Before discussing why the patient is reluctant to take HRT, take an accurate history. The average age for the menopause – the final menstrual period – is 52, with a usual range of 48–54. Vasomotor symptoms – especially hot flushes and night sweats – occur in up to 90% of women at menopause. Symptoms may start up to four years before the cessation of menstruation and continue for a number of years after. So, the most likely diagnosis for flushes after the age of 40 is impending menopause. Carcinoid, phaeochromocytoma and hyperthyroidism are very rare causes of hot flushes, but you should bear them in mind.
You may want to look at blood FSH levels during menstruation. Basal levels above 10 mIU/ml suggest the onset of ovarian failure, but it is not a very reliable test. The only sure way of confirming the diagnosis is to give a short course of HRT to see if it alleviates the problem, although this would be difficult in a woman who is reluctant to take hormones. After taking a history, explore why your patient does not want to try HRT – she may have had a bad experience or be worried about breast cancer, or VTE risk.
Explain the pros and cons of HRT
If your patient has been put off taking HRT by stories of increased breast cancer or cardiovascular risk, explain the evidence and the pros and cons of taking HRT.
HRT has been a well-established treatment for menopausal symptoms since its introduction in the UK in 1941. In 2002, a five-year study of postmenopausal women on a continuous combined form of HRT was published – initially the trial was set up to look at the effect of HRT on cardiovascular disease but it also found an increase in breast cancer risk of 27% and an increase in heart attack risk of 23%. These results were reported widely, causing alarm and resulting in many women abandoning treatment. But, the average age of the participants in the trial was 63, two-thirds were overweight or obese, half were smokers or ex-smokers and a third were hypertensive – hardly representative of the average HRT taker.
The way that the figures were reported was also confusing – the increase in breast cancers was from 30 to 38 (a relative increased risk of 27%) but this was per 10,000 women per year, meaning that for each woman the actual increase in risk was only 0.08%.
With regard to heart attacks, we know that oestrogen is cardioprotective, which is why the incidence of heart attacks is low in premenopausal women. But in this trial, women were, on average, 12 years postmenopausal and had high risk factors for arteriosclerosis. Not surprisingly there was a small increase in the number of infarcts in this group, who had damaged coronary arteries and commenced a thrombogenic hormone. Only 10% of the cohort was under 60, but this group has now been studied and had a cardioprotective effect from HRT – there was no increase in the incidence of stroke, and overall mortality was better than in non-users.
The authors of the original paper have recently said that ‘overgeneralising the results from women in the trial to all postmenopausal women has led to needless suffering and lost opportunity for many’.1 Recent evidence also shows that women using oestrogen preparations alone (who had a hysterectomy) had a lower incidence of breast cancer than those not taking oestrogen replacement,2 suggesting that progestogens are the promoter of breast cancer.
The major disadvantages of not taking HRT are the increased risk of osteoporosis and cardiovascular disease – though a recent study in the BMJ found that women who took HRT for 10 years after menopause had a reduced risk of mortality, heart failure and heart attack.3 Of course, women will also not have a cure for their bothersome symptoms. Quality-of-life indicators show a marked improvement in HRT users compared with non-users.
Suggest alternative management strategies
For women who are adamant that they will not or cannot take HRT and are troubled by vasomotor symptoms, you can offer general advice on avoiding hot environments, reducing stress, cutting down on alcohol and caffeine and maintaining a reasonable BMI.
Drug therapies such as clonidine have failed to show any improvement, except an initial placebo effect. Venlafaxine is effective and ß-blockers may help palpitations. Black cohosh and phyto-oestrogens such as soya, red clover and yam may help some patients, but the isoflavone dose must be at least 80mg per day. Properly controlled randomised and blinded trials have failed to show any advantage from herbal preparations and vitamin supplements – most of the evidence for them is anecdotal.
Mr Peter Bowen-Simpkins is a consultant gynaecologist at Singleton Hospital, Swansea, and Medical Director of the London Women’s Clinic
This article was produced in collaboration with Wellbeing of Women. Wellbeing of Women is a charity dedicated to improving the lives of women and babies. Further information can be found at wellbeingofwomen.org.uk
1 Langer RD, Manson JE, Allison MA. Have we come full circle – or moved forward? The Women’s Health Initiative 10 years on. Climacteric, Jun 2012; 15(3): 206-212
2 Anderson GL, Chlebowski RT, Aragaki AK et al. Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women’s Health Initiative randomised placebo-controlled trial, The Lancet Oncology, 2012; 13(5): 476-486
3 Schierbeck LL, Rejnmark L, Tofteng CL et al. Effect of hormone replacement therapy on cardiovascular events in recently postmenopausal women: randomised trial. BMJ Oct 2012; 345: e6409