On menopause
Tags: Medicine, Menopause, Health

Where are we now? Go to the website of Cancer Research UK and you will be told: “The evidence that HRT can cause some types of cancer (breast, womb and ovarian) is strong.” Go to the British Menopause Society website and its fact sheets will tell you the risk of cancer is “small” (breast) or “not high in statistical terms” (ovarian). Go to your GP and anything could happen.

Hannah Short is a trainee GP who set up the website Menopause UK in frustration at the confusing, poor information available not only to women, but to medical professionals. “The menopause wasn’t in any of my textbooks,” she told me during the British Menopause Society conference coffee break. She’s heard of women going to one GP to be put on HRT, then going to another who takes them off it. She’s heard of one GP who said that women just need to pull themselves together. She told me of a nurse who had gone through a surgical menopause who was treated as a hypochondriac when she complained her oestradiol treatment wasn’t working.

Most patients who end up in Julie Ayres’ menopause clinic in Leeds arrive with preconceptions. “They say, ‘I know there’s a risk of breast cancer.’” But they’re so desperate, they come anyway. “They come with palpitations, anxiety and panic attacks and think they’re going crazy.” They’re not, but they are suffering from the wide-ranging power of oestrogen in the body. “As soon as they say they’re having palpitations,” says Ayres, “the GP won’t prescribe HRT because of the cardiac risk.”

This would infuriate some speakers at the British Menopause Society conference, where John Stevenson, a consultant metabolic physician at the Royal Brompton Hospital, presented research on the protective role that HRT can have on the heart. He is so convinced of the benefits he’s prepared to prescribe HRT, because, according to him, it is “probably the best treatment for postmenopausal women, [though] sadly only one cardiologist seems to know this… If women come to see me who are at risk, I ask them if they’ve had a hot flush so I can prescribe HRT,” he says. “If they say no, we turn the heating up.”

It’s a good joke, but he is deadly serious: “There is hard evidence of the protective effect of oestrogen for adverse cardiac events. There’s no firm proof that HRT causes breast cancer.” He is dismissive of the Women’s Health Initiative study (and was one of Samuel Shapiro’s coauthors on the series of critiques published in 2011). “They got the same dose of hormones no matter what age. Great for a 50-year-old, absolute poison for a 70-year-old. No-one in this room would do that.”

The Daily Mail, which recently published a powerful and useful series on the menopause, often runs articles about ‘bioidentical hormones’, also known as bespoke HRT. Yehudi Gordon runs a bioidentical hormone clinic in Harley Street. He is slender, tanned and looks 20 years younger than his 73 years, and he is evangelical about the benefits of bioidentical hormones.

They are better, he said when we met over coffee near his clinic, because the oestrogens are derived from plants such as yam and soy, and the progesterone is micronised (finely ground). Both these facts, he claims, mean bioidentical hormones are better processed by the human body than conventional preparations. He gives mea handout which explains further: the molecular structure of Premarin, it reads, “may bear some similarity to that of human hormones, [but] it has been altered”. Other “branded and patented HRT consists of synthetic hormones that have a different molecular profile to those produced in the body”.

With his bioidentical therapy, patients have blood taken and are prescribed a particular hormone combination according to their hormonal levels, which is made by a compounding pharmacy (one that can make up its own preparations). To listen to Gordon, you’d think he had found the holy grail.

It’s persuasive. I leave almost tempted to make an appointment, despite the hefty private fees and cost of treatment (though Gordon says the HRT, daily, costs little more than a cappuccino). But other menopause specialists are circumspect. The bespoke preparations are prepared by a compounding pharmacy, but as Heather Currie wrote in an issue of Menopause Matters, “there are currently no controls or regulations on the production, prescribing or dosing of bioidentical hormones”. In the USA, custom-compounded hormones, as they are known, are not regulated by the Food and Drug Administration.

“Bioidentical is just a brand,” says Nick Panay, a leading gynaecologist. “We can tailor HRT too: it’s the same stuff.” Julie Ayres has tested oestrogen levels in women taking ‘bespoke’ hormones and found them to be far too high. “We can try combinations of oestrogens and progesterone,” says Ayres. “We can prescribe bioidenticals. There are so many types of HRT. It’s great when we get it right. Women tell me they’ve got their life back. And I can’t tell you how often I’ve heard, ‘Thank you for taking me seriously.’”