Women and health - more confusion than ever?
In an interview centred on the recent International Women's Day, I was asked about the biggest challenges facing women today as far as their health is concerned. The clear winners in terms of women's health issues aren't rocket science if you ever open a newspaper.
First, there's fertility - the 'can we afford to have a baby?' discussion is going on in homes all across the country, if the statistics, and the questions in my consulting room, are anything to go by. Women in the UK are putting off having children longer than ever, but finding it isn't as easy to plan their first delivery date, as it was to plan their careers.
While there are lots of disadvantages to having babies too young, there's no doubt that nature is more likely to put a spanner in the pregnancy works as you get older. Fertility drops off sharply once most women are over 35, and at the same time the chance of having a baby with an inherited abnormality like Down's syndrome rises. Weight can also affect your fertility, with your chances of getting pregnant dropping steadily as your body mass index rises above 27 - even before you get close to the 'obese' range. Local healthcare providers are constantly trying to cut costs, and many are refusing to treat women who are very overweight, on the grounds that procedures like IVF are less likely to succeed and they need to get the best success rates for their money.
Next there's health screening. Every woman in the UK is invited for a mammogram every three years from the age of 50-70, and in some areas that age range is being extended. In 2012 we discovered that there are risks as well as benefits to screening. No longer could women rely on their doctor to tell them what was best - they had to weigh up the evidence and come to their own conclusions.
Then there's the menopause. Four in five women are affected by hot flushes around the menopause, which can leave you drenched in sweat or embarrassingly bright red at the most awkward of moments. In decades gone by, GPs happily prescribed HRT, which settles hot flushes and vaginal dryness, and had the added benefit of cutting the risk of osteoporosis to any woman with the faintest hint of a hot flush.
In 2002 that all changed with the publication of the Women's Health Initiative (WHI) study, which suggested HRT could increase your risk of heart attack by almost 1/3 and your risk of breast cancer by a quarter. (1) Things got worse in 2003 with news of the Million Women Study, suggesting that taking some forms of HRT for 10 years could double your risk of breast cancer. (2) Women started coming off HRT in their droves.
But, as so often happens, the pendulum has swung back. In 2012, a careful review of the original study suggested the Million Women Study was flawed and its results couldn't be relied on (3).
The more recent Danish Osteoporosis Prevention Study (4) challenged the findings of both the two earlier worrying studies. It showed that in women given HRT at around the time of the menopause, there was actually a lower risk of dying or of having a heart attack or heart failure, without any increase in the risk of breast cancer. The study has its limitations - it was relatively small and the number of women in either group having heart attacks was small - but actually it doesn't contradict the WHI study. In fact, when researchers looked back, it turned out that the increased risk of heart attack on HRT only applied to women in their 70s - and that's definitely not the group most likely to be getting hot flushes. (5)
I recently appeared on Radio 2 to referee a heated argument between two specialists, one ardently pro and the other equally opposed to HRT. Once I'd told them they were both being economical with the truth and should be ashamed of themselves, my conclusion was that there is a middle ground. HRT may not cut your risk of heart attack, but if you take it around the menopause there is no good evidence that it increases it. It may increase your risk of breast cancer, but the risks have probably been overplayed in the media. Certainly for HRT taken for a few years around the menopause, the risks are very small if they exist at all. As for whether that possible risk outweighs the benefits? You'd have to ask a woman whose life is ruled by hot flushes.
4) Schierbeck L L et al. BMJ 2012;345:bmj.e6409 http://www.slas.ac.cn/upload/20121029-3.pdf
5) Rossouw et al.JAMA. 2007;297:1465-1477. http://www.ncbi.nlm.nih.gov/pubmed/17405972