27042017-creagh-alison-dr-july 16

Over recent years, three doctors have written in Medical Forum that HRT, on the available evidence and risk-benefit analysis, was underused. What do they think today?

Over recent years, three doctors have written in Medical Forum that HRT, on the available evidence and risk-benefit analysis, was underused. What do they think today?

Dr Alison Creagh (ex-FPWA medical educator, pictured above) thinks GPs not prescribing HT is part of the problem. “This is unfortunate, because the risks of hormone therapy for perimenopausal women are low, and there are significant benefits. It’s time we took a balanced approach,” she said adding that taking a good history was key as contraindications to hormone therapy were mainly “past breast cancer, stroke, ischaemic heart disease and VTE”.

For significant hot flushes she recommends hormone therapy and gabapentin; and consideration of SSRIs and SNRIs (although less effective). The risks and benefits of hormone therapy should be discussed with the patient – “for combined hormone therapy, the benefits are effective treatment of symptoms, small decreased risks of colon cancer and osteoporotic fracture, and a decreased risk of death. The small increased risks are for breast cancer, VTE, heart disease and stroke.”27042017-smith-margaret-dr-feb06Dr Margaret Smith

Dr Margaret Smith (retired gynaecologist) is tired of the profession’s post-2002 response to the Women’s Health Initiative data and recommends the Jean Hailes website as a great resource, saying HRT is “safe and effective”. Like others she points to flaws in the WHI study – different hormones studied to those used today, women studied were older and had a different risk profile, etc.

“The major deficiency symptoms that [may] need oestrogen are hot flushes, sleep disturbance and vaginal dryness. HRT can also relieve depressed mood” she said. On the main issue of breast cancer scare she said “oestrogen does not cause breast cancer but can encourage its growth when it already exists” and “heart attack and stroke risks are usually due to other factors but may be enhanced by HRT.” She re-emphasised the same risks and benefits as Dr Creagh, adding that “all women should have a mammogram before HRT is started.”

27042017-welborn-tim-dr-jul15Prof Tim WelbornProf Tim Welborn (endocrinologist) clarified his stance. “Doctors and patients continue to show extreme caution about the use of HRT since the critically flawed Women’s Health Initiative report. Recent evidence-based guidelines indicate that women with moderate to severe menopausal symptoms will get substantial relief from early supervised therapy. Oestrogen treatment also gives vascular protection and improves bone density.”

“There is further data that the added risk of breast cancer is negligible for 20 years. Clear contra-indications to HRT include long duration menopause lasting beyond 5-10 years and/or a family history of hormone dependent cancers. Those at risk of thrombo-embolic disease should be offered trans-dermal oestrogens. Women with an intact womb can be prescribed an oestrogen-progesterone combination, to protect against endometrial hyperplasia or cancer, or be given cyclical oestrogen (with withdrawal bleeds) or oestrogen plus a Mirena coil.”

By Peter McClelland

 

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