Eleven reasons for HRT

Professor Studd answers questions regarding his article Ten Reasons to be Happy about HRT and adds an eleventh reason. This question and answer format on the role of HRT is largely based on the podcast with Professor John Studd with Chloe Russell, and the subsequent transcript. 

Q. How much has the research changed and advanced since publication (first published in 2010)?

Studd:  Well, it's still up-to-date.  There's nothing inaccurate in it.  Yes, I wrote this paper about ten years ago, and a lot of my colleagues have printed it off to give to their patients, and it is just a summary of the important points where HRT can be of great benefit.

Q. It seems like the most important message you want to communicate is that it's effective, beneficial, and, most of all, safe to use?

Studd:  Well, it's all of those things.  That's right.  HRT is really a breakthrough. I started the first menopause clinic in Europe way back in 1968 when I was a young trainee because I was teaching to students the familiar story that women didn't need hormones for the menopause, they needed some tranquilisers and a nice husband, and I taught that rubbish for a long time until I realised that there was a different way and I started this clinic in Birmingham and it was closed down following a protest from the local BMA, but then it started running again and is still going now. It was quite clear that the patients we saw with the appropriate symptoms got better.

Studd: Initially, no-one would dispute that the principal symptoms of the menopause were hot flushes, sweats, and vaginal dryness, vaginal pain. Now, that's been known for 50 years or so, and they're the first two of my ten points, that HRT will stop hot flushes and sweats.

Q. How would that work?

Studd:  Well, the problem is of course that this causes insomnia, tiredness, depression, irritability as you can't sleep all night, and it's quite clear that antidepressants that have been used for this condition don't work, and oestrogens always work, I'd say.  And the second thing is the vaginal dryness. There's a lot of collagen, a lot of mucous thickness in the vagina, which causes pain, difficulty in intercourse, discharge, and of course loss of libido. 

Q.  Is it the oestrogen that you have to take?

Studd:  Yes. You have to take oestrogens, that's right. After the menopause, women lose collagen from their skin, their vagina, their nails, their hair, the bladder, the bone. All those things are affected and we know from our studies over the years that the loss of collagen and the loss of thickness in the skin you can replace in one year.

In one year you will replace all of that and the same thing applies of course to the vagina and, just as importantly, bones because the other major problem with the menopause is that women get thinner bones and that 30% of women in the age of say 80 will have had an osteoporitic fracture. That's a fracture of the hip or fracture of the spine and that is all preventable by giving oestrogens.  

Q. And I read that HRT is also good for women who suffer with anorexia. Is that right?

Studd:  Well, that's right. That's the other group. The other group are the young women with anorexia who are thin, whether they are exercise freaks going to the gym for two hours every day or whether they are anorexic, or athletes like ballet dancers, they have problems because they lose their periods and they lose their body fats, and they have terrible bones. It is all related again to the loss of oestrogen and the loss of collagen and the loss of the bone matrix, the bone scaffolding.

Q. If a male has anorexia, can they still take HRT as if they were a woman? Or is it different?

Studd:  Well, yes. Men who have osteoporosis, it's a different story actually. The men that have osteoporosis have low testosterone and this is manifested sometimes when they go to the doctor with loss of libido, loss of erection, tiredness, grumpiness, etc.  They often have low bone density and, if you give them testosterone for the symptoms, it improves their bone density considerably.  

Q. Do you have a lot of male patients?

Studd:  I have quite a few male patients, far more women of course. The male patients come with sexual problems and they are amazed that the testosterone is low and their bone density is low, so there's an equivalence in men, but it's much, much more common and better understood in women.  

Q. I read here that oestrogen helps depression in many women. Is that the same in males, as well?

Studd:  No.  It's very different. Depression in men is different from depression in women. Psychiatrists are hardly aware of this. It's because psychiatrists don't recognise the hormonal factors in depression. Men have virtually no hormonal factors in depression.

Q. Do they not?

Studd:  Not much, but women do in three obvious ways; premenstrual, post-natal after the birth of the child, and at the menopause. 

So, these are three times of hormonal flux where you have depression; premenstrual depression occurring before every period that gets better with pregnancy when the hormone levels are higher and static. And then they deliver the baby and the oestrogen levels go down and the depression recurs as postnatal depression. Then, years later, when they're towards the menopause, they have depression and it's important to realise that these symptoms of the menopause are at their worst before the periods stop. So, you haven't got to be 55 and having no periods for years, you can be 45 and you're still having regular periods and you still have these problems with depression. These years have been called the menopausal transition.

Q. how do oestrogen protect the spine?

Studd: HRT protects the intervertebral discs. The discs are entirely collagen lying between the vertebral bodies they act as a cushion over the years, stopping you developing a crush fracture in the spine. It is these fractures that a cause the loss of height that old women may get, the so-called 'dowager's hump'. So not only does oestrogen protect the bones via putting collagen back in the matrix, but also it protects the discs between the bones because they are entirely collagen.

Q. Do you need to take HRT before you hit your menopause in order to protect the discs?

Studd:  It's difficult to answer that.  You may want to start treatment before the menopause for other reasons like flushes, sweats and depression of course, to protect the bones.  Women in this age group should probably, if they're thin, have a bone density scan around the menopause if not before the menopause, if they are showing that they have osteopenia, which is the step before osteoporosis, then they should be given oestrogens straight away.

Q. So, it really depends on patient-to-patient?

Studd:  Yes, of course, and when we speak about oestrogens let's make one thing clear. The oestrogen should be through the skin and not by tablets. There was a view that HRT caused heart attacks and we do know that giving oral oestrogens, oestrogens by mouth, whether it's young girls on the pill, or older women having HRT, there is a slight increase in thrombosis because oestrogens by mouth produce the coagulation factors from the liver, so there's this slight, slight increase in heart attacks and strokes with oestrogens by mouth. Therefore we always, always give oestrogens through the skin, transdermally, by patches or gels or sometimes by implants.

Q. Can you explain why HRT improves libido?

Studd:  Well, loss of libido is a very common symptom aged 40+ up to 60. The obvious reason is that treatment can stop the vagina being painful and dry, so that's one aspect. However, the HRT improves energy, improves mood and whatever, but, added to the oestrogen therapy, we should also give testosterone. Testosterone is not just a male hormone, testosterone occurs in women and it is present in ten times the quantity as oestrogen in women. It's a very normal female hormone and giving testosterone again through the skin helps energy, libido, number of orgasms, all sorts of things

Q. Does testosterone also help with your skin?

Studd:  No, it's the oestrogen alone. Testosterone can cause problems with the skin with excess hair growth, spots and acne. However, in the right dose it doesn't and if it does you can merely stop the testosterone. So that's a very rare but obvious complication, but the benefits of increased libido are considerable.

Q. In addition to the skin does HRT also help other parts of your body like your nails, is that right?

Studd:  Well, that's right.  As I said before, around the menopause or after the menopause you lose collagen from the vagina we've mentioned, the bones we've mentioned, the intervertebral discs, the skin certainly and the bladder and the nails and the hair. All these things are improved by getting back your normal collagen levels. 

Q. How does HRT affect the bladder?

Studd:  Well, for the same reason. The bladder has components of muscle and membrane and both of those things are related to collagen. We do know that many women have problems of getting up to pee about four or five times a night or they have pain with micturition. They would frequently just have dilatation of the urethra, which is not necessary. They'd be much better off having oestrogens, which will help these women who have painful micturition and too frequent passing-water at night.

Q. Patients tell you, "I'm a nicer person to live with", do you hear this a lot?

Studd:  That's right, I do hear it a lot from patients. And also from husbands as well. Many women say that oestrogens stop their depression, improve the libido with less irritability and they generally become more agreeable people because their mood is better and they are happier.

Q. Is HRT safe?

Studd:  What we're saying is that in spite of all the occasional bad news you get about cancer of the breast or strokes or whatever, it really isn't true and there was this very expensive 2002 study of oral oestrogens in America where they chose the wrong drug, the wrong route, the wrong patients, the wrong age, and came to the wrong conclusions and this is a study that cost more than one billion dollars.

The investigators are now going around the world lecturing and apologising for the mistakes they've made and for this big baby-boomer generation in America who have been denied for about ten, twenty years hormone therapy for their symptoms and their long-term health based upon bad data, so all the evidence now is that there are not more heart attacks but fewer heart attacks, there are not more strokes but fewer strokes, and the breast cancer story that keeps popping up is not related to oestrogens because every study that looked at oestrogens alone showed no change or a decrease in breast cancer.  It is due to using continuous progestogen to stop the bleeding, which is what I don't do.  We use discontinuous progesterone, that's a natural progesterone for seven or ten or thirteen days a month and not synthetic progestogen every day, which is the risk factor for breast cancer. 

Now, that was number ten and there's a number eleven.

Q. What is the eleventh benefit of HRT?

Studd:  Which wasn't published.  Number eleven is that there is almost certainly a decrease in Alzheimer's disease, Alzheimer's is more common in women than in men.  It's more common in women with early menopause and logically oestrogens should prevent Alzheimer's as it does other degenerative conditions.  Now, it's difficult to prove this to everyone's satisfaction but we know from big population studies including the huge Utah study in America that Alzheimer's is less common with women having long-term oestrogens but the pure epidemiologists must have a randomised control trial.  Now, how do you have this with thousands of women starting from when?  Age 50?  40?  30?  And what happens for the placebo group when the patients, when the women shall we say, develop symptoms and want to have hormones?  So, the study is invalid to begin with, so this compulsion to do a randomised control trial is not possible for looking at Alzheimer's and I would remind you of a little piece of history.  When it was first discovered that smoking caused lung cancer and that smoking doctors had a thirteen times greater incidence of lung cancer than doctors who didn't smoke, people still asked for randomised trial and Sir Richard Doll, the author, famously said "there's no point in a randomised trial to prove the bleeding obvious".  So that's gone back to medical history that statement. 

It's very logical and all of the population studies strongly suggest that women on long-term oestrogens have less Alzheimer's,

Editors comment

Professor John Studd passed away on the 17th August 2021. The enormous contribution that he made in the area of women's health and to our understanding of the menopause in particular cannot be overstated. He pioneered the use of HRT, setting up the first specialist menopause clinic in Europe in 1969 - in Birmingham. He also co-founded the National Osteoporosis Society, now the Royal Osteoporosis Society. Total Health had the honour of working with "The Prof" for over a decade and he will be very badly missed. However, his legacy will endure, and a number of specialist consultant gynaecologists who were trained by by him now contribute to Total Health - please click here for further information.