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A Preliminary Literature Review of Attitudes to HRT

A preliminary literature search was conducted to access the feasibility of the topic and develop further insight into it. This comprehensive search using various databases and the internet brought in many

studies and information on the journey of HRT and the various aspects attached to the risk of

breast cancer.


HRT has been used for its curative effects on menopausal symptoms since the late 1920s. The scientist then linked HRT not only to its benefits in treating menopausal symptoms but also for its beneficial effect in the psychotic manifestation of menopause (Sevringhaus, 1935). It was not much later that the speculation of a relation between HRT and its carcinogenic effect began. Some prospective studies were conducted to examine this issue, concluding that no significant relation exists between the two (Greene and Brewer, 1941).

This view was followed by a study conducted later in 1962 by Wilson et al. to evaluate the possible carcinogenic effect of hormone therapy on the breast, which concluded that HRT does not induce cancer but is actually a protective factor (Wilson, 1962). He further emphasized his opinion in his best seller book “Feminine Forever” published in 1966 in which he gave the preventive status to menopause (Pinn, 2006;Wilson, 1966).


This practice of prescribing HRT for numerous ailments associated with menopause was supported by numerous observational and epidemiological studies conducted world wide in the 1980’s and 1990’s (Pinn, 2006). In a study conducted to evaluate the effect of use of HRT on bone loss and reduction in fracture risk it was reported that HRT helped to reverse the osteoporotic change of menopause although the extent was unclear. They added that this was associated with a possible increase in breast cancer risk (Compston, 1997). Later, the findings of these studies was reviewed by an expert panel who concluded that HRT had little or no benefit in treating ailments other than menopause for which it is primarily prescribed (Lawrence, 2002).

Around 100 epidemiological studies have linked the use of HRT to the increased risk of breast cancer (Beral et al, 1999). Earlier in the wake of a possible link between the use of HRT and the elevated risk of breast cancer, a large-scale reanalysis of 51 studies with data on 52,705 women with breast cancer and 108,411 women without breast cancer from 21 countries was conducted with the objective to evaluate this possible association. This study concluded that breast cancer risk increases with increasing duration of HRT treatment, however there was a need of more information on use of types of HRT (Collaborative group, 1997).

The Women’s Health Initiative (WHI) (Rossouw et al, 2002) conducted a landmark randomized controlled clinical trial in the United States to evaluate the risk and benefits associated with the use of HRT. This study was ended prematurely, as the primary outcome was coronary heart disease (CHD) and the adverse outcome was invasive breast cancer. Stroke, pulmonary embolism (PE), endometrial cancer, colorectal cancer, hip fracture, and death due to other causes were also outcomes of this study (Rossouw et al. 2002).

Cancer Research UK and the National Health Service (NHS) Breast Screening program jointly conducted the ‘million women’ study in 2003 to investigate the link between HRT and Breast Cancer. This study enrolled one million women between the age of 50 to 64 years for a span of 5 years and 47 % of them had used HRT (Banks et al, 1999). This study concluded that there was little or virtually no increase in the relative risk of breast cancer in past users of HRT compared to current users and that current use of HRT is nullified within 5 years of stopping the use of HRT (Banks et al, 2003).


The landmark WHI (Rossouw et al, 2002) and million women (Banks et al, 2003) studies brought about considerable changes in the way women patients and gynecologists approached the treatment of menopausal symptoms by HRT (Kumle, 2008).

With study records suggesting that half million women were using HRT, as a precautionary measure in 2002 regulatory bodies recommended that HRT be used only for “as short a time as possible” and only to treat menopause related symptoms (Kumle, 2008). This suggested that HRT could be used with some attached advice within a well crafted prescribing strategy. With these recommendations, the incidence of breast cancer had decreased within a few years, which the medical fraternity linked to the decreased use of HRT (Kumle, 2008). Simultaneously the American Chemical Society reported that the sales of Premarin one of the best selling prescription drugs dropped from more than $2 billion in 2001 to $880 million in 2004 (Chemical and Engineering news, 2005). The Wyeth Women’s Health care was trying to reach their sales by educating women on appropriate low doses of the drug (Chemical and Engineering news, 2005).

The symptoms of menopause which women were undergoing remained unchanged and as a result, more women were considering Alternative and Complementary Therapies (ACT) like Acupuncture, homoeopathic, Herbal medicine, dietary supplements like soy, massage therapy and chiropractice (Newton et al. 2002). In order to evaluate the usage of ACT by menopausal women, a telephone survey was conducted in United States (US) which found that the use of ACT was presumed to increase with the decline of HRT (Newton et al, 2002).


As an outcome of these study reports not only did the outlook of women changed towards the use of HRT but also mixed attitude was seen in women gynecologists. In Israel a study was conducted to evaluate the outlook of women gynecologists towards the prevention of breast cancer, treatment by HRT in respect to themselves and their prescriptions for HRT (Weissman-Brenner et al. 2010). Results saw a great impact of the WHI (Rossouw et al, 2002) study as it was observed that HRT was not being routinely prescribed to menopausal women by women Israeli gynecologists and the prescriptions of HRT had declined (Weissman-Brenner et al. 2010). A similar survey was conducted in Belgium (Ena and Rozenberg, 2003). Despite the findings of WHI (Rossouw et al, 2002) which suggested that the risk of prescribing HRT outweighed the benefits, it was found that Belgian gynecologists intended to continue prescribing HRT even for a long duration though this would vary for different regimens (Ena and Rozenberg, 2003).


It is important to know the outlook of women in context to their health, awareness and need of HRT. A small grounded theory study with 16 women was conducted to understand the decision-making processes of women regarding menopausal concerns (Gourley, 2001). The study concluded that the patient’s background, knowledge and outlook were integral and guided the decision-making process (Gourley, 2001). It also reported that menopause was looked upon as an aliment in the US which needs to be treated with HRT as compared to other parts of the world where it was considered as an ongoing part of the aging process. As a result, menopausal women were being prescribed HRT on a routine basis which left them with fewer options and was further narrowed by their inadequate knowledge of the safety issues of using HRT (Gourley, 2001). This study also suggested that to capacitate the women and actively involve them in the decision making a model could be made to assist both the doctors and the patients (Gourley, 2001).

There have also been studies conducted in other parts of the world exploring how women perceive or view menopause. In one such study conducted in Taiwan to understand the attitude of women towards menopause it was learnt that women weren’t regretful of not having periods and had a positive attitude towards it (Cheng et al., 2005). In a similar study conducted in Canada, women perceived menopause as a liberating experience and added positive meanings to it with no fear of unwanted pregnancy attached to it. They also considered it as a natural part of ageing (Bonetta, 2001).

In terms of medical treatment, it was generally perceived that women were discontinuing the use of HRT due to the elevated risk of breast cancer (Kumle, 2008), but actually withdrawal bleeding was found to be the prime reason for women not to adhere to the regime (Sarrel, 1999). It was proposed that effective doctor-patient communication would help patient understand their treatment and adherence and side effects could be well managed (Sarrel, 1999). However, HRT is prescribed to patients despite the complications. It is fairly evident that there are some associated factors and considerable benefits given this picture which drives these actions.

This preliminary literature search presented the findings of studies which helped develop insight into the subject for the research question. These issues will be explored further in this dissertation.

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