Menopause and HRT - The Robert Frew Perspective and Policy
HRT has recently been a subject of media frenzy, and sometimes misleading media statements have caused difficult consultations. The following outline the Robert Frew approach and policy
The Clinical Facts
HRT is licensed to treat menopausal symptoms, and in some cases prevent complications that can arise because of prolonged oestrogen deficiency especially in women with premature menopause or ovarian failure.
Not all women have menopausal symptoms of hot flushes, mood instability, vaginal dryness, and other symptoms associated with menopause. Some women continue to produce low level of oestrogens from adipose tissue (fat in the body) not to suffer from menopausal symptoms. The prevalence of menopausal symptoms is about 75% in the first 2years of menopause and then lessen after this might only be needed for the first 2-4years of menopause. Most study do not show clinical benefits after the age of 60years.
Clinical Benefits of HRT
Relief of vasomotor symptoms of hot flushes, most beneficial during the first few years after menopause or in patients with premenopausal flushes.
Relief of uro-genital atrophy of vaginal dryness and urinary symptoms, these are best treated with low dose oestrogen vaginal pessaries.
Osteoporosis – prevention of osteoporosis particularly in women with early menopause- but there are non-hormonal treatments of exercise, including diet, vitamin and mineral supplement.
Risks
There is overwhelming evidence that the use of HRT increases the risk of breast cancer, especially in susceptible individuals. In one study, HRT was associated with a 10% higher risk for each 5years of use. It follows that the longer the usage, the higher the risk of exposure.
Oestrogen increases the risk of thrombo-embolic phenomenon of Deep Vein Thrombosis, Pulmonary embolism, because oestrogen increases the production of coagulation factors in the liver. That risk can be ameliorated by using transdermal patches, but people with defined risk of coagulation disorders should nor be on HRT.
The Women’s Health Initiative Memory Study worryingly concluded that HRT (oestrogen-progesterone therapy) increased the risk for probable dementia in postmenopausal women taking HRT over the age of 65yrs, although other studies have suggested cognitive benefits in women who take HRT in their 50s.
Who Should We treat and for how long?
The Robert Frew Policy. The policy has been collated based on existing research and guidelines.
We do prescribe HRT for premenopausal and postmenopausal symptoms for relief of symptoms, and prevention of long-term complications who have no contraindications to HRT.
The decision to treat is a clinical one, based on individual assessment of risks and benefits.
We will not prescribe HRT for any patient with clinical risks, and in whom prescribing HRT posed an obvious health risk. It is not acceptable for anyone to disrupt a consultation because of an opinion honestly held. If a patient does not agree with a clinical decision, the correct thing is to seek a second opinion.
We have no obligation to honour prescriptions obtained from private consultations, unless we judge that the prescribing is rational and conform to practice policy. There is no obligation to turn a private prescription to NHS prescription to avoid the cost of prescribing, although in most cases that will be done so long as it accords with NHS medicine management policy, and practice policy.
It is practice policy not to prescribe HRT beyond the age of 65years, except in exceptional circumstance. This is because there is no evidence that taking HRT beyond the age of 65yrs has clinical beneficial effects, but more worryingly the indication is that the risks outweigh the benefits.
We do not put HRT on repeat prescriptions because there is an obligation for drug monitoring. We do prescribe for 6months at a time, and there is a need for a review before the expiry of symptoms.
In conclusion, I hope we can work together to provide the care that women need during this change of life.