Doctors urged to prescribe HRT menopause treatment despite 'cancer risks'

Watchdog says controversial hormone replacement therapy can be the right choice for many women

Most women on HRT take oestrogen tablets combined with a synthetic progesterone (Rex)

Doctors are being encouraged to prescribe hormone replacement therapy (HRT) for women suffering from hot flushes and night sweats in the first national guidance on the menopause, despite potential cancer risks.

Issuing the guideline today, the National Institute for Health and Care Excellence (Nice), acknowledges that many medical professionals have become reluctant to offer HRT but arguing it is the right choice for many women.

Prescriptions have almost halved in the past 10 years, according to Nice, following a number of scientific studies in recent years warning of links to certain cancers, as well as blood clots and strokes.

“For the last decade, some GPs have been worried about prescribing HRT, and women worried about taking it,” said Dr Imogen Shaw, one of the experts involved in developing the guideline.

The proportion of menopausal women taking HRT is no more than 15 per cent in most parts of Britain, said Professor Mary Ann Lumsden, chair of the menopause guideline development group. “What we would like is that people who need it and would benefit from it have the option of considering it, we’re not saying any more than that.”

What is Hormone Replacement Therapy?

Hormone Replacement Therapy (HRT) works by boosting levels of oestrogen and progesterone hormones which drop after women begin the menopause. 

Most women on HRT take oestrogen tablets combined with a synthetic progesterone. It can also be taken through gel, patches or implants. The oestrogen used in HRT is derived from plants such as soya or yam, or the urine of pregnant mares.

There are three main types of HRT – oestrogen-only HRT, usually recommended for women who have had a hysterectomy; cyclical HRT, for those with menopausal symptoms whose periods have not ended; and continuous combined HRT, for post-menopausal women, where both hormones are taken at the same time.

The treatment may not be suitable for women with a history of breast, ovarian or womb cancer; blood clots; heart disease or stroke. 

More than a decade ago, two major studies – the Women’s Health Initiative in the US and the Million Women Study in the UK – found that those taking HRT were at higher risk of breast cancer and heart disease. And a paper published in The Lancet in February, found that women using HRT were 40 per cent more likely to develop ovarian cancer.

“No other treatment has been shown to be as effective as HRT for menopausal symptoms,” states the guideline, which aims to “clarify the balance of benefits and risks” of the treatment. It seeks to “help GPs and other healthcare professionals to be more confident in prescribing HRT and women more confident in taking it”.

Dr David Richmond, president of the Royal College of Obstetricians and Gynaecologists, welcomed the advice, describing it as “a milestone for both healthcare professionals and women”. He said it “will help ensure that the best possible care is provided in the diagnosis and treatment of menopause”.

Women suffering night sweats, depression, and other symptoms after their periods stop can benefit from using HRT, which replaces lost hormones. Women start the menopause at 51 on average. Some 1.5 million (around 80 per cent of those going through menopause) experience symptoms which range from mood swings to joint pain, vaginal dryness, and a lack of interest in sex. Post-menopausal women also face an increased risk of osteoporosis.

Dr Shaw, a member of the menopause guideline development group, told The Independent: “There are some risks associated with taking HRT but probably no more than a lot of the other things that people take like statins and aspirin. If you wake up in the morning with backache you’ll reach for the ibuprofen and you won’t think this is going to give me a stomach bleed. What we’re trying to do with the guideline is to push the benefits... and put the risks into context.”

Over seven and a half years, there would be an additional 17 cases of breast cancer, six cases of stroke, and five cases of heart disease per thousand women using HRT, according to the Nice guidelines.

But some experts accused Nice of not clearly presenting the risks which, they claim, could result in thousands of increased deaths from cancer and heart disease.

Professor Klim McPherson, visiting professor of public health epidemiology at the University of Oxford and an expert on HRT, said: “This guidance leans too far in the direction of playing down the risks... the aftermath of accepting this new guidance stands a very good chance of increasing the breast cancer, cardiovascular disease and ovarian cancer numbers by several thousand in the next 10 years.”

Dr Julie Sharp, head of health information at Cancer Research UK, commented: “The link between cancer and hormone replacement therapy is well established and is underpinned by a large body of evidence.”

A spokesman for Nice said the guideline was based on the “best evidence following robust evaluation of relevant peer-reviewed published research” and “gives an overview of the evidence considered”.

Case study: 'HRT gave me my life back'

Julie Clark, 59, a businesswoman from Poole in Dorset, says that HRT changed her life for the better.

I went into the menopause at just 45. I didn’t know what was happening and assumed that either I was seriously ill or was suffering from depression, and I had to sell my business because I couldn’t cope.

“After three years of getting on with things, my daughters said, ‘Mum, you’re just not you’ and forced me to go to my GP who suggested that I might be menopausal.

“The blood test showed that I had no oestrogen left – but all I felt was relief. HRT gave me my life back and despite the risks, I intend to stay on it for as long as I can.

“I wish that I had known sooner what was happening to me as I had to scratch around the internet thinking the worst. At least women should be aware. These guidelines will help inform women and help them make the right choices.”