Doctors, patients wary of HRT usage
(Times News Network-January 5, 2004)

MUMBAI: Until early this year, city gynaecologist Kiran Coelho often prescribed a combination of the hormones estrogen and progestin to help women through menopause.

Like many doctors, Dr Coelho believed that hormone replacement therapy (HRT) was a panacea for older women, not only for easing menopause symptoms like hot flushes and insomnia but preventing long-term disorders like osteoporosis, Alzheimer's and heart disease.

But a series of studies on HRT published over the last year has changed all that. The studies—beginning with a survey in the US of more than 16,000 women over a period of five years—not only called into question the long-term benefits of combined hormone therapy but also showed that the risk of breast cancer was much higher than previously believed.

Experts say the usage of HRT has dropped since the recent findings have left both gynaecs and patients wary. Dr Coelho now uses HRT only for shortterm treatment of selective patients.

"I prescribe it for a year or two and only for women who are symptomatic and who don't have contra-indications like a family history of cancer," she says, adding, "We always thought that the benefits outweighed the side-effects, now
we have to think anew."

"Usage has definitely come down after these studies," agrees Dr Rashmi Shah, deputy director of the National Institute
for Research into Reproductive Health, adding, "HRT usage is not high in India anyway, and those who do go in for it are educated and upper middle-class women who read the headlines."

Dr Shah says the treatment has always been controversial, with doctors divided on its efficacy. "Now, more doctors will take the middle path, using it for only short-term symptomatic cases."

Pharmaceutical companies are cagey about the exact figures, but admit that sales have come down and strategies are
shifting to accommodate the new research. Wyeth India, for example, now markets its HRT product Premarin for primarily short-term symptomatic relief and no longer makes claims about preventing Alzheimer's or heart disease. Pharma companies describe HRT usage in India euphemistically and hopefully as a "nascent market".

What this means is that unlike Europe and America, where HRT usage is high among older women seeking to stay young and has become part of their lifestyle, in India it is used by barely ten per cent of working women of similar age in the
metros.

While low awareness and high costs are important factors here, it also appears that menopause is not as severe for Indian women.

A study conducted by the Indian Menopause Society, Mumbai chapter, chapter, on 500 women in 1998-99 found that only 20 per cent complained of menopause symptoms.

Compared to this, the prevalence ranges from 70 to 80 per cent among Western women. Experts attribute this to the traditional Indian diet and the social and family support system.

"We know that diet is one reason Japanese women have so few menopause symptoms, but more studies need to be done to establish this," says Dr Shah, referring to Japan 's high consumption of soya, which is a natural estrogen producer.

However, some believe that low awareness has led to poor reporting. "Women in India are more adjusting, they bear pain and distress uncomplainingly and their perceptions  about menopause are very different," claims Dr Vishwas Sovani, medical director of Wyeth India. He adds that women also tend to reject treatment because their mothers and grandmothers never had them.

If doctors are more careful about prescribing HRT, what are they looking at as alternatives? Some are switching to newer drugs called 'selective estrogen receptor modulator', or serm, for alleviating long-term symptoms like osteoporosis.

While estrogen is generally not prescribed alone because it can cause cancer, these "designer estrogens" are so engineered that they give the benefits of the hormone without the bad side-effects.

"They have a good effect on the heart and bones, but don't cause breast cancer," says Dr Usha Saraiya, head of the
Federation of Obstetricians and Gynaecological Societies of India.

Dr Saraiya feels that usage of HRT has not so much reduced but has been "rationalised".

"So, we can use combined hormone therapy for short-term selective use and designer estrogens for the longer term benefits," she says, adding that doctors have to be careful even with the newer drugs since they carry a risk of deep vein thrombosis.

Doctors are also advocating lifestyle changes to deal with menopause. This includes switching to low cholestrol and fat
diets, upping the intake of soya, sprouts and calcium as well as doing regular exercise.

"Some women sail through menopause on this combination," says Dr Coelho.