oestrogens without the balance of progesterone was increasing women’s risk of thickening of the womb lining, endometrial cancer and breast cancer. This spurred the development of HRT medications that combined a lower dose of conjugated oestrogens with protective progesterone, in the form of progestins (synthetic forms of progesterone).
This new combined HRT held much promise for menopausal symptoms and protecting women from chromic disease such as osteoporosis, dementia and heart disease and the world waited in anticipation for the results of two large clinical studies.
HERS Study – HRT and Heart Health
In 1998 the first randomized clinical trial called The Heart and Estrogen/Progestin Replacement Study (HERS), assessed the cardio protective effects of a combined HRT containing synthetic oestrogen and synthetic progestin. The study followed 2736 postmenopausal women with diagnosed heart disease and the results didn’t show any difference, in the four-year follow-up between the group of women taking HRT and those that received a placebo. The study did however show an increase in cardio events (heart attacks) after one year of HRT. This result slowed down the popularity of HRT. The medical world was curious and further research was called upon.
WHI Study – HRT and Chronic Disease
A much larger study involving over 16,000 women was set up in 1998 called the Women’s Health Initiative (WHI) to further assess whether older women could benefit from HRT in terms of protecting them against cardiovascular disease, cancer, osteoporosis. Women of all ages were recruited with a large proportion of the women recruited being age 63, typically 12 years past the menopause.
The women were split into groups:
- Placebo group – received a pill without any hormones in
- Women with a womb - received combined HRT containing a very high dose (much high than what’s prescribed today) of synthetic oestrogen and an old fashioned from of synthetic progestin.
- Women without a womb (had a hysterectomy) - received an oestrogen-only HRT
It was soon established that some of the women were having heart attacks and developing breast cancer, so the study was stopped very quickly. The researchers didn’t have time to analyse the data before the press and public had realised that some serious side effects had occurred and suddenly HRT gained a reputation for being unsafe.
Revealing the Truth
However, when the researchers finally managed to investigate what had happened, they found that the results highlighted some interesting insights. Turns out the HRT gave positive results to the younger women in the study and the older women were likely to be gaining factors because they were poorly selected, rather than because of the effect of the HRT. Here’s a summary of the results:
- Most of the women that were in their 60’s that took part in the study were overweight or obese and already had heart disease – so they were already at risk of having a heart attack.
- The younger women who took the oestrogen-only HRT also had a lower risk of breast cancer.
- The women who started the HRT 10 years after their menopause (so in their 60’s or 70’s), these women were found to have a small increased risk of heart attack
- There was a small increased risk in breast cancer for the 60+ age group who took the combined HRT.
- For the younger women in the study who took either oestrogen-only or the combined HRT, when these women started HRT within 10 yrs of their menopause (under the age of 60), their results showed a lower risk of dementia, heart disease and osteoporosis
- For the younger women who took HRT the occurrence of risk factors was incredibly small so for this age group the researchers concluded that the benefits of a smoother menopause far out weighted the risks.
The Safety of HRT Today
As time has moved on and as more studies involving HRT have been conducted what become crystal clear is that the safety of HRT is dependent on several factors
- The age you start taking HRT is important. HRT comes with fewer risk if you start taking it within 10 years of your menopause. So as soon as you start your perimenopause, that the time to start talking to your doctor.
- Combined HRT rather than oestrogen only – progesterone balances out oestrogen, so unless you have had a hysterectomy it’s vitally important that you are prescribed oestrogen and progesterone to protect your womb lining.
- Synthetic vs body identical is important - There are several differences between synthetic and natural HRT. Synthetic oestrogens and progesterone come with increased risk factors including increased risk of blood clots, heart disease, raised cholesterol and increased risk of breast cancer. BUT body identical hormones which have an identical chemical structure to the hormones that your body produces have no increased risk of blood clots and no increased risk of heart disease. These are now widely available on NHS prescription and are considered to be very safe. Examples are Estrogel (oestrogen gel) and Utrogestan (progesterone).
- Correct dose is important – the new modern body identical HRT contain dosages that are much closer to the dosages that your body naturally produced before the you started the menopause. These are much safer for your body to handle.
Don’t wait to talk to your doctor about HRT, taking a body identical HRT is likely to help you feel so much better, more able to cope during the day and more able to sleep well at night. Both these factors mean that you are then more likely to make better food choices and exercise regularly and this healthier lifestyle means you are more likely to have fewer risk factors.