HRT, PAP smear and Bedside manners

In the NST letter section,

Our hospitals need doctors with better bedside manners

May 07:

I AM a pensioner and I am under the care of a gynaecologist at a government-run hospital.

For quite a while, I have been on hormone replacement therapy (HRT).

With the recent controversy over HRT, I am apprehensive about its long-term effects especially when told that all hormone tablets are a form of synthetic steroids.

So I voiced my concerns to the gynaecologist.

I was appalled when she replied in no uncertain terms that if I wished to be taken off HRT, I would not qualify to seek treatment for my menopausal symptoms. Are we not given any other choice? Have the health authorities done enough research to warrant that all women of a certain age be put on HRT in government hospitals? I was also told that women over 60 years of age do not qualify for a pap test. She said that statistics show that only three per cent of women over 60 get cervical cancer. What if I am among the three per cent? How uncaring and high-handed can doctors be in government hospitals? Minister of Health Datuk Dr Chua Soi Lek said he was working towards cutting short the waiting time in government hospitals. That is commendable.

What we government pensioners would like to see are specialists with better bedside manners.

JANE WONG

Subang Jaya

Hormonal Replacement Therapy remains a controversy ever since the Women’s Health Initiative Study results were published. It used to be the wonder drug for post menopausal women. Despite its effectiveness in alleviating menopausal symptoms like hot flushes, new data have cautioned physicians especially gynecologists on potential side effects. The WHI study suggested a link between HRT and Coronary Heart Disease. It also suggests a possible link with breast and ovarian cancers. So doctors are now more apprehensive when treating for menopausal symptoms. It is no longer a knee jerk reflex in giving HRT to all menopausal symptoms.

Below is an article i wrote earlier on MMR:

Hormonal Replacement Therapy(HRT) : A continuing dilemma



HRT which contains estrogen and progesterone in combination, has been widely prescribed to peri and post menopausal women until several years ago when fresh data (in particular the Women’s Health Initiative study) suggests an increase in cardiovascular and stroke risk. HRT has been useful in alleviating disturbing menopausal symptoms, eg hot flushes and irritability. The increased risk of breast and endometrial cancer(if estrogen given alone) has also been noted. Thus it appears that the recent revelation has been the final nail in HRT’s coffin.

The recently concluded 11th World Congress of Gynecological Endocrinology held in Florence, Italy, discussed HRT at length. THe controversies surrounding the recently published studies remain. However, there is a trend to look for alternatives that are superior to conventional HRT.

One alternative drug is the Selective Estrogen Receptor Modulators (SERMs) namely Raloxifene. It is a synthetic compound that binds to estrogen receptors at different sites and can be both pro or anti estrogen depending on the target tissue. In the bones, it prevents bone resorption, increases bone mineral density and decreases the incidence of spinal fractures as shown by the MORE study (Multiple Outcomes of Raloxifene trial). Most importantly, it has little effect on the endometrium or the breast. However , the effects on the cardiovascular system needs further evaluation. As SERMs do not alleviate menopausal symptoms, the drug may not be well received by patients. Perhaps for long term protection, SERMs may have its best advantage.

Tibolone(livial) has long been available in Malaysia. Tibolone is a synthetic steroid that can display estrogenic, androgenic, or progesterone-like effects, depending on the target tissue. It alleviates vasomotor symptoms, improves BMD, and has no significant endometrial and breast effects. Its cardiovascular safety has not been established in large trials. Experiences of family members on Tibolone has been marred by elevated liver enzymes on routine investigations , thus discontinuation of this drug adn the return of liver enzymes to normal values.

The combination of estradiol and drospirenone, a synthetic progestin, was also mentioned and is associated with favorable vasomotor, cardiovascular, skeletal, and quality-of-life effects.It is available in Malaysia as Yasmin tablet.

Remifemin, a CIMICIFUGAE RHIZOMA EXTRACT is a traditional compound that has positive effects on menopausal symptoms.(see table below) Nevertheless it has no protective effects on the bone and heart and probably neutral effects on the breast and endometrium. However, experiences of my patients on Remifemin was not as dramatic as those on conventional hormonal replacement therapy.

However, conventional HRT cannot be totally ignored. It will still serve its purpose and remains the best agent in alleviating menopausal symptoms. Its other previously stated benefits remain under the microscope. The best strategy may be to start early , even in the peri menopausal period and not exceed 10 years of therapy or discontinuation earlier if menopausal symptoms do not recur. There is no right or wrong in this scenario and only time will tell if we have been doing the right things for our patients. “God guide us!”, we pray.

With regards to a PAP smear, there should be no age limit. Any woman with sexual exposure is at risk. Although some studies suggest a lower incidence of progression to dysplasia in menopausal women, these are just figures and each population will vary. So when the gynecologist in the above case mentioned that PAP smears are not for women above 60, it is utter rubbish.

It is important that doctors explain certain issues carefully to ensure that patients understand what they are being told. Perhaps there was a misunderstanding in the case above leading to more confusion and thus dissatisfaction and anger. I have to agree with Jane that some doctors will need some brushing up on bedside manners.

Womens Health Initiative

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