Hormone Replacement Therapy
The Wonder Drug for the ’90s
By Isabelle Trépanier and Marie Cocking

Imagine taking a pill a day for the next 15 years. You would do it if you had diabetes or some life-threatening disease. But would you do it to “treat” the natural symptoms of menopause and, maybe, add a year to your life by reducing your risk of osteoporosis and cardiovascular disease? The Canadian Society of Obstetricians and Gynaecologists think you should. The Society’s Menopause Consensus recently fanned the flames of the debate surrounding hormone replacement therapy (HRT) with the release in May of its guidelines for the treatment of menopause. The Committee believes women should consider reaping the benefits of HRT.

Certainly, HRT should be a choice in the treatment of women with surgical menopause or the estimated 10 to 20 per cent of women with severe menopause symptoms. But we believe that the Committee has overstated the case in favour of HRT. The Committee, itself, states that HRT carries an increased risk for developing certain cancers — how high a risk the Committee is not even sure.

These are considerable risks to incur — risks that may well be higher in DES-exposed women because of their prior exposure to estrogen — particularly when HRT is not a treatment for a disease but a hormonal program to manage a natural transition. Like DES in the 1930s, HRT has become the wonder drug for the 1990s.

The Advantages of HRT

Since 1960, women have been given estrogen supplements to counteract the natural drop in estrogen production that occurs with menopause, usually beginning around age 50. Then, it was given to prevent wrinkles and keep women “feminine forever.” Now, the Consensus Committee is selling estrogen — this time, with a dab of progestin (synthetic progesterone) to control estrogen’s bad effects — as a way to prevent heart disease and osteoporosis. You can choose injections, a regime of daily pills, or an estrogen-releasing patch, with progestin pills on the side.

Cardiovascular Disease

According to The Canadian Heart and Stroke Foundation, cardiovascular disease — diseases of the circulatory system, heart disease or stroke — is the number one cause of death in Canada. Cardiovascular disease kills 40 per cent of all women.

With this in mind, the Committee reports that the use of estrogen during menopause seems to protect against heart attack. However, the authors add that the studies to date are inconclusive on whether estrogen protects against other forms of heart disease, notably stroke. And whether estrogen taken with a progestin (the most common hormone regime) still protects against heart disease is anyone’s guess.

Three large U.S. studies looking into that question will not publish their results until the end of 1994, 1999, and 2004 respectively. Still, the Committee recommends the use of estrogen — with or without a progestin — to protect against heart disease before there is even proof that this regime is safe and effective.

Osteoporosis

Osteoporosis is the progressive loss of bone density, which can add to the risk of fracture. According to The Osteoporosis Society of Canada, this process accelerates after the onset of menopause.

Using estrogen can protect bone density, states the Consensus Committee. It goes on to say, however, that there is a lack of data on whether better screening tests for the risk of fracture could also protect against osteoporosis(1). Such tests could be useful if used systematically, notes the Committee, because they would encourage more women to take hormones before the onset of menopause.

The Committee even recommends using estrogen along with natural alternatives for maintaining bone density such as diet and exercise in order to achieve optimal results. It seems that there is no way to avoid taking hormones!

However circular some of the Committee’s reasoning, the use of estrogen for HRT does seem to protect against heart disease and osteoporosis. But the report becomes really murky when the Committee discusses whether HRT adds to the risk of developing certain cancers.

The Disadvantages

Endometrial Cancer

The Committee blames the media for spreading rumours about a possible link between HRT and cancer. This said, the Committee cannot ignore alarming studies done in the 1970s demonstrating that the risk of endometrial cancer is four times higher for women taking estrogen. But there is no need to worry now, according to the Committee, because more recent studies show that women using a combination of estrogen and a progestin have the same risk of developing this cancer as women taking nothing.

For women who have already suffered from endometrial cancer, the Committee notes that the use of HRT is “confusing.” The Committee nevertheless recommends using hormones for women with low grade (stage one, grade one) treated endometrial cancer because of its protective effect against heart disease and osteoporosis.

Ovarian Cancer

On the link between estrogen and the risk of ovarian cancer, the Committee states that studies to date offer no firm answers. Many doctors are reluctant to prescribe hormones to women suffering from ovarian cancer. But, based on one study, the authors recommend that women who have been treated for ovarian cancer and women who have had their ovaries removed, should not be denied HRT.

Paradoxically, the Committee concludes by saying that more randomized, controlled studies are necessary to confirm HRT’s advantages for women with this cancer.

Throughout the report, the Committee approaches women's reproductive lives as a medical problem needing a technical solution. And this attitude is particularly strong in the section on ovarian cancer. The Committee suggests that because the use of the Birth Control Pill would lower the risk of ovarian cancer, all women should take the Pill. If that’s not enough, the authors go on to suggest that women with close relatives who have had ovarian cancer should have their ovaries removed after child-bearing as a preventative measure!

Breast Cancer

There is no consensus among the Committee whether HRT raises the risk of developing breast cancer. Basing its findings on five studies, the Committee states that the risk of developing this cancer after taking hormones for 15 years is very weak. The Committee adds that the risk could vary according to the dose prescribed and that it's not clear whether the use of progestins raises or lowers the risk.

But despite that lack of clarity, the Committee tenaciously insists that even when breast cancer has been diagnosed, the use of hormones does not seem to reduce the chance of survival.

The authors close this section with four suggestions — not recommendations — for prescribing HRT:
First, a benign breast tumour is not a contraindication.
Second, where there is serious risk of breast cancer, a physician should not automatically recommend HRT, but should let the woman decide if she will accept the risk.
Third, when a woman has one close relative who has had breast cancer, choosing HRT is left up to the woman. When a woman has two close relatives who have had breast cancer, HRT is contraindicated.
Fourth, when breast cancer is already present, HRT is contraindicated except with the clear consent of the woman.

Without conclusive research on the link between breast cancer and HRT, it’s not surprising that according to the report itself, 70 per cent of women refuse to take hormones for fear of developing cancer. The Canadian Cancer Society estimates that in 1994 women have a one in nine lifetime risk of developing breast cancer and that their risk increases significantly after age 50. Faced with these odds, it seems only sensible that women don’t want to add to their risk by taking hormones.

Report Unconvincing

The so-called Consensus Committee, despite calling for a “therapeutic partnership” with women, doesn’t have time to investigate less risky alternatives. Instead, the Committee offers a polemic to counter the “misinformation” offered by lay educators and to convince more physicians and women that the benefits of HRT greatly outweigh the risks.

Its report is not convincing. The Consensus Committee states again and again that it does not have all the necessary data. With such incomplete data about the safety and efficacy, and with so little new information about HRT, the release of the report begs the question: why now? When the Committee can’t state with authority whether HRT is truly beneficial and truly safe to “virtually all” menopausal women, why does it want us all to choose HRT?

It’s true that HRT does appear to reduce a woman’s risk of developing cardiovascular disease and osteoporosis after menopause. But at what cost? After at least 15 years of taking two pills a day — at the cost in 1994 dollars of about $2700 — you’ll get an extra year of life. You'll exchange a reduced risk of cardiovascular disease and osteoporosis for an increased risk of endometrial and breast cancers. Some women may be trading hot flashes and vaginal dryness for headaches, “premenstrual syndrome,” and monthly “bleeds”.

For the vast majority of the 4 million Canadian women aged 50 and over, the trade-offs are not worth it. In 1988, only 11.4 per cent filled their prescriptions for hormones. There is now a massive menopause market offering alternative ways to cope through diet, exercise, meditation, herbs and teas, and the like. Menopausal women are speaking with their pocketbooks; most do not want or need hormones.

It's hard not to come to the cynical conclusion that this report, generously supported by educational grants from major pharmaceutical companies and dotted with ads for Premarin and Provera, seems like an industry driven attempt to keep a hold on the Baby-boomer market, soon coming off the Birth Control Pill in massive numbers.

But the Committee has bought the industry line. And many gynecologists are so convinced of the benefits of HRT that every menopausal woman will now have to decide, according to her experience of menopause and her health history, whether the benefits of hormones are worth the risks, known and unknown.

For some, it may be the best choice. But for the rest, we can only hope that this rush to prescribe hormones to healthy women will motivate more premenopausal women to make positive changes to their diet and exercise programs now.

1. Specifically, the bone densitometry test which in Canada is only used selectively.