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Hot topic - Long-term HRT use, osteoporosis prevention and cancer risk4 December 2003 - written by BUPA's Health Information Team In August a study looking at the risk of breast cancer associated with hormone replacement therapy (HRT) was published in the medical journal The Lancet. This study, known as the "Million Women Study", provided important information and its findings prompted the UK Committee on Safety of Medicines (CSM) to issue new advice to doctors over prescribing HRT. This advice is covered in a previous BUPA article: Key facts - HRT and breast cancer risk. The UK CSM has now studied the findings in greater depth and has issued further advice to doctors in the UK over the use of long-term HRT to lower the risk of developing osteoporosis. Why is HRT used to prevent osteoporosis?The female hormone oestrogen reduces the amount of bone that is broken down and so helps to protect against osteoporosis. In women, the ovaries make oestrogen from puberty to the menopause. After the menopause, oestrogen levels fall and the risk of osteoporosis increases. By taking HRT, women increase their oestrogen levels and reduce the risk of osteoporosis developing. For more on the role of HRT in the prevention of osteoporosis, please see: What advice has the CSM issued on using HRT to prevent osteoporosis?The CSM has advised doctors that the balance of risks and benefits with the long-term use of HRT to prevent osteoporosis is unfavourable. The CSM now advised that HRT should only be used for preventing osteoporosis by women who are unable to take other osteoporosis prevention treatments or for whom other treatments have been unsuccessful. As the chairman of the CSM, professor Gordon Duff put it: "[HRT] should no longer be considered as the therapy of choice for preventing osteoporosis, in women over the age of 50 years." In what instances does the CSM say HRT shows favourable benefits?The CSM states that HRT is an effective treatment for the short-term relief of menopausal symptoms and remains a suitable treatment option. For such short-term use the balance of risks and benefits is favourable. However, the CSM advises that the minimum effective dose of HRT should be used for the shortest length of time possible. The CSM also notes that each decision to start to HRT should be made on an individual basis through informed discussion between the woman and her doctor. And the CSM advises that the treatment should be re-evaluated at least once a year. What instances does the CSM suggest that HRT does not show favourable benefits?Another situation in which the CSM advises that HRT should not be started is in healthy women who have no symptoms of the menopause. For these women, the CSM notes that the balance of risks and benefits is unfavourable. What advice does the CSM have on HRT use for women who have experienced an early menopause?The CSM advises that HRT may be used for women below the age of 50 who have experienced a premature menopause (due to ovarian failure, surgery or other causes). For these women, HRT may be used to treat their menopausal symptoms and to prevent osteoporosis until the age of 50 years. After this age, the CSM says that therapy for preventing osteoporosis should be reviewed and HRT considered as an option after other osteoporosis prevention treatments have been explored. What is the advice to women who are currently taking HRT?The CSM has issued the following advice to women who are currently taking HRT:
The chairman of CSM, professor Gordon Duff said: "These latest recommendations should come as no surprise to most clinicians in the UK. While this new advice does not require any urgent change in treatment, women who are currently receiving HRT as long-term prophylaxis should have their treatment reviewed at the next routine appointment. The CSM is keeping the safety of osteoporosis treatments, including HRT, under continual review, and will issue further advice as necessary." Further informationBUPA resources:
External website:
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