HRT Risks vs Benefits

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But isn’t HRT dangerous?!

The FDA has a black box warning listed on all estrogen products in the US, which says:

WARNING: ENDOMETRIAL CANCER, CARDIOVASCULAR DISORDERS, BREAST CANCER AND PROBABLE DEMENTIA.

With such a frightening label, is it any wonder that so many people, both patients and doctors alike, are scared of HRT?

Much of the fear around HRT came about from the Women’s Health Initiative (WHI) results, published in 2002, which seemingly showed that HRT had more risks than benefits (with increased risk of breast cancer, heart disease, stroke, and dementia). Rightfully so, many people stopped using HRT and became afraid of it. Nowadays though, the stance of many doctors, researchers, and menopause societies has changed. This is because reanalysis of the WHI data reached new conclusions, showing that these fears were overblown, inaccurate, or not applicable to people of all ages or on all hormone formulations. Also, since 2002, we now have even more studies on different HRT formulations, regimens, and delivery methods, which we can use to have a more comprehensive picture of the risks and benefits of HRT.

Additionally, the results of the WHI study (the actual results as shown by the reanalyses of the data) can’t be extrapolated to all hormones formulations nor for all people – these were specific outcomes for certain hormones for certain people: The average age of the women in the WHI was 63, so that is 12 years past the average age of people (51) when they go into menopause! These study participants were also asymptomatic and didn’t have menopause symptoms. 16,608 healthy postmenopausal women with a uterus, ages 50-79, were randomized to either test or placebo group, and given conjugated equine estrogen alone or in combination with a single progestin, medroxyprogesterone acetate.

The current stance of the North American Menopause Society (NAMS)

“The 2022 recommendations reiterate the importance of shared decision-making and patient education when addressing treatment options, stating that—for most healthy, symptomatic women under the age of 60 who are within 10 years of menopause onset—the benefits of hormone therapy outweigh the risks.” [Source: Contemporary OB/GYN]. 

“The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing therapy.”

“It can be considered for continuation beyond age 65—after appropriate evaluation and benefits-risks counseling—for persistent VMS [vasomotor symptoms], quality-of-life issues, or osteoporosis prevention.” [Source: Contemporary OB/GYN].

What about breast cancer?

The panic in the press over the risk of breast cancer while taking HRT was one of the main reasons that HRT prescriptions plummeted after the WHI trial data was released. But in reality, this was overblown and not the full picture:

“Most women and healthcare professionals are concerned about the possible risks of breast cancer in women taking HRT. However, the risk is far lower than many realise. Women who take oestrogen only HRT (women who have had a hysterectomy) have a lower future risk of breast cancer. Women who take oestrogen and a progestogen who are over 51 years old may have a small increased risk of breast cancer. However, this increased risk is a lower magnitude to the risk of breast cancer for women who are overweight or drinking a glass or two of wine each night. Telling them this often really helps to put this risk into perspective. This risk with synthetic progestogens has not been shown to be statistically significant in any studies. Studies have shown that women who take micronised progesterone have an even lower risk of breast cancer than other women who take other progestogens. There has not been a good quality study showing that there is a risk of breast cancer at all in women who take oestrogen with micronised progesterone.” [Newson Health Menopause Society’s Easy Prescribing Guide]

• Relative risk is the change in risk between two groups. For example, this is a statement like, “people taking HRT have a X% higher chance of breast cancer than those who don’t take it!” This is how the WHI data was presented in the media and it caused widespread panic.
  
  
• Absolute risk is the risk of the event in two groups. This is much more helpful for people to understand, because even if the relative risk sounds scary (X% higher!!), the absolute risk might still be low for both groups. The WHI study only found an additional couple of cases per year of breast cancer in women using estrogen + progestin HRT. Have a look at the visual guide put together by Newson Health for actual numbers.

Benefits of HRT

Apart from improving quality of life for many people living with bothersome perimenopausal or menopausal symptoms, estrogen plays a protective role in many aspects of our health.

“There are numerous potential benefits to be gained by women taking HRT. Symptoms of the menopause such as hot flushes, mood swings, night sweats, and reduced libido improve. In addition, taking HRT has also been shown to reduce future risk of cardiovascular disease, osteoporosis, type 2 diabetes, osteoarthritis and dementia. Most benefit is afforded when women start HRT within 10 years of their menopause.” [Newson Health Menopause Society’s Easy Prescribing Guide]

Early menopause

There’s evidence to suggest that if you go into menopause before 45 (and especially before 40), and you don’t use estrogen therapy, it’s associated with a higher risk of osteoporosis, heart disease, dementia, and premature death. This is scary to think about, especially because some of us have had our ovaries removed at a young age. Since estrogen does have a protective effect on many aspects of our health, losing years or even decades of estrogen may have a long term negative effect on our health.

Not to mention, that sudden plunge into medical menopause – or even the transition into natural menopause – can make us suffer with a lot of miserable symptoms from being in a low estrogen state.

What about HRT for people in their 50s and 60s?

Have a look at the visual guide put together by Newson Health, which shows data on the major long-term benefits of HRT covering the following topics: all-cause mortality, coronary heart disease, diabetes, osteoporosis, and dementia”. It also shows data on the risks of HRT covering the following topics: breast cancer, venous thrombosis (blood clots), stroke.

Estrogen Matters: Why Taking Hormones in Menopause Can Improve and Lengthen Women’s Lives—Without Raising the Risk of Breast Cancer by Avrum Bluming, Carol Tavris, et al is an excellent book which breaks down the WHI study data (and it’s flaws) and brings in data from decades of studies on HRT to talk about the potential benefits and risks in topics such as if estrogen causes breast cancer, if breast cancer survivors can take estrogen, cardiovascular disease, bone health, dementia and brain health, progesterone, among others. I read this book and was impressed by how much data there is to suggest/show the benefits of HRT go far beyond just alleviating menopause symptoms.

“It now appears that HRT does far more than improve the quality of women’s lives during menopause. It also saves lives and prolongs lives by significantly reducing the risks of heart disease, osteoporosis, colon cancer, and diabetes.” [Source: Estrogen Matters by Avrum Bluming, Carol Tavris, et al]

The NAMS position statement from 2022 on HRT goes over in detail the affect of HRT on various health conditions such as osteoporosis, diabetes, blood clot, dementia, depression, cardiovascular disease, and more, looking at data for women over and under 65 years old.