Hormone replacement therapy: navigating the debate

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Shirley Weir didn't know why she suddenly felt anxious and forgetful, her moods swinging like the pendulum on a grandfather clock. Unable to sleep one night, she consulted the only medical authority available at 3 a.m.: Google.

After keying in her symptoms, Weir found herself facing a screen filled with information and advertisements about vitamins, pharmaceutical drugs and natural therapies that promised to ease the symptoms of menopause. At the time, Weir, who lives in Vancouver, was in her late 30s and nowhere near menopause. But she learned that many women can experience symptoms for years in advance. She also discovered that finding unbiased, informative and trustworthy information about what works – and what doesn't – is a nearly impossible task.

"If you're genuinely trying to do your research and be an informed patient, it's very difficult to do," said Weir, who is now 47.

Treatment options for menopause have been a minefield for many women since the publication of a landmark study in 2002 that warned about potentially negative side-effects of hormone replacement therapy (HRT). It was developed to treat hot flashes, night sweats, insomnia, vaginal dryness and other unpleasant symptoms of menopause. Women who have not had their uteruses removed typically receive combined HRT, which consists of estrogen and progestin (estrogen alone can increase risk of uterine cancer). The idea is HRT can help counterbalance the natural decline of hormones.

But the 2002 study suggested the therapy increased the risk of breast cancer, heart disease, stroke and blood clots. As a result, many women went off the drugs and doctors advised against taking them – research showed the number of all Canadian women taking HRT dropped to five per cent in 2004 from nearly 13 per cent in 2002.

Rather than put the question of HRT safety to rest, however, that famous Women's Health Initiative study ignited an ongoing fiery debate over the extent of the risks, the role played by drug company-funded research and making a natural process into a medical one. Studies are published each year either exonerating HRT or pointing to the fact that, either way, it's still a risky venture. Major medical organizations are in disagreement about whether women should take synthetic hormones. And many doctors have trouble giving definitive advice and instead suggest that patients have to make up their own minds after hearing the facts.

The initial allure of HRT wasn't just about relieving the misery of hot flashes. Doctors and companies began selling women on the notion that HRT was a way to maintain their womanliness, an idea summarized in the bestselling 1966 book Feminine Forever by Dr. Robert A. Wilson. Decades later, critics claim the book is misogynistic and paternalistic.

"Along with the selling of hormone replacement therapy, there is the selling of the idea that menopause is this horrible thing that a large proportion of women have a hard time with and that needs drug treatment," said Barbara Mintzes, assistant professor in the department of anesthesiology, pharmacology and therapeutics at the University of British Columbia.

More recent studies argue that the risks of HRT aren't that high and that the therapy may offer some protection against colorectal cancer and hip fractures. These studies have tempered the fears around HRT and may have led more women to take it. In fact, the annual number of prescriptions sold is increasing. In 2009, 5.5-million prescriptions for HRT products were dispensed at retail pharmacies in Canada, according to IMS Brogan, a firm that tracks the drug industry; in 2013, that number climbed to more than 5.7-million.

Too often, Mintzes said, the studies that play down the risks of HRT have financial ties to companies that market HRT. That has created a confusing landscape for women.

Even authoritative medical bodies can't find consensus. The Society of Obstetricians and Gynaecologists of Canada updated its HRT guidelines in 2009 to state that HRT is generally safe for women to take, if they are on it for five years or less. The guidelines note that alcohol consumption, physical inactivity and choosing not to breastfeed all carry similar risks for breast cancer as HRT. And the society says that hormonal drugs may simply speed the growth of pre-existing cancer, which could actually lead to better outcomes.

Even then, though, most of the individuals involved with writing the society's guidelines declared numerous potential conflicts of interest in terms of their relationships with drug companies, including speaking engagements, research grants, advisory board membership and consultant work.

The Canadian Cancer Society, on the other hand, says the breast cancer risks to women are too high. It recommends that women stay away from HRT unless their symptoms are severe. And even then, they should take hormonal therapy for the shortest period possible, said Prithwish De, an epidemiologist and spokesman for the society.

Among women taking HRT, "we do see a pretty consistent increase in breast cancer no matter where you live," he said. Other studies have shown HRT can increase the risk of cognitive decline and can lead to denser breasts, which can compromise the interpretation of mammograms, De added.

He said that alternatives such as bio-identical hormones, which are synthesized from plant materials, are not necessarily a good choice. Many women have been turning to bio-identical hormones and other natural health products instead of prescription HRT products, but many of these compounds haven't been subjected to rigorous research proving they actually work and are safe. Bio-identical hormones are not tested or regulated by Health Canada. The U.S. Food and Drug Administration said the marketing of these products is misleading to women and that they carry the same risks as other hormonal therapies.

What's missing from the debate is a sober reflection on what place HRT should have in the lives of women given that menopause is a natural process, not a medical condition, Mintzes said. "I would say the place for it is really quite limited," she said.

Shirley Weir has come to a similar conclusion. After months of research, she decided that progesterone cream was the right option for her. But she also realized that medications aren't the only answer, and that diet and physical activity can go a long way to helping her symptoms. "The misunderstood statement in society is that there's a magic-wand solution," she said.