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Balancing risk and benefit of HRT

New national guidelines on treating menopause symptoms in women will re-open the discussion between clinician and patient on the merits of using hormone replacement therapy.

New national guidelines on treating menopause symptoms in women will re-open the discussion between clinician and patient on the merits of using hormone replacement therapy. In the image, illustration of a variety of lilies in a garden

Source: Callie Jones

For some women, menopausal symptoms have a hugely detrimental effect on quality of life and long-term health. Hot flushes and night sweats can lead to poor sleep, which may chronically affect work and personal life, while some women experience joint and muscle pain, headaches, urinary tract infections, osteoporosis and low mood.

UK women experience menopause at an average age of 51 years, but one in 100 women under the age of 40 years will develop premature menopause. In all, 1.5 million UK women — 80% of those going through menopause — experience some combination of symptoms usually for around four years, although for 10% of women these can last up to 12 years.

In November 2015, the National Institute for Health and Care Excellence (NICE) published its first menopause guidelines, which evaluate the benefits and risks of hormone replacement therapy (HRT). Once widely taken for menopausal symptoms, HRT prescriptions in the UK almost halved following the publication of two significant studies by the Women’s Health Initiative in 2002 and the Million Women Study in 2003. The publications linked HRT to an increased risk of breast cancer and cardiovascular disease, and concern over the treatment has persisted ever since among both women and health professionals.

Some saw it as controversial when NICE’s new guidelines advised that HRT should be considered more often as a treatment option despite the reported risks. As a result, the long-running debate about whether HRT is a safe and appropriate treatment has been reignited.

According to NICE, the increased absolute risk of breast cancer from using HRT is small but significant. For every 1,000 menopausal women not taking treatment, there is a baseline rate of 22.5 breast cancer cases over a 7.5 year period. Evidence from randomised trials suggests that if these 1,000 women started taking oestrogen and progestogen HRT, cases would increase to 27.5 per 1,000 — or 0.5% — reducing after they stop treatment. Observational studies suggest a higher absolute risk increase of 1.7%.

The guidelines set out these figures to improve clinicians’ awareness of the quantified risk, so they can discuss risk within a meaningful context, helping patients to understand the information in front of them.

NICE’s review explains how these studies linking HRT with cancer focused on potential long-term risks rather than considering the benefits of symptom relief. The fact is that HRT is an effective treatment for several menopausal symptoms and, similarly, there are risks from not treating these symptoms, including the possibility of debilitating osteoporosis and depression.

Although any increased risk of cancer must be taken seriously, so should the chronic and sometimes intolerable symptoms of menopause. A balanced judgement is impossible without considering beneficial effects and the opportunity cost of not treating symptoms.

NICE says that a “knowledge gap” among some healthcare professionals may have made them reluctant to prescribe HRT “because they overestimate the risks and contraindications, and underestimate the impact of menopausal symptoms on a woman’s quality of life”.

One aim of the new guidelines is to clarify this balance. It also advocates a discussion between a woman and her clinician about the impact of menopause on her well-being and potential treatment options. This is a particularly valuable recommendation since so many women do not come forward for help.

Menopausal woman deserve the right to discuss whether HRT could benefit them, even if it will not be right for everyone. The hope is that the guidelines provide the advice and tools clinicians need to hold a balanced discussion, so that many more women can obtain relief for their symptoms, and that treatment decisions are well informed.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2016.20200341

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  • New national guidelines on treating menopause symptoms in women will re-open the discussion between clinician and patient on the merits of using hormone replacement therapy. In the image, illustration of a variety of lilies in a garden

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