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In 2002, a major study called the Women’s Health Initiative (WHI) found that HRT could increase the risk of breast cancer, heart disease, stroke, and blood clots.
This led the FDA to issue a strong safety warning, and as a result, far fewer women started using HRT.
However, more recent studies show that these risks don’t seem as big a factor as the WHI study initially reported, says Professor MC van Aardt , an obstetrician and gynaecologist (gynaecological oncology) at Mediclinic Kloof.
“The patients they tested back then were a bit older, and when you compare it to younger patients, you don’t see the same increase in the risk,” he explains. “It also shows that patients using oestrogen-only therapy don’t seem to have an increased risk of breast cancer, whereas patients using both oestrogen and progesterone – combined HRT – who have a uterus that is still intact, do have a slight increase in breast cancer risk.”
He adds that starting HRT within the first 10 years of menopause can bring significant health benefits, including protecting the heart and helping prevent dementia.
Ultimately, HRT is still an important treatment for menopause symptoms that seriously affect daily life. This makes the FDA’s decision to ease warnings significant. “It improves quality of life, so the patients feel better and they have more energy too,” says Professor van Aardt.
South Africa’s approach to HRT
South Africa generally follows FDA guidelines from the United States, but we also have our own regulatory body, Professor van Aardt explains. “We follow the newer HRT studies that say the risks are lower than initially reported. I don’t think black box warnings in our country have as much of an impact. While the warnings exist, we look at each patient individually and counsel them appropriately.”
Speaking from experience, he says most gynaecologists in South Africa prescribe HRT based on each woman’s individual needs. HRT is mainly used to ease hot flushes and to support bone health, which can decline with lower oestrogen and lead to osteoporosis.
“However, you can’t just say there’s one thing for everybody and everyone should be on HRT,” he emphasises. “The treatment depends on the type and severity of a woman’s menopausal symptoms.”
Weighing up HRT risks and benefits
Before starting any medication, patients should be fully informed about the potential risks and benefits. While no treatment is entirely risk-free, Professor van Aardt says the key lies in weighing those risks against the benefits for individuals. “For example, if you use combined HRT, there is perhaps a slight increased risk in breast cancer but if you compare some of the other advantages, there is a slight protective benefit for colon cancer.”
“You have to discuss it on a case-to-case basis,” he continues. For example, a patient with a strong family history of breast cancer may be less likely to use HRT because of concerns about the associated risks. “If you can manage those patient symptoms in a different way and they don't have that constant fear of getting breast cancer, that's also completely acceptable.” That said, patients’ preferences may differ and those with a family history may still choose to use HRT and will just be regularly screened.
Alternative treatment options
When treating a menopause patient, care is guided by the symptoms they’re experiencing. For example, if a patient has hot flushes and prefers not to use HRT, a low-dose antidepressant may be prescribed. This approach is commonly used for breast cancer survivors who experience frequent hot flushes.
“Patients who experience vaginal dryness or painful intercourse can be treated with local, topical oestrogen. This is not systemically absorbed and patients do quite well on it,” Professor van Aardt says.
There are also many natural products on the market, he adds, but because there are too few controlled studies to confirm their safety, these options are considered more experimental.