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Yet again scientists and epidemiologists are publicly debating the controversies around the previously reported risks of HRT (hormone replacement therapy). Is this further publicity deserved? The impact of studies such as the Million Women Study (MWS)1 and Women's Health Initiative (WHI)2 has been profound, leading to significant reductions in the use of HRT. This has understandably affected millions of menopausal women globally who deserve to be fully informed of any doubts that may exist concerning the studies and should be aware of the debate.3 4
Ever since these papers were published the headlines in the popular press have been biased towards the ‘bad news’ messages, resulting in our patients feeling confused and under pressure to stop HRT. Following a recent web-based survey 70% of women who came off their HRT were below the age of 50 years. More importantly, had these women known what we know today, 45% would have stayed on treatment.5
Many patients have been advised by their doctors to stop HRT and in some cases have had their prescriptions unilaterally withdrawn. These women have sought additional, poorly researched products with unproven safety and efficacy – often sold as food supplements to circumvent regulatory authorities.
Which risk is greatest? Taking a treatment that has little evidence of effectiveness or safety, or taking a product with the enormous research base that applies to HRT? Do we really know the answer? Is there enough information to allow carers or patients to be fully informed? We believe that the risk, if any, is small and it is the view of the British Menopause Society (BMS) that, when used appropriately, any risks are outweighed by the benefits for the majority of women.
We must not forget that at the centre of the current published arguments there are millions of women who want to be properly informed about whether they should be taking HRT. Further, there are likely to be thousands of doctors and nurses who want to be more knowledgeable and confident about prescribing HRT.
In recognition of the menopause having diverse consequences, and in an attempt to improve the provision of essential information for women, the BMS has recently submitted recommendations to the Department of Health. The key recommendation is that women should, around the time of the menopause transition, have a formal assessment of their needs, including advice concerning lifestyle, diet and individualised discussion of the risks and benefits of any suitable hormonal therapies. The BMS also suggested that while this would require additional resources, the potential long-term health gains would make this consultation highly cost effective in disease prevention terms.6
The two main areas that require addressing urgently are as follows:
1) A robust understanding of the benefits and risks of HRT for patients and carers
Most women who have been taking HRT since the publication of WHI and MWS will have been doing so having weighed up the pros and cons of treatment. Many women, even if there were genuinely a small increased risk of breast cancer, would accept this, if they could have a good quality of life through relief of the debilitating symptoms that invariably affect personal, social and wider quality of life.
The clear benefits in osteoporosis treatment and prevention have recently been included in a recommendation from the National Osteoporosis Society that recommends HRT for the treatment and prevention of osteoporosis in women under 60 years of age.7
2) HRT is not a single drug as the press and our patients seem to have derived from the publicity
HRT is a comprehensive suite of preparations and delivery routes produced by the pharmaceutical industry in response to women's needs over more than 20 years of development, refinement and research. This research continues, even though research funding is a fraction of what it once was.8
Recently completed trials not only suggest that natural progesterone may not affect the risk of breast cancer and have a neutral effect,9 but also that soon to be released small studies of lower dose, endogenous-type hormone treatments given to recently menopausal women show great promise.10
The BMS feels that the research must continue. As the female population lives longer after the menopause we need to establish safe ways to prevent disease and maintain a high quality of life. This requires a trial to establish definitively the correct indications, patients and hormones for optimal postmenopausal health.11 We should harness the wealth of knowledge from the debates around WHI and MWS to design this study rather than watch the arguments from the sidelines.
The BMS is dedicated to advancing education in all matters relating to the menopause and to the primary prevention of the burden of preventable chronic disease.
Competing interests Nick Panay (NP), Edward Morris (EM) and Heather Currie (HC) have received sponsorship for lectures and advisory work performed for pharmaceutical companies. NP and HC have received educational grants for meetings and NP has received funding for pharmaceutical trials. NP is Co-editor-in-Chief of Climacteric (International Menopause Society journal) and EM/HC are Co-editors-in-Chief of Menopause International (British Menopause Society journal).
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