Facing the HRT dilemma


It has been said that there are three major decisions in a woman's career - whether to get married, whether to have children and whether to take Hormone Replacement Therapy (HRT). But when I brought the last one up with a senior woman politician you wouldn't have thought it: "HRT? I'm more concerned about who's going to cut my hair," she said.

The bravado may have had something to do with the fact that while she is 50, she has yet to experience the symptoms of the menopause: sleeping problems; night sweats so severe they make you want to hang naked out the bedroom window; hot flushes so intense you have to dash home and change your clothes; mood swings which make PMT (premenstrual tension) look like a little girl's tantrum. Then there are the less-discussed symptoms such as dryness of the vagina, making a woman feel itchy and uncomfortable and possibly destroying her libido. Add to that: withering, prematurely ageing skin and a general sense of depression at growing older, and for many women the menopause is a major crisis. Yet it's still spoken about in whispers.

These days you can find women who are willing to be quoted on just about anything - marriage, abortion, contraception, sex - but there's one thing few will go public on: HRT. Privately, everybody's talking about it: so what's the truth behind the hype? Is it safe? And does it really cause breast cancer?

Women's growing sense of alarm about HRT is a worry for Prof Brian Sheppard of Trinity College's Department of Obstetrics and Gynaecology at St James's and the Coombe Women's Hospital. Amid the hype, "there's a real danger that women who need HRT are not taking it," he says.

HRT can literally save women from the diseases which killed their mothers. The evidence is irrefutable that HRT protects against a major killer of women: coronary heart disease. The menopause is caused by the withdrawal of oestrogen and progesterone. These hormones influence blood clotting, and without their protection there is a greater risk of clogged arteries and thus heart attacks. It also prevents osteoporosis, a disabling, painful and often fatal condition in which bones become brittle and easily broken.

HRT can also lower the risk of dementia and Alzheimer's disease, as well as protecting against ovarian cancer. The hype may be about softer skin and a more active sex life but these benefits are superficial compared with what HRT can do to extend a woman's lifespan.

HRT is an important women's health issue, yet when I contacted normally outspoken women in fashion, business, the media and politics and asked them the dreaded question - "have you yet had to make a decision on HRT?" - their response was to pretend they didn't know what I was talking about. Gemma Hussey, director of the European Women's Foundation and soon to become chairwoman of the Board of the Coombe Women's Hospital, has no problem talking about HRT. The former Fine Gael politician is refreshingly up-front about the fact that she has been on it for 10 years, initially to prevent menopausal symptoms and now in order to prevent osteoporosis.

"I'm a great fan and I've never had more energy in my whole life," she says. "I combine it with an exercise programme of four miles fast walking a day and hill-walking and I have a very healthy diet. I've lost two stone. I find that a general all-around health programme is the best medicine for everything."

Hussey's disclosure is unusual and brave. For most women coping with an ageist society, to be asked the HRT question is like being told: "You're losing your sexuality and generally over the hill, aren't you?" It's like questioning a male politician on the functioning of his prostate gland. Actually, it's a pity they can't yet do for the prostate gland what they can do for menopausal women. Many women today are finding new leases of life in their late 40s and 50s - and in some cases it is HRT which is making this possible.

HRT cannot make you look like Joan Collins - it's plastic surgery that does that - but it can help you to remain active through the menopausal years if the menopause is a problem. Along with Gemma Hussey, other role models using HRT include Margaret Thatcher, the former British prime minister and Betty Boothroyd, the Speaker of the House of Commons.

HRT does no more than replenish the hormones that a woman has had all her life. For a woman experiencing a difficult menopause - and not all do - it can mean the difference between suffering in silence and having a life. But you don't have to take it. "I get the impression on occasion that people are pushed into it a little bit," says Dr John Fleetwood, a GP in south Co Dublin. "Under pressure from friends or family, women may feel that HRT is a must because we're living in times when women aren't allowed to age gracefully. Doctors are also under pressure from vested interests to put people on HRT."

He finds that given the choice, about 50 per cent of his menopausal patients opt for HRT. "It certainly works for some women. It keeps them younger and you can see a difference. It has to do with how patients feel about themselves. Their skin becomes softer and smoother and they enjoy their sex life more, because the tissues in the vagina become moister. In 20 years I haven't seen any problems with HRT."

But it's not a miracle medicine. There are problems with HRT which women must take into account when making the decision, and chief among them is breast cancer. Earlier this month the Lancet medical journal published a landmark study on HRT, which showed that there is a slightly increased risk of breast cancer among HRT-users. The study looked at 160,000 women around the world who participated in 51 different epidemiological investigations over the past 25 years. There was an increased relative risk of breast cancer among current or recent users of HRT for more than five years. It also showed that this slightly increased breast cancer risk is linked to duration of use - the longer you use HRT, the greater your risk.

This is important news for Irish women because they have the highest rate of breast cancer in the EU - a rate of about one in 13 women - or 77 women per 1,000. According to this new research, the effect of HRT on breast cancer risk is to increase the number of breast cancer cases by two women per 1,000 for those taking HRT for five years; by six women per 1,000 for those taking HRT for 10 years and by 12 women per 1,000 for those taking it for 15 years or more. This increased risk of breast cancer disappears within five years of stopping using HRT. Encouragingly, the study found that HRT-users who were diagnosed with breast cancer tended to have localised - i.e. non-metastasised - cancers which were consequently highly responsive to treatment. The smaller size of these cancers may be because women on HRT tend to be more health conscious than others and so tend to find lumps earlier, either because they examined their breasts or had mammography screening.

While an additional breast cancer risk of between two and 12 per 1,000, depending on duration of use, may seem small, it is not small at all if you are one of the two or 12 women affected. It requires a cool head for a woman to sit down with her GP or gynaecologist and weigh up the pros and cons of HRT, taking into account her own family history of coronary heart disease, osteoporosis or breast cancer.

Women with a first degree relative (a mother or sister) with breast cancer are sometimes advised not to take HRT - although this is controversial. Some practitioners are actually prescribing HRT for women who have themselves had breast cancer.

Another potential danger is cancer of the uterus. A woman who still has her uterus must never be prescribed oestrogen-only HRT. She should only be prescribed the combined oestrogen-progestogen form, or else risk endometrial hyperplasia, which can lead to cancer. This is because oestrogen promotes thickening of the lining of the womb and without progestogen to control it there is no limit on the endometrial thickening. There is also new research on HRT and strokes, a relationship which has, until now, been controversial. The Lancet also reported this month that HRT has no effect one way or another on strokes - important information for women with a family history of this condition.

Prof Sheppard and his colleagues at St James's and the Coombe are continuing to investigate various forms of HRT. Any woman interested in participating in this work should contact the Trinity College Department of Obstetrics and Gynaecology at St James's and Coombe Women's Hospital, Dublin (Tel: 01-608 2560).