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Can HRT prevent disease?

In the last 20 to 30 years the arguments for and against hormone replacement therapy (HRT) have come full circle, and then some. But can it really help to keep us healthy?

As I explained last month, in the early 1990s HRT was recommended for the prevention of heart disease, osteoporosis, dementia and some cancers.

Ten years later, after negative outcomes in a big US trial, the pendulum swung the other way. Now we believed the risks outweighed the benefits.

A few studies later, and after a reanalysis of the trial data, the argument shifted again to endorse hormone therapy for women in their 50s, or within 10 years of menopause.

This was called the ‘timing hypothesis’. It was claimed that for women in this age group there were more benefits than risks, and that problems came about when HRT was used in women over 60.

Most current guidelines recommend hormone therapy for symptom relief (not disease prevention) at the lowest dose for the shortest period of time.

But there are still strong advocates for using hormones to help prevent conditions such as heart disease and osteoporosis. 

A recent paper by an English GP promotes the use of HRT within 10 years of menopause to help prevent heart disease. The Australasian Menopause Society have published her views on their website, implying that they agree.

And last month a team of American researchers argued that hormone treatment reduces fracture risk and should be used to prevent osteoporosis. They’re fans of low dose treatment delivered via the skin (patches, gels, etc) rather than orally.

We’ve even seen researchers calling lately for HRT to be part of a general chronic disease prevention strategy at the onset of menopause — which brings us back to where we were in the early 90s.

Why has this gone around in circles? Because HRT is complicated, with lots of possible combinations, doses, durations and ways of administering it. Other variables include the age and health of the women using it. 

There’s also the cost of doing long-term research with big numbers of women. It’s expensive, so there aren’t a lot of top quality studies.

For all the arguments about hormone therapy and disease prevention, it’s mostly not supported in the mainstream.

As I noted last month, a major analysis of the best studies from the five years between 2011 and 2016 concluded that HRT is still too risky to be used as a preventative. That analysis also rejected the timing hypothesis.

If you want to prevent disease, start with diet, exercise and lifestyle. After that, there may be a place for HRT in managing the health of some individuals. For example, estrogen is clearly good for tissues such as bone and blood vessels, as long as those benefits are greater than the risks.

It’s estimated that about 15% of Australian women use some form of HRT, presumably mostly for symptom relief. 

If hormone therapy is a path you want to explore, the Jean Hailes Foundation provides good advice: start low (dose), go slow and review often.

You also need a skilled practitioner. It can take a good while to find the right combination and dose, so you (and they) may need to be patient and rigorous. 

We probably haven’t heard the last of HRT as a way to prevent disease and chronic conditions. Watch this space.  

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Wednesday, April 18, 2018 | Rhonda Anderson