Is HRT for me?

Subject Expert: Professor Charles Kingsland

I have been specialising in medical disorders associated with the menopause for over thirty years and I still remain staggered by the amount of misinformation that surrounds this very common and poorly understood disorder.

A lot of what we hear about this syndrome is based on our own opinions which have been formed by our beliefs, biases and then shaped further by information we have gathered from all sources, be they Doctors, Nutritionists, health food shops, news paper articles and the like.

What I am going to try and do in this article is to give you some basic facts about the menopause on which you can base your own conclusions and what you want to do about it.

The major reason why there are so many opinions about the menopause is that it is a new disease. It’s only been common for about a hundred years, or  three generations and that’s not a long time in the history of human evolution which has been going on for much much longer.

This is because in the last hundred years, womens’ lives have changed more dramatically than in the previous 40,000.

Let’s go back, say one hundred years, which again, is not a long time in evolutionary terms. In 1900, the average age of a woman having her first period, the so called menarche was 18 years. In 2018 in the United Kingdom it was 11. The big change has been brought about by improvements in general nutrition and health care which means that girls are now more fertile at a younger age.

The average age of a woman having her first child one hundred years ago was 19, less than one year after her first period. Today the average age of a female having her first child in Great Britain is 31.

One hundred years ago, the average life expectancy was 45 years. Today a female is expected to live, on average, 82 years, that’s six years longer than a male, although one of my colleagues claims that women don’t live longer, they just take longer to die.

So, one hundred years ago, the average female had her first period when she was 18 and her first baby when she was 19. She then spent the next thirty years or so, having babies, breastfeeding, miscarrying, having stillbirths, getting chronic anaemia, contracting tuberculosis and dying at the age of 45.

Two things a woman never suffered one hundred years ago; firstly she never had a period, so no premenstrual tension. Secondly, she never suffered from menopausal symptoms as she was dead. Women who did survive into old age were seen as old crones.

We’ve come a long way!

This is one of the reasons why disorders such as PMT and menopause are still so poorly understood, simply because they are modern medical disorders which have not yet fully established themselves into society or medicine for that matter and because they are not seen as fatal and are ostensibly ‘womens disorders’ they are treated just that little bit differently to proper diseases.

As our standards of medicine, nutrition and general health have improved, so has our life expectancy.

Then, about a hundred years ago, one thing changed which altered planet earth forever. Women learnt how to control their fertility. Up until then, women had no choice but to reproduce. Once they learnt how to control their fertility, choices became available. They got educated, got a vote, went to university and who knows, one day might even see a female Prime Minister.

The world opened up for women but with it society expected more from these liberated beings. Up until then, society expected very little from women except the necessity for them to have babies and nurture them. Now we expect everything from women, with the results that women, out of necessity delay their family, hence the need to delay having babies until their thirties.

But because women are fitter, healthier and better educated, they live much longer, longer than males, because their superior physiology allows them to. Women have better hearts than us males; their physiology has to be better, how else could they have babies? Males couldn’t, we simply couldn’t cope with the added stress to our bodies.

Yes! I love my superpowers!

Take a bow……oestrogen

The massive design fault in the female body, however, is that ovaries only live for 50 years. They have a store of fifty years worth of eggs. But with eggs comes that magic ingredient; the world’s most powerful natural anabolic steroid, the drug that makes females who they are, the magical hormone that allows women to grow babies, that makes their hearts beat slower and stronger than males, that gives them brain power to multitask, the hormone that makes women so attractive to the opposite sex. Take a bow…. Oestrogen.

Oestrogen is present by the bucketful in a woman’s early life but as she ages, so too does the output of oestrogen from her ovary; from the cells right next to the eggs. By the time a woman reaches her early forties, her oestrogen supply is on the way out and so too are her superpowers; she has difficulty sleeping, she gets hot and sweaty and she occasionally gets flushing particularly of her face. She gets a bit tired and the tasks she could perform with one eye closed earlier in life, she finds a bit more difficult. Her vagina goes a bit dry and sex becomes a little more difficult.

She sees her children grow and become less dependent on her and her husband becomes fat, less interesting and less interested. At just a time in her life when she needs her oestrogen the most, her ovaries are beginning to fail.

She goes to see her Doctor, who tells her she’s depressed or it’s the change of life, nothing more and she must face it with stoicism, because to give her oestrogen would be the kiss of death because she would die a death most horrid from breast cancer.

That amazing compound that has kept you happy, healthy, fertile, and attractive to yourself and others has now become a poison. A poison of such profound toxicity that to ask for it would result in instant death.

We try and replicate it. Health food shops sell all sorts of potions that purport to offer the same benefits as the real thing but with none of the side effects. They are all reassuringly expensive and have lots of fancy names often extracted from delicate flowers that grow by babbling brooks coursing through verdant meadows.

They even make bread with oestrogen infused into it. Yet nothing comes close to the real thing.

Other organs in our bodies such as liver, lungs, hearts last us a lifetime. Ovaries, however only live for 50 years. They lasted a lifetime one hundred years ago but not now. Maybe in a million years or so, ovaries will have caught up with the massive evolutionary changes that have affected women over the last three generations.

So, at the moment, women outlive their ovarian function. If another gland in our bodies failed, for example the thyroid gland and the female presented with symptoms associated with an underachieving thyroid gland, we would take an entirely different view of the situation and replace the thyroid hormone as a matter of urgency.

Why then, is the ovary so much different to other glands in the body and why is it that we view oestrogen so differently to other hormones such as thyroxine, adrenaline, prolactin and in the male, testosterone? I go back to our own prejudices, beliefs and bias and the fact that somehow, oestrogen is all tied up with having babies and femininity. The issue is that oestrogen does so much more than these basic functions. There are, in fact, oestrogen receptors all over a female’s body. Oestrogen thickens bone and keeps it healthy. Did you know that for every year a woman is without oestrogen, she loses one per cent of her bone mass? So by the time she reaches seventy, she’s lost up to twenty per cent. It’s around this time that a woman’s bones start to break, the hip and wrist in particular.

Did you also know that 50% of women who fracture their hip will be dead within eighteen months? The brain is also laden with receptors and as oestrogen is essentially a happy drug, it keeps women happy, healthy and, well, feminine. It keeps the vagina moist and although oestrogen is not directly associated with libido in the female, if you feel good about yourself, you are more likely to have a positive attitude towards sex.

If you feel good about yourself, you are more likely to have a positive attitude towards sex

I often see women in their thirties who end up in my clinic having been told that they are depressed. They have been prescribed antidepressants. They feel a bit under the weather, can’t be bothered, life is a chore, the kids are getting them down. In a large proportion of them, when you measure their circulating oestrogen levels you find that their ovaries are in fact failing, causing their symptoms. This is often the case also when women present with period problems around the same time. They are experiencing fluctuating oestrogen production from the ovary, hence, the irregular or heavy periods.

Why is it that we therefore have such a strange view of the menopause? There are a number of reasons.  Firstly, as I demonstrated earlier, the disorder is a relatively recent phenomenon and as such, medicine and society are still coming to terms with the condition. Secondly, the menopause is a ‘woman’s problem’ and it’s related to ovaries, babies etc and, as it affects all women who reach that age, to varying degrees, it is somehow seen as a condition that all women should accept and face with stoicism.

Just imagine if men’s testicles failed when they reached the age of fifty with all the attendant symptoms of weakness, lethargy, hot flushes and sweating. What would happen? I suspect you would be able to buy testosterone over the counter at your local newsagents!

Why is it then that we fear oestrogen so much?

Just imagine if men’s testicles failed when they reached the age of fifty ………….I suspect you would be able to buy Testosterone over the counter at your local newsagents!

Oestrogen replacement has been around since the mid 1930’s and has been clearly demonstrated to alleviate symptoms associated with the loss of oestrogen. It has been demonstrated to lengthen women’s lives; some who take oestrogen live on average six years longer than women who don’t. We are not sure whether this is cause and effect or whether it’s just because women who take Hormone Replacement Therapy ‘HRT’ are healthier anyway, less likely to smoke or be obese or just visit their doctor more often.

One of the major reasons why HRT gets such bad press is that we think it gives you breast cancer. I saw a fairly poor programme recently on television where a famous celebrity personality was telling the viewers that she stopped taking HRT as, like many of her friends, had developed breast cancer whilst on it and this was probably the cause. Yet there she was, clearly demonstrating three far greater risk factors to developing breast cancer than HRT itself, namely being a female, being older and being obese. These are three highly significant risk factors to developing the disease.

Also it seems perfectly acceptable for a woman to die from dementia, a fractured hip and its attendant immobility, heart disease but whatever happens, she must not die from Breast Cancer. She is allowed to suffer all those quality of life issues that can so badly affect women as they mature but she must not take oestrogen as it can cause breast cancer.

Because women have been blessed with oestrogen in their early life, their hearts are so much stronger, so as they age, bits start to fall off but as in the old “my heart will go on’. Men, on the other hand, do not have the benefit of oestrogen in early life so their bits wear out quicker. Without oestrogen, women’s degeneration is that bit slower than men’s, they go more wrinkly, more stooped when they walk and a bit more dotty as their brain slowly fails.

So, what are the risk factors to developing breast cancer? First and foremost, being female.

So what are the risk factors to developing breast cancer? First and foremost, being female. You are one hundred times more likely to develop breast cancer than if you are male.

Secondly, being overweight increases your risk enormously.

Thirdly, getting older; as you age, so does your risk of getting cancer.

Fourthly, smoking. Women who smoke are far more likely to die a horrible death than those who don’t.

Fifth, women who breast feed their children reduce their risk of developing breast disease and finally, and this is the factor I always stress to my patients, the best thing a woman can do is to pick her mother as carefully as possible as one day she may end up like her. Some diseases have a tendency to run in families, breast cancer being one of them.

Finally, I want to give you some facts about replacing oestrogen when your ovaries fail.

Oestrogen is beneficial to all parts of your body with the exception of two organs, the breast and the lining of the womb, the endometrium.

Studies have shown that if you take oestrogen for more than five years over the age of fifty, you increase your risk of developing breast cancer from 15 to 19 in 1000, ie one chance in 250. But, and here is the big but, you do not increase your risk of dying from breast cancer. No scientific  study has ever demonstrated an increased likelihood of dying from breast cancer when you take HRT. This means therefore that if you do get the disease after taking HRT for more than five years over the age of fifty, it’s either a milder form or it’s simply detected earlier by the patient.

Two studies in the USA at the turn of the century did HRT a great disservice. They demonstrated an increase in Breast Cancer and deaths from heart disease in HRT takers and as a consequence there was huge negative publicity. The trials were abandoned early. The popular press gorged on the HRT cancer story for years with the result that fewer practitioners were willing to prescribe HRT and fewer women were wanting to take it. There were huge numbers of ‘told you so’ stories that almost killed off HRT altogether.

However, in the intervening years, those studies have clearly been demonstrated to be flawed and were abandoned too early before the full results were available, a fundamental error when performing scientific studies. The researchers had got the results they wanted and so stopped the studies when if they had carried on, would have found a much different outcome.

These errors have caused a great deal of unnecessary suffering, morbidity and mortality in women. Crucially, studies in the under fifties have demonstrated overwhelming benefits to women taking HRT.

Long term oestrogen therapy is also not good for the endometrium. Earlier in life, oestrogen is necessary to thicken the endometrium in order to prepare it to receive a developing embryo. Long term use can cause it to overgrow which in some cases can lead to abnormalities and eventual malignant change.

This can be easily remedied in women with an intact uterus taking oestrogen by adding in progesterone to their HRT preparation. There is a draw back to taking the hormone progesterone however. Whereas oestrogen is a happy drug, progesterone on the other hand is the drug of misery. In some patients it can cause irritability and water retention and is sometimes viewed as an unnecessary evil. It does, no doubt, protect the endometrium from harm and only needs to be taken for a short while. There are also different preparations that minimise the side effects.

When progesterone was first discovered in 1926, it was described as the hormone that was God’s punishment to women for not being pregnant. Just imagine, that quote is only one hundred years old and was, needless to say, written by a male.

However, it was a woman, a very prominent woman who once stated that HRT was a drug devised by men to be given to females so they maintain their femininity so that men…… wait for it…… can continue to dominate them! Really? In 2019, is that why women want to maintain their femininity? I don’t think so.

It’s time for us as a society in general to look at Menopause in a different way. It affects different women in different ways and just because all women who live that long get it, doesn’t mean to say it is somehow normal. It is not normal in this day and age to suffer in the menopause. That’s a bit like saying the only reason women are put on the planet is to have babies, wean them and then snuff it when their usefulness has come to an end. If we extend that argument, one can debate why men are here. Is it just to fertilise a female’s eggs, hunt and gather food for their mate and offspring until they can lead an independent existence and then gradually recede into the background?

I’m sure that may have been the case when dinosaurs roamed the planet but we are not dinosaurs. We are sophisticated, highly developed human beings who enjoy a quality of life unthinkable just a few hundred years ago. To deprive mature women from that quality simply because we are suspicious of oestrogen, based on myths and legends, is simply barbaric.

Professor Charles Kingsland is an internationally renowned authority and well respected specialist in the field of reproductive medicine and in menopause management. He is a consultant in gynaecology and reproductive medicine at Liverpool Women’s Hospital and media spokesman for the Royal College of Obstetricians and Gynaecologists. He appears regularly on television and radio programmes.  A BBC documentary of his work in Liverpool was broadcast in 2014.

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