Ten years on and where are we now?

Having been involved for many years in advising, educating and always still learning about the menopause, the effects of estrogen deficiency and treatments, many changes have been seen but none so dramatic as the views on hormone replacement therapy (HRT). In the early days, HRT was seen as the answer to many problems and while it was known that it was not perfect and that all medicines carry some risk, it was strongly believed that for most women, the benefits outweighed the risks. Then, in July 2002, publication of the initial results of the Women’s Health Initiative (WHI) trial led us to be more concerned about risks and less aware of benefits with a subsequent huge fall in the use of HRT. Ten years on and a full review of the WHI trial and of other available evidence has been published. The key message appears to be that in fact, when used appropriately especially for women under the age of 60, or within 10 years of the menopause, HRT provides far more benefits than risks. It is re-assuring that the media have given this news some attention, since women and their health-care providers need to be aware of this information, so that they can make informed choices about the management of their menopause. It seems that for the last 10 years, decisions have been made based on incorrect information. Women can once again be re-assured that HRT is safe when used correctly and while not all women will need HRT, those who do need not worry unduly about risks but can enjoy the benefits. What is of great concern is that with reduced use of HRT over the last 10 years, some health-care professionals have become less familiar with the prescribing of HRT. Reports are being heard of more women being prescribed unopposed estrogen incorrectly, with four such cases being seen in 2011 in the editor’s region alone. Such cases were rare in the past. When investigated, all had endometrial hyperplasia which responded to progestogen therapy. Further discussions with primary care colleagues overwhelmingly revealed a lack of familiarity with types of HRT, e.g. with prescription of an estrogen only product which has a very similar name to a combined product, and examples of removal of Mirena and lack of appreciation that if HRT is continued, then progestogen must be added. Since it is likely that the use of HRT will increase, all those prescribing HRT should ensure that they are up to date with current thinking, principles and types. Many have stated that as a result of the WHI trial and the ensuing publicity, we have had 10 wasted years and that women have suffered unnecessarily. This may be the case but we cannot turn back the years and decisions were made in good faith. Lessons have been learnt and perhaps we should realize that major shifts in practice should not be based on one study, no matter how large. Further, over the last 10 years, aspects of menopause care have broadened away from HRT, leading to a better understanding of the consequences of estrogen deficiency in terms of early, intermediate and long-term effects, the role of dietary and lifestyle changes and alternative therapies. While HRT certainly has a role in menopause management, it is far from the only aspect about which we should be concerned. We have learnt much from the WHI trial but much uncertainty still exists, and we are far from being able to offer women who require treatment the ideal preparation with maximum benefits and minimal risks. It is sincerely hoped that research will continue and that results will be published without bias and without exaggeration. Meanwhile we must make the best sense that we can of current evidence, and as always, individualize.