What about that study in the 90′ that said HRT was dangerous?

The Women’s Health Initiative (WHI) study was a long-term (1993-2005) national health study in the United States that focused on strategies for preventing heart disease, cancer, and osteoporotic fractures in postmenopausal women. In 2002 the researchers thought that HRT made things worse, in all areas, except osteoporosis. It was the study that altered the way many women and doctors viewed HRT. At the time millions of women immediately stopped using HRT. Since then, millions more have been terrified to start. And I know from experience, it was scary to start prescribing, and then continue prescribing until more information became available.

So, what’s changed?

The two main changes are the type of hormones used and the age of starting HRT. On top of this, the data captured at the time was re-analysed with newer scientific knowledge.

Here are a few of the changes, including two non-HRT changes.

Calcium and Vitamin D Supplements: The WHI study examined the effects of calcium and vitamin D supplementation on bone health and fracture risk. Initially, the study found no significant reduction in hip fracture risk. However, further analyses indicated that women who were compliant with both types of supplementation had a reduced risk of hip fracture. The calcium-alone arm of the trial showed no decreased risk of fracture. Unfortunately, there was no trial of vitamin D alone, only with calcium. So the recommendation remains to take both.

Dietary Fat Intake: The WHI dietary modification trial aimed to assess the impact of a low-fat diet on the risk of heart disease and breast cancer in women. There was no significant reduction in either. Thus current dietary guidelines suggest a balanced and varied diet, focusing on the quality of fats. For example, the Heart Foundation no longer suggests low-fat dairy products for everyone.

Hormone Replacement Therapy (HRT): The major finding of the WHI study was of course related to hormone replacement therapy. The study initially reported an increased risk of heart disease, stroke, blood clots, and breast cancer in women taking combined estrogen plus progestin hormone therapy. However, subsequent analyses and follow-up studies have revealed that the risks associated with HRT vary depending on factors such as age and time since menopause and the type of HRT used. So blanket statements should not be made for women in general!

What is required to maintain safety?

Individualized Approach: The revisions in HRT recommendations highlight the importance of an individualised approach. Factors such as a woman’s age, menopausal status, symptoms, personal medical history, and family history must be taken into account when considering HRT.
This is not 5 minute medicine. Many GPs simply don’t have the time to talk about what is best for each patient.

Length of time to continue on HRT – The previous recommendation for HRT was – to take for the shortest time possible. It has now been revised to – take for as long as the woman feels it is beneficial.

Time of HRT commencing.

Healthy women younger than 60 years (or within 5-10 years of menopause) should not be overly concerned about the safety of HRT. For most women, HRT has many potential benefits, and few risks, when initiated within a few years of menopause.

HRT can also be commenced prior to menopause. It is often the perimenopausal time when symptoms are the worst.

Straight from the International Menopause Society 2020 statement.
“The excessive conservatism engendered by the presentation to the media of the first results of the WHI in 2002 has disadvantaged nearly a decade of women who may have unnecessarily suffered severe menopausal symptoms and who may have missed the potential therapeutic window to reduce their future cardiovascular, fracture and dementia risk.”

Many of these recommendations changed as the hormones we use are not the same as those used in the WHI study. Most doctors now only prescribe topical oestrogen, which is a bioidentical hormone replacement therapy (BHRT). BHRT are hormones (oestradiol, progesterone, and testosterone) that are structurally identical to those naturally produced by the body. These hormones are derived from plant sources.

In contrast, the hormone therapy used in the WHI study predominantly involved conjugated equine oestrogens (derived from the urine of pregnant horses) in combination with medroxyprogesterone acetate (a synthetic progestin). These hormones were not identical to those produced by the human body!

BHRT is a term that can be used broadly and encompasses various formulations, including TGA-approved bioidentical hormone products as well as custom-compounded hormone preparations. Custom-compounded BHRT is not regulated by the TGA and traditionally has been a subject of controversy due to concerns around inconsistent dosages and purity from inexperienced pharmacists. To try and differentiate between compounded and non-compounded preparations, Australia tries to use the term ‘body identical’ to describe factory-made medications. However, in a global internet search the terms are used differently on different websites. In summary, any oestrogen found in Australia that is applied topically is bioidentical or body identical.
Progesterone is a different story and sometimes despite a very small increased risk in safety with non-bioidentical progesterone (progestins), needs to be prescribed. The Mirena for heavy bleeding is one example of this.

In summary, HRT is no longer an evil thing that some women need. It is a fantastic therapy that can be used for symptom control or to prevent long-term health changes.

It is not something that all women must have.

It is not magic.

The basics of diet and lifestyle and a good microbiome still need to be present to round out better longevity for all of us, regardless of whether we choose HRT or not.