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Pharmacy Links

MENOPAUSE: CHALLENGES OF HRT

April 21, 2009

Opponents of the widespread and protracted use of HRT challenge the notion of universal hormone deficiency. They point to big individual differences in sex hormone levels at and after menopause, the difficulty of translating these measurements into symptoms or disease risks, and to the diversity of experiences of menopause. While conceding that production of oestrogen by the ovaries declines after menopause, they say that older women need less oestrogen. A relatively small amount seems sufficient for the many and varied organs that oestrogen influences.

In most women, oestrogen production by the adrenal glands and by fat and muscle tissue partly compensates for the diminished oestrogen output of the ovaries from menopause onwards. Jill is a woman who found the ‘HRT for everyone’ approach worrying. Most of her friends seemed to be on HRT, yet at fifty-seven she was in exuberant postmenopausal health without it. For Jill, fitness has been something of an obsession for many years, partly because she has a tendency to put on weight easily: in spite of vigorous daily exercise and a carefully balanced diet she remains ‘well covered’. After reassurance that her sensible lifestyle was providing protection for her bones and heart, and her fatty tissue was supplying adequate oestrogen for her needs, she decided that HRT was not necessary for her.

The second main challenge to advocates of near-universal long-term HRT has come from those who question the confidence with which clinicians attribute benefits to HRT that are based on specific research findings. The research quoted usually involves the use of oestrogen on its own, rather than the more usual combination of oestrogen and progestogen. These critics also argue that, until the results of long-term studies of current HRT formulations and dosages are available, it is foolhardy to widely prescribe hormone therapy without firmer selection criteria than operate at present.

It makes more sense to identify specific groups for whom menopause is a particularly distressing or potentially dangerous experience; to analyse carefully the immediate and future risks and benefits they face, and the pros and cons of HRT in their situation; to upgrade selection criteria; and to campaign for fair access to screening tests that can assist decision-making. This would help to ensure that women in need of HRT have access to it, while those for whom it is unnecessary do not embark on it. Taking up these challenges is, of course, a matter for the women concerned, as well as researchers.