A lot of the confusion and negative publicity about HRT stems from research published in 2002/2003, which scared millions of women off the treatment. The Women’s Health Initiative (WHI) in the USA and the Million Women Study in the UK in 2003 both raised concerns about HRT’s safety. These centred on an increased risk of breast cancer with combined progestogen and oestrogen HRT, and blood clots, raising the risk of stroke and heart attack. The WHI trial was even halted early, so great were the risks thought to be. 

“GPs were told by the Medicines and Healthcare Regulatory products Agency (the UK’s drugs safety watchdog) that they should take patients off HRT because of the higher risk of breast cancer and clots, and we had to listen to that,” explained Dr Arif. “It made a lot of doctors scared to prescribe it and if they did, warnings would flash up on their computer screens. But the data was never easy to decipher or that clear cut.” 

Later analyses of the studies showed that both were flawed: they weren’t double blinded (so people knew what they were taking), and the studies were done in older women in their 60s and didn’t consider the background risks that older women have of clots and breast cancer due to their age, said Dr Arif. 

“Neither did they consider other risk factors such as smoking, drinking alcohol, family history and being obese. For example, having a BMI of 32 gives you a 50 percent increased risk of breast cancer, and all women have a background risk of 1 in 8 for developing breast cancer during their lifetime, but this wasn’t considered, and any cases of breast cancer or clots were just blamed on HRT. By then the damage was done and a massive panic had been created.” 

Dr Arif said another source of confusion is people wrongly believe that HRT uses the same artificial hormones as the combined contraceptive pill (with its association with increased risk of blood clots) which suppresses hormone release to prevent pregnancy.  

Publication of the NICE Guideline on Menopause in 2015 was a real turning point though, as the independent body analysed all the evidence and came out with clear advice that said HRT is safe if given transdermally (through the skin) and started before the age of 60. “This has given doctors confidence to prescribe it again,” said Dr Arif. 

HRT has also moved on in the last twenty years. Older studies are based on HRT which used artificial hormones and chemicals in its formulation, but newer types, such as body identical hormones, are made from yams and root vegetables. There are natural, and can be given through the skin as a gel, patch or spray. “Studies have shown that, with this type of HRT, your background risk of breast cancer or clots does not increase,” explained Dr Arif. “If HRT is given through the skin, it doesn’t go into the bloodstream or fat cells and doesn’t go into the liver and affect clotting.’” 

Oestrogen HRT can also be delivered vaginally, and this has a localised effect, treating vaginal atrophy (where the skin of the vagina becomes dry and shrinks) and it also doesn’t raise the risk of breast cancer and strokes. 

“Even with oral HRT the risk is very small, and I still prescribe it to some patients after careful counselling with them about the risks v benefits as I would with any medication.”