It is one of the most widely-used medicines and yet it is also one of the most controversial. HRT (Hormone Replacement Therapy) is prescribed to women who suffer from menopausal symptoms. The principle is simple: the woman gradually stops producing the female hormones (oestrogen and progesterone), normally around the age of 50. The HRT is basically a synthetically made hormone to replace the natural hormones that are no longer produced by the body.
In reality, it is a bit more complex than that as there are different hormones and different HRT prescriptions, but this is the general principle: the body won’t supply any more, and that causes symptoms. So, logically, the solution is taking these hormones as medicine. On the face of it this sounds like a perfect solution, so why it is so controversial? After all, this type of treatment is used with other hormonal insufficiency conditions like Hypothyroidism, Diabetes and Addison disease. I have never heard controversy regarding those treatments. In fact, they are all considered to be a great success of modern medicine. So how come the HRT issue is almost constantly in the media in one form of debate or another?
The uniqueness of Hormone Replacement Therapy
The HRT is unique in a few ways. Firstly, every woman will go through the menopause in certain stages. The majority will experience some symptoms and are very likely to be offered HRT by the Doctor. Secondly, menopause in a way is a natural part of growing old. In the case of Hypothyroidism or Diabetes (Type 1) the hormone gland is attacked and destroyed by our Immune system, and, in these cases, there is clearly a disease that needs treating. Is the menopause a disease? Or is it just part of getting old? Does it matter at all if it is a “real” disease? My instinctive answer to this one is: of course not. If someone is suffering from symptoms, they deserve to be treated. However, there is another aspect here. As we know, medical treatment is not perfect. There are almost always unintended consequences, side effects and long-term risks. Does the fact that we are attempting to change a pattern of a body function, that has developed in women over millions of years of evolution, by giving them HRT create a bigger risk? I set to find out.
Is HRT a risk?
Looking at the general literature available regarding the HRT treatment benefits and risks was frustrating. The usual picture of mixed and contradicting studies became obvious almost from first look. This very common pattern in modern medical research was one of the main things that put me off modern medicine in the first place. For example, how is it possible that six large, well-designed, modern studies show that HRT use increases the risk for cardiovascular diseases whilst four other studies of the same calibre showed completely the opposite? This phenomenon is almost the norm in modern medicine and is completely accepted with no questions asked. So, what is going on? How can it be explained?
I think these contradictions are a result of subtle differences in the way these studies are designed. Examples include: the wording of the questions asked, which patients are included and which ones excluded from the study, which aspect of the problem is being examined and so on. Whatever it is, it has become clear that even with the strict standards of medical research today it is still possible to design a study in a way that will affect the results (probably to suit the needs and desires of the persons conducting the study). Considering pharmaceutical companies are behind the great majority of modern medical research it doesn’t take a genius to see the problem.
Allow me to present an example: the group of medicines for reducing cholesterol (statins) are a massive best-seller. The Doctor likes it as it claimed to reduce the risk of strokes and heart problems. However, it became apparent quite quickly that the use of this medicine carried a potential side effect of weakness and pain in the limbs. A few studies have followed and confirm this observation. The Pharma company which owns the statins brand, on seeing their best seller potentially going down the drain, has sprung into action and hurried to recruit some big names in the medical research world and bankrolled a big study on the issue. In this particular study, patients who complained of aches and/or weakness of the limbs following the use of statins were only included in the statistics if they also had an elevated level of muscle enzymes in the blood! Sure enough, the study concluded that statins do not cause those particular symptoms in any meaningful quantity. These results paraded across the media for a few days, and everyone was reassured. People don’t tend to read the details, but I do!
This example demonstrates a trend: a new drug arrives; initial short-term studies are very positive. The drug becomes a best seller. After ten, fifteen, twenty years of use, review studies observe that there are a lot of problems and side effects and then a third wave of research comes to contradict these findings and to reassure the doctors and the patients. A very similar pattern happened with HRT.
A brief history of Hormone Replacement Therapy
Let’s look at some history: surprisingly HRT was discovered in the 1930s, by a Canadian researcher called James Bertram Collip, who managed to extract some oestrogen from pregnant women’s urine. It started to be used more extensively during the 60s and 70s and very quickly became a hit. Sadly, I am old enough to remember talks about this new wonderdrug which would restore your youth and heal all your symptoms. It claimed not just to cure the menopausal symptoms but also to make you feel young again and to protect you from deadly diseases like cancer, heart attacks and strokes! What a wonderful thing. Naturally, millions of women around the world started to use it.
Around the 1990s a new method of research – review studies – had started to emerge. Review studies examine all the studies and available data regarding certain issues and synthesise them together into one super-study. It is a reasonable way to bypass all sorts of bias in medical research and very quickly it became the gold standard of medical research. The first review studies on the use of HRT were not a comfortable read. They found that the great majority of the initial claims regarding the benefits of HRT use were not just wrong but were, in reality, the complete opposite. They found that long-term HRT use actually increases the risk for heart attacks, strokes and many types of cancers. These findings sent a shockwave through the medical world. The problem was two-fold. Firstly the realization that, yet again, the modern medical world, in its haste to endorse positive short-term studies, has probably caused the premature death of many tens of thousands of women. Secondly, what were they going to do now? HRT is the only treatment available (in western medicine) for menopause symptoms. What should be the advice to the millions of women around the world who use it? It will sound a bit lame to say: sorry, but we were poisoning you for years, you have to stop now, with the probable consequences of your sweats and mood swings coming back. Can you imagine that?
What followed was a change in attitude toward HRT treatment. Doctors became much more careful before prescribing it and also tried to limit the duration of the course of treatment. Another thing that happened following that study is similar to what happened in the case of statins. Pharmaceutical companies started to arrange new studies which they hoped would contradict the later findings which – as you can imagine – were threatening to cause big losses for the HRT manufacturer. Sure enough, within a few years those started to arrive.
It has to be said that the stark difference between the conclusions of the original review study which found increased risk and those recent ones which generally conclude that there isn’t one, is not only due to the reasons I mentioned earlier when discussing the statins study. Some of the reasons are probably genuine. For example: over the years a new preparation of that became available; another is the fact that it has been prescribed for shorter periods. The problem remains: how do we know? Can we trust these studies? Or the biggest question of all, is taking HRT safe?
In light of the confusion and mixed messages one faces when trying to get to the bottom of the HRT dilemma, I wouldn’t like to join the general crowd by giving you another non-committal and confusing answer. When I face a situation like this, I employ the acid test: I ask myself would I take the treatment myself – or in this case would I give it to my wife or daughter? The answer has to be, absolutely not if I can help it. By that I mean I will try healthier alternatives first. I will only use HRT if the symptoms are severe, and all other treatments have failed.
Are there effective alternative HRT treatments available?
The answer is a resounding yes. Herbal medicine supplements, Acupuncture and lifestyle changes can all be useful. Naturally, I am going to focus on the Chinese medicine answers to the hot sweats, dryness, mood swings and all the other menopausal symptoms.
The big difference between the Traditional Chinese Medicine (TCM) approach and the Modern Medicine approach is that in TCM we are not trying to replace the Oestrogen. Instead we are looking to see what is the imbalance in the woman’s body that has been caused by the change, and then we treat this imbalance to allow the body to go back to normal function.
This approach has a few advantages: firstly, people are different and react differently to the change in hormones. Different women will suffer from a different combination of symptoms. In TCM we can tailor the treatment to the woman according to her individual set of symptoms caused by her constitution’s individual response to the change. Secondly, after we have successfully treated the imbalance we can stop the treatment and the symptoms won’t come back. If we have done a good job then the body at that stage will be back to its normal function. That is not always the case with HRT. Often, when the hormone supply to the body is stopped the symptoms will return!
How does the Traditional Chinese Medicine treatment work?
According to Chinese Medicine, the most common imbalance caused through the menopause is a big drop in the kidneys’ energy, particularly in the Yin aspect of it. This means that there is a strong reduction in the ability of the body to keep us cool and moist, resulting in overheating, hot flushes and dryness. Anxiety and sleep problems may also be present as the Yin energy – on top of keeping us cool and moist – also keeps us calm. The TCM approach in this situation is to restore the balance by using Herbs and Acupuncture points which strengthen the body Yin energy and some which reduce the heat that has already formed in the body due to the lack of Yin. Simple, yet extremely effective.
Other imbalances are possible. If the liver is involved, then mood swings and irritability will often be present. If Qi (the body energy) deficiency is present then fatigue, tiredness, and inability to think properly may be common symptoms. As we mentioned earlier, different women will present with different imbalances and all the TCM Practitioner has to do is identify the imbalance and then prescribe the Herbs and/or Acupuncture points to correct the imbalance and help the body to go back into healthy working order.
I cannot claim that TCM treatment will work for each and every woman suffering with menopausal symptoms, but the success rate is very high, and most importantly there are no dangerous side-effects in sight.
Wrapping up
The dilemma regarding the use of HRT for menopause symptoms will face most women at a certain stage of their life. It is a personal decision according to each individual’s circumstances. However, it is important to be in grasp of the facts in order to make the right decision.
Trying to find the facts has proven to be not so simple. Many contradictory studies and data make it a bit hard to be conclusive. The current official line is that while HRT may increase the risk for some conditions (e.g. Thromboembolism, Breast and Endometrial Cancer), it also reduces the risk for others (e.g. Bowel Cancer, Cardiovascular Diseases and Osteoporosis) and is therefore, overall, considered safe. However, a deeper look into the studies made me very uneasy with this conclusion. Despite significant efforts by the medical science establishment to eliminate all biases they have failed to do so regarding a) the psychological need of the medical establishment to justify itself; and b) the urgent need of the pharmaceutical industry to be profitable. Are these two things the reason for the mess? I can’t be sure, but what is clear is that, at the moment, a woman using HRT cannot be sure of the level of safety regarding her future health.
Considering that, and the fact that there are very effective and safe alternatives to HRT use, I am strongly recommending every woman who is facing this dilemma to try alternatives first.
Best of Health,
Dr Ilan Shahor