The Economist 14Dec2019

52 International The EconomistDecember 14th 2019

2 popular. In America before 2001 some 20%

of post-menopausal women used it at

some point. By then a synthetic form of

progesterone was being administered

alongside oestrogen; it had been shown to

protect women from an increased risk of

uterine cancer caused by giving oestrogen

on its own.

The benefits of hrtseemed clear. Most

immediately, it offered relief from the mis-

erable symptoms of menopause. In the

longer term it reduced the risk of osteopo-

rosis (which rises after menopause) and

therefore the risk of bone fractures. Wom-

en liked that it seemed to stop their skin

thinning (probably because it boosts the

levels of collagen, a protein). It was thought

to reduce the risk of cognitive decline. But

most importantly, studies suggested that it

prevented the onset of cardiovascular dis-

ease—one of the biggest killers of women.

The great hormone scare

By 1997 a report in the Journal of the Ameri-

can Medical Associationconcluded that hrt

extended life expectancy for post-

menopausal women by as much as three

years. It had become a standard treatment.

But then a bombshell dropped.

In 2002 the results of a large random-

ised trial conducted by America’s National

Institutes of Health, known as the Wom-

en’s Health Initiative (whi), were rushed

into publication. It concluded that taking

oestrogen with synthetic progesterone in-

creased women’s risk of breast cancer,

heart attacks, strokes and blood clots.

Women were told that the dangers of hrt

mostly outweighed any benefits.

This finding overturned decades of

medical practice. As a final kicker, it

emerged that Mr Wilson had received mon-

ey from Wyeth-Ayerst, a company that

made oestrogen, while writing his pro-

hormone book. hrtwent from wonder-

drug to killer pill peddled by profit-hungry

pharmaceutical firms. Within six years

fewer than 5% of American post-meno-

pausal women were taking it. In Western

countries use of hrtincreased rapidly dur-

ing the 1990s but halved in the early 2000s.

To this day doctors are reluctant to pre-

scribe hormones to their patients.

But the first conclusions of the whi

study, on which so much antipathy to hrt

is still based, were almost entirely wrong.

The study had hoped to look at strategies

for preventing heart disease, cancer and

osteoporosis in post-menopausal women.

Avrum Bluming, an oncologist and co-au-

thor of a recent book, “Oestrogen Matters”,

says that instead of recruiting healthy

women in their late 40s and early 50s, who

were entering menopause, the median age

was 63. These older recruits were already

unhealthy. Half were obese. Nearly 50%

were current or past smokers and more

than a third had been treated for high blood

pressure. The women included in the study

probably suffered from atherosclerosis—

where plaque builds up inside arteries and

makes heart disease more likely—when it

began, says Mr Bluming. What the analysis

in 2002 actually showed was that offering

older and more unhealthy women hrtwas

a bad idea. It said nothing about the women

at whom the treatment was aimed.

There were other problems. The whi

study almost completely excluded from

the trial women who were experiencing

menopausal symptoms, fearing that those

given the placebo would abandon the trial

when their symptoms were not relieved.

But these are the women who would be ex-

pected to benefit most from the preventive

effects of hrt. Recent research suggests

that hot flushes and night sweats are asso-

ciated with an increased risk of heart attack

and stroke.

It is now clear that the long-term bene-

fits of hrtfor women given it as they enter

menopause are significant. A careful re-

analysis of the studies showed that women

in their 50s were actually 31% less likely to

die in the five to seven years that they were

taking hormones. For women who have

had their uterus removed or who start

menopause before the age of 45, it is life-

saving, preventing osteoporosis and heart

disease for as long as 18 years. There is a tiny

increase in the rates of breast cancer

among hrt-users after five years of the

treatment. This was lower than the risk

from working as a flight attendant.

A study published in the Lancet, a Brit-

ish medical journal, earlier this year has re-

ignited controversy over the level of risk of

breast cancer that comes with hormone

therapy. But Ms Davis and others worry that

its conclusions are not reliable. Moreover

any increase in risk must be weighed

against that of developing other diseases.

Taking hrt reduces the mortality of

women aged 50-59 by at least 20% and as

much as 40%, mostly because they suffer

fewer heart attacks. One in 25 of all women

will die of breast cancer; one in three will

die of coronary heart disease; and one in

six will die of a stroke. Around 90% of

women with breast cancer survive it in rich

countries. If women are on hrtat the time

of their breast-cancer diagnosis they are

less likely to die from the disease. Weigh-

ing such risks is part of the decision about

whether to embark on a course of hrt.

In addition to the flaws in the structure

of the whistudy, a change in the versions

of hormones used in hrt explains the

shifting scientific consensus on the treat-

ment’s effects. The synthetic form of pro-

gesterone used in the whiprobably trig-

gered cardiovascular problems. The

progesterone that many women now take

with an oestrogen supplement is thought

less likely to do so.

No long-term clinical trials of this spe-

cific combination of hormones have been

carried out. But, in theory, it should bring

all the benefits of oestrogen found in the

whitrial, with none of the risks of taking

synthetic progesterone.

In the absence of such studies, hrtre-

mains in medical limbo. And so women in

their late 40s and early 50s are losing out.

The window of opportunity to begin hrtin

order to capture its full benefits—includ-

ing resisting the effects of cognitive de-

cline—may be as little as two or three years.

Lucy’s symptoms worsened after her

doctor brushed her off. Convinced by her

online research that she was transitioning

into menopause, she paid to have blood

tested. The results confirmed her suspi-

cions that her hormone levels were the

problem. She was prescribed personalised

amounts of three hormones: an oestrogen

patch, micronised progesterone and tes-

tosterone. Within three days her hot

flushes had stopped, she was sleeping

peacefully and her mood had returned to a

happy equilibrium. She felt “superhuman”.

But her happy ending is less common

than it should be. In Britain more than 1m

women are thought to be missing out on

treatment. Elsewhere, the prevalence of

hrtis even lower. In Hungary and Russia

just 3% of menopausal women receive it. In

the absence of prescribed hormone thera-

py, some women turn to natural potions

which may alleviate the symptoms of

menopause but will not reduce a woman’s

future risk of a heart attack. Some types of

black cohosh, a popular herbal supple-

ment, have been associated with liver poi-

soning. In countries such as China, Japan

and Singapore, Chinese traditional medi-

cines are used. A diet rich in phytoestro-

gens, such as soya, may reduce the symp-

toms of menopause. This may explain why

East Asian women suffer less. But nothing

works as well as hrt. By shunning it, some

women are harming themselves. 7