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To take HRT or not: what should we tell our patients?

Carol Clapham
RGN MSc BSc
Nurse Practitioner
The Health Station
Private Medical Clinic
Hitchin, Herts
Practice Nurse
Knebworth Surgery
Herts
Cardiology Specialist Nurse
E&N Herts NHS Trust

Women receive information regarding the menopause predominantly from the media - and mostly (76%) from women's magazines.(1) This can lead to unrealistic expectations of what HRT can provide. Women often choose not to take HRT for various reasons. The most cited factor is the dislike of having menses or erratic bleeds, while another major reason is fear of developing cancer.
Menopause is a natural event, and because of this many women avoid HRT.(2) Although women seem to have a basic understanding of the symptoms of the menopause, their knowledge of the long-term health risks is poor, and this may explain the low uptake.
Many women will stop taking HRT because they are not fully informed of what to expect. Over half of women said they had left healthcare appointments with unanswered questions about the menopause and HRT.(1) Compliance is affected by factors such as inadequate explanation of the advantages and disadvantages of HRT, lack of access to expert advice, and prescribing HRT to women who do not wish to take it. The uptake of HRT is much lower than the rate prescribed. HRT is often abandoned due to side-effects or lack of motivation, but it is also stopped due to fear of cancer. Approximately one-third of women started on HRT discontinue treatment, sometimes on the advice of physicians.(3) HRT is often prescribed to relieve symptoms rather than as a preventive measure, and is also often prescribed for a short time with many doctors reluctant to prescribe for older women.
Health professionals may be aware of some of the beneficial effects of HRT (see Table 1), but often have no time to inform their patients. A nurse counsellor can positively affect compliance rates and enable women to make informed choices about HRT and the management of the menopause.

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Coronary heart disease (CHD)
Epidemiological studies suggest that there is a decreased risk of CHD in healthy women taking HRT. The beneficial effects were present after one year of HRT use.(6) There is uncertainty regarding the validity of many studies as women who use HRT may represent a healthier cohort than those who reject it.(7)
The nurses' health study of nearly 60,000 women studied over more than 600,000 person-years and has shown a large decrease in the risk of major CHD among women taking HRT.(8) A meta-analysis has supported this evidence by stating that HRT reduces cardiovascular events by 30%.(9) The Heart and Estrogen/Progestin Replacement Study in the USA suggested that the risk of myocardial infarction increased by 50% in the first year of taking HRT but then decreased by 40% in the fourth and fifth years, leaving no overall benefit.(10)
Due to conflicting evidence on the effect of HRT and CHD, the American Heart Association (AHA) has warned against prescribing HRT for secondary prevention of heart disease. It recommends considering discontinuation of HRT and instituting prophylaxis for venous thrombosis in women who develop an acute coronary event while taking HRT.(11) The AHA stated that "initiation and continuation of HRT should be based on established non-coronary benefits and risks, possible coronary benefits and risks, and patient preference".(12)
 
Osteoporosis
HRT aids bone resorption and formation, preventing bone loss and possibly enhancing bone gain.(5) There is a significant reduction in osteoarthritis (OA) with long-term HRT, and five years or more use of HRT is associated with a 40% reduction in risk of OA of the hip.(13) Recent use of HRT is required for optimum fracture protection, and therapy can be started several years after the menopause. The protection against OA increases with the duration of use, and lower oestrogen doses can provide protection when progestogens are included.(14)

Breast cancer
Breast cancer is one of the main concerns of women considering HRT. Epidemiological evidence suggests that using HRT for five years translates to about two extra cases of breast cancer diagnosed per 1,000 women before the age of 70.(15) After 10 years this could mean an extra six cases, and for 15 years an extra 12 cases.(15) Any risk of breast cancer with HRT use should be viewed as a possibility but not a certainty. Health professionals have an ethical responsibility to advise women of the possible increased risk of breast cancer.(16) There is little evidence that HRT will increase the risk of breast cancer in those with a family history of breast cancer or with benign breast disease,(4) and current evidence suggests that HRT does not increase breast cancer mortality.(17)

Endometrial hyperplasia, cancer and bleeding
Abnormal vaginal bleeding is the most frequent reason for women discontinuing HRT. It occurs almost exclusively in premenopausal and perimenopausal women. In premenopausal women with a regular 28-day cycle it is important to start administration of progestogens on day 17 of the cycle (counting the first day of normal bleeding with the period as day 1), to coincide with endogenous production of progesterone.(18) Failure to do so will result in two bleeds each month - one due to ovarian function and the second due to exogenous administration of hormone.
Many drugs, including antibiotics, can cause irregular bleeding for women on HRT. Periods may cease with these drugs, probably because of increased oestrogen metabolism, which often leads to higher doses of oestrogen being needed to alleviate menopausal symptoms.(18)
Oestradiol implants release oestradiol for up to three- and-a-half years after insertion.(19) Implants can produce higher concentrations of plasma oestradiol than tablets or patches, and the risk of endometrial hyperplasia may be increased if the progestogen is not taken properly. This may explain why one study reported a 55% incidence of endometrial hyperplasia with oestrogen implants.(20)
Endometrial hyperplasia and cancer is more likely if unopposed oestrogen is given, so all women with a uterus should take HRT with progestogen to reduce the risk.(21) Remember to ask all patients experiencing abnormal bleeding with HRT if they are taking their progesterone. Hyperplasia is more likely when progestogen is given every three months in a sequential regimen compared with a monthly progestogen sequential regimen.(22)
One important step forward would be to introduce a technique for endometrial sampling into general practice, allowing earlier diagnosis of endometrial cancer and reassurance for women without serious pathology.(23)

Weight gain
Many women are concerned about weight gain. Evidence shows that HRT has no effect on body weight and does not cause extra weight gain in addition to that normally gained at menopause.(24)

Conclusion
Providing specialist information to women about HRT is a very valuable area for nurses in primary care, but it does require further training and support.

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References

  1. Clinkingbeard C, et al. Women's knowledge about menopause, hormone replacement therapy (HRT), and interactions with healthcare providers: an exploratory study. J Womens Health Gend Based Med 1999;8:1097-102.
  2. Toozs-Hobson P, Cardozo L. Controversies in the management of HRT? Universal prescription is ­desirable. BMJ 1996;313:350-1.
  3. Vihtamaki T, Savilahti R, Tuimala R. Why do postmenopausal women ­discontinue hormone replacement ­therapy? Maturitas 1999;33:99-105.
  4. Rozenberg S, Vandromme J, Kroll M, Vasquez JB. Managing the climacteric. Int J Fertil Women Med 1999;44:12-8.
  5. Rees M, Purdie D, editors. Management of the menopause: the ­handbook of the British Menopause Society. London: BMS Publications; 1999.
  6. Varas-Lorenzo C, et al. Hormone replacement therapy and incidence of acute myocardial infarction. Circulation 2000;101:2572-8.
  7. Rödström K, et al. Pre-existing risk factor profiles in users and non-users of hormone replacement therapy: prospective cohort study in Gothenburg, Sweden. BMJ 1999;319:890-3.
  8. Grodstein F, et al. Postmenopausal estrogen and progestin use and the risk of cardiovascular disease. N Engl J Med 1996;335:453-61.
  9. Seagroatt V. Impact of postmenopausal hormone therapy on ­cardiovascular events and cancer. BMJ 1997;315:676.
  10. Berger A. HRT may not protect against further heart attacks. BMJ 1998;317:556.
  11. Mosca L, et al. Hormone ­replacement therapy and cardiovascular disease. Circulation 2001;104:499-503.
  12. Josefson D. Heart association advises against HRT for heart protection. BMJ 2001;323:252.
  13. Dennison EM, et al. Hormone replacement therapy, other reproductive variables and symptomatic hip osteoarthritis in elderly white women: a case-control study. Br J Rheumatol 1998;37:1198-202.
  14. Michaëlsson K, et al. Hormone replacement therapy and risk of hip ­fracture: population based case-control study. BMJ 1998;316:1858-63.
  15. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and HRT. Lancet 1997;350:1047-59.
  16. Wise J. Hormone replacement ­therapy increases risk of breast cancer. BMJ 1997;315:967-72.
  17. McPherson K, Steel CM, Dixon JM. ABC of breast diseases. Breast cancer: epidemiology, risk factors and genetics. BMJ 2000;321:624-8.
  18. Spencer CP, et al. Management of abnormal bleeding in women receiving hormone therapy. BMJ 1997;315:37-42.
  19. Gangar K, et al. Symptoms of ­oestrogen deficiency associated with supraphysiological plasma oestradiol concentrations in women with oestradiol implants. BMJ 1989;299:601-2.
  20. Paterson MEL, et al. Endometrial disease after treatment with oestrogens and progestogens in the climacteric. BMJ 1980;280:822-4.
  21. Pike M, et al. Estrogen-progestin replacement therapy and endometrial cancer. J Natl Cancer Inst 1997;89:1110-6.
  22. Lethaby A, et al. Hormone ­replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev 2000;2:CD000402.
  23. Seamark CJ. Endometrial sampling in general practice. Br J Gen Pract 1998;48:1597-8.
  24. Norman RJ, et al. Oestrogen and progestogen hormone replacement ­therapy for peri-menopausal and post-menopausal women: weight and body fat distribution. Cochrane Database Syst Rev 2000;2:CD001018.
  25. Lawrence M, at al. Hormone replacement therapy: patterns of use studied through British general practice computerized records. Fam Pract 1999;16(4):335-42.

Resources
British Menopause Society
W:www.the-bms.org
The Women's Health Initiative
W:www.nhlbi.nih.gov/whi/index.html
Breast Cancer Care
W:www.breastcancercare.org.uk
National Osteoporosis Society online
W:www.nos.org.uk/