Help for menopausal women

India's National Magazine from the publishers of THE HINDU

A debate over HRT is on in medical circles. Those who support it portray it as a life saver for menopausal women. Those who do not, say it is unnecessary interference with a natural process.

THREE words guaranteed to start an argument in medical circles are Hormone Replacement Therapy, better known as HRT. Also referred to as oestrogen replacement therapy, HRT is a clinical alternative offered by doctors to women whose bodies no longer produce the same levels of oestrogen as they used to. This could be owing to two reasons. One is that the woman has reached menopause. The other is that she has had a surgical menopause - one where her uterus and ovaries have been removed.

Longer life spans mean that Indian women now spend one-tenth of their lives in a menopausal state. Since this stage has implications for a woman's health, some of which can be severe, physicians are beginning to prescribe HRT. The therapy, however, is not without its side-effects.

Those opposed to HRT say menopause is a natural occurrence. Invariably, those who oppose HRT cite the example of their grandmothers who never needed any treatment. Advocates of HRT say that this argument ignores the fact that earlier generations of women did not live long enough for menopause-induced diseases to manifest themselves. HRT replaces the body's oestrogen level and can provide relief for many symptoms.

There are two categories of recommended HRT use. One is short-term use for relief of symptoms caused by a lowered oestrogen level. The other is long-term use, which is believed to be preventive in nature. It is the long-term therapy which is controversial.

Short-term HRT has a higher level of acceptance and compliance from women. Such use of HRT has been found to be effective in cases vasomotor symptoms that appear in the early stages of menopause. The least expensive tablet for this condition available in India is Estriol. The cost of a 2mg tablet is Rs.3. The usual dosage is two tablets a day and one course runs for three months. Thus the user spends Rs.540 per course. Success is usually assured but often the course needs to be repeated over a period of two years.

Long-term HRT implies usage over 5-10 years or even for life. At the top of the list of advantages is a lessening of the risk of osteoporosis, heart disease and Alzheimer's Disease. The downside is the higher risk of developing breast cancer and other cancers common among women.

The biggest cause of opposition to HRT on medical grounds is the danger of breast cancer. Ahmedabad-based gynaecologist and obstetrician Dr. B. S. Anklesaria calls it the "biggest challenge of HRT" but says that if a woman takes HRT for less than five years there is no danger of breast cancer. While statistics for India are unavailable, Anklesaria insists that world figures prove that the danger is much less than is perceived by patients but he also cautions that "women who have no family history of breast cancer and who are on a long-term HRT course could develop breast cancer."

Doctors who favour HRT insist that it is safe because the woman is under constant surveillance. For instance, a woman on long-term HRT has to have a mammogram every two years. They also say that HRT is only prescribed after a careful study of the woman's medical condition. Dr. Rani Bang of NGO SEARCH in Maharashtra says that this is true only in the case of a handful of doctors. "Doctors now use HRT as some sort of miracle medicine. It is frightening," says Bang, recalling the instance when she took an elderly relative suffering from depression to a gynaecologist. The relative also had cervical cancer. Bang says the doctor did not even wait for this part of the case history. "When she heard that the lady was depressed and menopausal, she instantly recommended HRT. Then I had to tell her about the cancer. As a doctor I know that the cancer can be aggravated by HRT but a non-medical person doesn't. Shouldn't the doctor have conducted a thorough study before recommending HRT?"

Anklesaria says that even cases with contra-indications for HRT usage now have a wider choice. For instance, if a woman has high cholesterol, she is advised not to take HRT orally but to use a HRT patch or an ointment. The HRT patch actually lowers her level of triglycerides. Oral HRT is also not given to women who have gallstones or those who have high blood pressure.

Pointing out the benefits of life-long HRT, Anklesaria says, "I agree the breast cancer risk is significant but we should weigh the benefits. The risk of heart disease, which occurs in 300 per 1,000 women, is halved with life-long HRT usage." Comparing the risk rates of men and women he says, "For a man at 45 the chances of a heart attack are 10 times that of a woman. A woman at that age is saved because she has oestrogen to protect her. But if after menopause she refuses HRT then her chances of a heart attack at 55 are the same as that of a man." But there is no denying the fact that the best way to fight heart disease is through diet and exercise and this is so even post-infarction or post-menopause.

HRT is also said to lessen the chances of osteoporosis. As a woman ages, calcium tends to be lost from the bones, making the bones weaker, less dense, more brittle. Women are at a greater risk from osteoporosis because they have lower bone density to begin with. Indian women also ignore their diet, especially the intake of calcium - essential to keep bone mass healthy. But the seemingly simple solution of giving an osteoporotic elderly woman calcium to strengthen her bones and prevent her breaking them when she falls is not possible. Doctors says calcium will not be absorbed into the body without oestrogen. Thus the need for HRT for the rest of a woman's life.

Dr. S. Rao, a United States-based endocrinologist, cautions against stopping oestrogen therapy "if you stop then the rate of bone loss would be greater than if you hadn't started at all."

But fears over HRT use make women shy away from it even though some may benefit from it. And ayurveda and naturopathy affirm that diet and exercise components play a far more important part than oestrogen loss in osteoporosis. Other alternatives for osteoporosis are non-sex hormone drugs like sodium alendronate, one of the new range of bisphosphonate class of drugs which prevent further bone loss without the side-effects of sex-hormone drugs such as oestrogen. These have been available for the last two years.

Researchers say that HRT can also lessen the chances of Alzheimer's disease. Alzheimer's is a disorder for which the cause is not known, for which there is yet no cure and which affects a high population of the elderly. Elderly women are at a far greater risk of developing Alzheimer's than men. The connection once again is oestrogen. The hormone is believed to preserve and even improve functions of the brain.

As in the case of osteoporosis and heart disease, oestrogen works by shielding cells from toxins that cause degeneration. Recent data also indicate that oestrogen can act as an anti-oxidant, soaking up highly reactive molecules called free radicals which can kill a cell by fracturing its membrane lipids, proteins and DNA. High oestrogen concentrations are believed to reduce the neuron killing effects of several toxins that boost the production of free radicals. Among these is betamyloid, a protein that accumulates in the brains of Alzheimer's patients and is thought to be a cause of neuronal degeneration.

THE use of HRT is also criticised by naturopaths. Owing to a high degree of environmental pollution, the system, particularly the liver, is not geared for constant dosages of medication. Rani Bang says: "People are more exposed to deadly pathogens today - from pesticides in food to chemicals in water to air - these take their toll on the body - especially the liver, which is the main organ for 'digesting' medication". Other criticisms of HRT include sporadic and sometimes prolonged vaginal bleeding in menopausal women. Most women find this recurrence of their periods objectionable and drop out of the therapy. Bang says, "in India menopause is a relief for many women because of all the social and religious restrictions menstruation imposes."

Many pro-HRT physicians believe that it has a big role to play in preventive medicine. Anklesaria is all for "universal HRT", saying "it can prevent complications in mature women (the politically correct term is 'mature' instead of 'menopausal')." Speaking to doctors at a function of the Indian Menopause Society in Delhi, Anklesaria said: "You are guilty of malpractice if you haven't put your patients on HRT."

A study of 500 women undertaken by the Institute for Research in Reproduction (IRR) to elicit their views on HRT showed that only 40.1 per cent agreed to take short-term therapy for up to one year. As regards therapy for more than five years, 67.8 per cent refused HRT. Among the common reasons for refusal was a feeling that menopause was a natural occurrence. Of the 156 women who agreed to use it on a long-term basis 55.1 per cent were willing to take it provided the per month cost was between Rs. 50 and 100. Present costs are in the range of Rs.200 a month. The latest HRT prescription, Infar, has to be taken only once a day. Its drawback is that one month's treatment costs Rs.1,000 - more than Rs.30 a pill.

Where does this leave the menopausal woman? Too little oestrogen can cause osteoporosis and other diseases and too much can result in breast cancer. State-of-the-art medicine now offers women SERMs, or Selective Estrogen Receptor Modulators. SERMs, also called boutique oestrogen, operates by targeting selected areas of the body. It has the dual capability of being beneficial to cardiac functions, to the bone and to the brain while not increasing the dangers of breast cancer. SERMs is at the cutting edge of research in HRT. Researchers have identified the receptors in the body that react to hormones, and this allows SERMs to react with receptors that benefit and not react with those that harm.

A multi-disciplinary approach to menopause is completely lacking in India. Menopausal ailments can require specialist attention ranging from urologists to cardiac surgeons to brain specialists. While an interdisciplinary exchange is essential within allopathy, it is also essential between the various systems of medicine. Allopathic physicians tend to ignore the cures offered by ayurveda, naturopathy, unai and yoga. Dr. S.K. Sharma, Adviser (Ayurveda), Union Ministry of Health, says; "The post-graduate teaching universities of Gujarat Ayurvedic University, Banaras Hindu University and the National Institute of Ayurveda in Jaipur have brought out doctoral theses on the management of menopausal symptoms. Ashwagandha, Ashoka and Chandan are the most useful as they are non-hormonal. They are said to be quite suitable to deal with menopausal symptoms. The medication is usually given to women between the ages of 40 and 50 for a period of two months and there is usually no need to repeat it."

Women who are uncomfortable with HRT can choose from among alternative therapies including the use of vitamins, minerals and herbs that provide relief from symptoms. Research has shown that phytoestrogens are an excellent source of replacement when oestrogen levels fall. Phytoestrogens are a diverse group of plant substances that have some of the effects of oestrogen. Preliminary studies indicate that a high intake of phytoestrogens also reduce hot flushes and vaginal dryness. The studies are supported by observations that women of the Far-East, who have a rich diet of phytoestrogens throughout their lives, report few menopausal symptoms.

No blanket ban or approval can be given to HRT. Just as there are definite indications for its prescription there are also definite contraindications for its usage. Supporting HRT is an 83-year-old gynaecologist who chose HRT for herself. In fact, she is probably the oldest HRT user in the country, having been on treatment for more than 30 years. She reports no negative effects from her two pills a day dosage. Her son, also a gynaecologist, explains why she started HRT when most women of her generation would normally have ignored the idea of medication for menopause. "She'd had a hysterectomy, she had a crack in her femur, she is a Parsi, she's fair... she is a classic case of osteoporosis," he says.

Requesting anonymity, the old woman recalls the days when menopause was ignored by physicians. "The earlier response of doctors was to dismiss symptoms like hot flushes as psychological. There was no acceptance even of the possibility of it being a physiological reaction. They used to say the woman was hysterical and give her sedatives. It's a very sensible change now to give hormones instead of sedatives. I believe every woman should be on it. It is happiness for themselves."

In the final analysis it seems that the best 'cure' for a trouble-free menopause is preventive treatment mainly based on a nutritious diet and an active lifestyle. Rani Bang believes that the government health care programmes should not even consider HRT treatment. She says "the money spent on HRT would be better spent ensuring that women had an adequate and nutritious diet throughout their lives."

Lyla Bavadam received the Panos Health Media Fellowship for research subject, Menopause in the Indian Context. This is the second article in a series. The first article was published in the April 9, 1999 issue.