Whenever it’s given, the evidence suggests HRT does more harm than good

I remember when I was at medical school hormone replacement therapy was being positioned, it seemed, as a sort of magic elixir for women of a certain age. Part of the hype surrounding it centred on its supposed ability to not only ward off menopausal symptoms, but chronic conditions such as heart disease. But then some evidence started to emerge which linked HRT with an increased risk of heart disease. And other evidence linked HRT with an increased risk of certain cancers, notably breast cancer.

The real turning point for HRT came around 2002, on the publication of a study which identified the risks of HRT quite clearly, to the extent that the trial needed to be stopped early on the basis of the risks women were being subjected to by being on HRT – not just an increased risk of heart disease and breast cancer, but also an increased risk of stroke, and pulmonary embolism (from blood clots that form in the legs that travel to the lungs) [1]. The results of this study are thought to be a major factor in the steady decline in the prescription of HRT (and the concomitant decline in breast cancer rates in post-menopausal women too).

Now, not everyone has been so keen to desert this sinking ship. Some have suggested that HRT really is beneficial, it just has to be started early enough. The idea here is that starting HRT nice and early means treating women with low levels of atherosclerosis (the underlying pathological process in heart disease), whereas later treatment in women with more advanced disease is going to be too late or even make matters worse. So, while the disadvantages of HRT do generally seem to outweigh the advantages, it has been suggested that if treatment is started early enough, it’s the other way round.

It’s a neat theory, but is there any evidence for it?

Reading the British Medical Journal this morning I was made aware of a recent study which examined this hypothesis. The authors of this study re-assessed data from the women who took part in the seminal 2002 study. Principally, they assessed data regarding the long-term health of these women and the timing of HRT.

One of the findings of this study is that starting HRT early was associated with an increased risk of breast cancer, and an increased risk of cancer overall.

Early HRT was also associated with an increased risk of ‘venous thromboembolism’ (e.g. pulmonary embolism) and stroke, but a reduced risk of fracture of the hip.

The authors conclude that, These analyses provide little support for the hypothesis of favorable effects among women who initiate postmenopausal estrogen use soon after menopause, either for coronary heart disease or for health benefits versus risk indices considered.

An accompanying commentary [3] summarises the effect of early treatment with HRT thus:

1. Either it has no affect of coronary heart disease risk of makes it worse compared to later treatment

2. It increases stroke and venous thrombosis risk (just like later treatment)

3. It may pose even greater risks with regard to breast cancer

And, again, they conclude that the data do not support the hypothesis of favorable effects in women starting hormone therapy soon after menopause. Whether it’s started early or late, the evidence suggests that HRT does more harm than good.


1. Rossouw JE, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 2002;288(3):321-33.

2. Prentice RL, et al. Benefits and Risks of Postmenopausal Hormone Therapy When It Is Initiated Soon After Menopause. Am J Epidem 25 May 2009 [epub ahead of print publication]

3. Banks E, et al. Invited Commentary: Hormone Therapy Risks and Benefits”The Women’s Health Initiative Findings and the Postmenopausal Estrogen Timing Hypothesis. Am J Epidem 25 May 2009 [epub ahead of print publication]

19 Responses to Whenever it’s given, the evidence suggests HRT does more harm than good

  1. Diana 1 7 June 2009 at 9:56 pm #

    Ref 1 refers to estrogen plus progestin. Does ref 2 again refer only to estrogen plus progestin HRT and is Ref 3 referring only to estrogen HRT? Different results have been reported for the two types of HRT and most have concentrated on the combined HRT.
    And HRT formulations have changed over the years which I believe has affected how the results can be interpreted.

  2. Dr John Briffa 7 June 2009 at 10:25 pm #

    Diana 1

    Reference 2 is a study which examined the health effects of both oestrogen alone and oestrogen plus progestin. From the abstract: “Hazard ratios for breast cancer and total cancer were comparatively higher (P < 0.05) among women who initiated hormone therapy soon after menopause, for both regimens. Among these women, use of conjugated equine estrogens appeared to produce elevations in venous thromboembolism and stroke and a reduction in hip fracture. Estrogen plus progestin results among women who initiated use soon after menopause were similar for venous thromboembolism, stroke, and hip fracture but also included evidence of longer-term elevations in breast cancer, total cancer, and the global index.: Reference 3 is a commentary on these findings.

  3. Dave 8 June 2009 at 12:17 am #

    Is there any evidence of the effects of bioidenticals as opposed to horse-derived hormones?

  4. Jake 8 June 2009 at 2:15 am #

    My wife has taken bioidenticals for 15 years and the results have been very beneficial. She has never taken any non-bioidenticals. She just took a heart scan and she shows no evidence of heart disease nor has she had any cancer.

    As far as I know there has been no studies showing bioidenticals cause heart disease or cancer.

  5. John 8 June 2009 at 8:52 am #

    Any evidence one way or the other on *male* HRT? I was diagnosed with low testosterone, and both my GP and my Urologist recommended replacement.

  6. Margaret Wilde 9 June 2009 at 9:49 am #

    The oestrogen in the HRT I took caused me massive weight gain and high blood pressure from sodium retention and fluid retention, and many other painful and unpleasant symptoms. But at the time I did not realise it was the HRT that was causing the problems.

    Reducing sodium intake lessened the damage.

  7. Barbara 10 June 2009 at 6:37 am #

    What exactly are bioidenticals? I am currently taking a combined oestrogen-progesterone supplement called Angeliq, which contins no equine-oestrogens.

    Somneone please answer!


  8. merlina 10 June 2009 at 4:13 pm #

    Does the age of participants have a significant impact here? I ask as someone who completed menopause at 40 and was put on HRT. On querying the dangers, I was told that these were unlikely to be applicable at such a young age and that the benefits at 40 outweighed the dangers – which wasn’t true of the (apparently) much older women in the various clinical trials
    Any info/comments appreciated as I’ve often wondered about this

  9. ethyl d 11 June 2009 at 1:01 pm #

    Yes, please clarify if these results were for synthetic or bio-identical hormones. A lot of women are now turning to bio-identical hormones with the understanding that they do not have the same side effects as reported in the studies linking synthetic hormones to heart disease and cancer.

  10. Dale 11 June 2009 at 6:44 pm #

    I’ve been taking Estradiol for 14 years (since a partial hysterectomy) and would like to stop.

    I need specific instructions on How to do so.

    Herbal and vitamin supplement recommendations appreciated as well.

  11. Helen Nutting 12 June 2009 at 8:28 am #

    My GP is in favour of Vagifem vaginal HRT tablets, suggesting that they are quite safe. I’d be interested to hear what you know about this, please, John. I am generally wary of HRT and would prefer not to use them.

  12. Cybertiger 13 June 2009 at 5:12 pm #

    Interfering with God’s will over the menopause is likely to come at a price … and perhaps women will suffer God’s wrath as a result. While I don’t believe in the Almighty, I do believe that there may be a reason why the menopause has evolved the way it has. Interfering with nature and that natural menopausal evolution may come at a price … and women may pay for it in a greater risk of cancer, heart disease, strokes and PEs. Just a thought.

  13. Dale 14 June 2009 at 3:35 pm #

    Gee Cybertiger.. what narrow thinking! Nature is about eat or be eaten and “God’s children” include pathogens/virus and bacteria aplenty. To imply warding off painful symptoms is angering the Almighty implies we might as well eat junk food and not exercise. HRT saves lives when tumors result in surgery.
    Wanting to be alive on this special planet is what the life force IS.. so no more preaching and blaming and casting doubt where folks are invited to ask questions fearlessly.

  14. Cybertiger 16 June 2009 at 2:31 am #

    Eh? What are you trying to say, Dale?

    PS. I wasn’t aware that menopausal symptoms included pain. But then, perhaps I’m not really in touch with the Almighty’s plan for the menopause.

    PPS. Are you an American, Dale?

  15. Liz 16 June 2009 at 4:58 pm #


    only a man could write that!!!

  16. Kitty 4 August 2009 at 9:46 am #

    My friend was post menopausal in her early 30’s and immediately started taking H.R.T, she’s 50 now and swears by it, she understands the risks but thinks they are worth taking.

    She has a theory that as she started taking them in her 30’s this has been some kind of magic pill which has preserved her bones from the moment she took them. She eats a tiny ammount, as she’s always been terrified of getting fat, and again she thinks this wonder drug is feeding her nutrients.

    she does look great ‘tho I have to say, is there any truth in her theory?

    Does any one know

  17. sarah 14 December 2009 at 5:00 pm #

    Hi Everyone!
    You should try a natural, herbal, Ayurvedic remedy for menopause symptoms. Shatavari is a great, rejuvenative herb for women.
    You can find it on many sites, but i use http://www.Ayurveda-Yoga.co.uk as i’ve never had a problem with them, and they often have good offers on.
    Good luck.

  18. Barbara 6 February 2010 at 10:29 am #

    I have heard some good feedback about Black Cohosh. Haven’t tried it myself but there seems to be some literature to support this.

  19. Brett Hardman 16 April 2010 at 9:17 pm #

    It would fantastic if there were anything even approaching consensus on the issues surrounding HRT.

    Yes, the doses are much smaller now; and yes, there are the new bio-identicals that many people seem to think are safer than the equine stuff. Even so, because there is so much (pharma money) at stake, I’m inherently mistrustful. My GP absolutely pooh-poohed the idea of risk, effectively saying that the belief that HRT is harmful is a function of people’s inability to understand the statistical implications of the studies… but is that really true?

    Dr John, if you were up to clarifying the issue(s), I think a lot of women would be deeply grateful. I certainly would.

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