Hormone Replacement Therapy for Menopause More Facts

There are a number of different approaches to hormone replacement therapy (HRT) during menopause. For the most part, conventional physicians use conjugated estrogens (these are non-human and chemically modified estrogens) and progestins (synthetic mimics of progesterone). The HRT can be systemic, meaning it circulates in the blood throughout your body or it can be applied locally, either on the skin or by the use of vaginal preparations. This article will cover the use and the precautions for using conjugated estrogens and progestins. Another article will give an overview for the use of bioidentical hormones.

Overall, with either form of HRT (conjugated estrogens/progestins or bioidentical hormones), the best advice is to take as low a dose as possible to improve your symptoms and to use it for the shortest time possible. After all, menopause is a transition period and the idea is to get you through the toughest parts but NOT to keep the hormone levels un-naturally high. Along with taking the lowest dose possible for the shortest length of time, you and your healthcare professional should review your hormone replacement therapy every 6 months, at least.

Systemic Hormone Replacement Therapy

Estrogen is usually prescribed along with progestins when a woman has an intact uterus (who has not had, in other words, a hysterectomy where the uterus was removed). The reason is that estrogen alone without the balancing effects of progesterone has been associated with an increased risk of endometrial cancer—the endometrium is the lining of the uterus.

These prescriptions can come in pill form, as a patch worn on the skin, as a gel, cream or spray. Generally, these are used to treat hot flashes and/or night sweats. Systemic estrogen/progestin can also be used to treat symptoms of vaginal dryness, burning, itching or discomfort, particularly during sexual intercourse.

Before actual menopause, during the peri-menopausal phase, the HRT can be given cyclically. Estrogen is taken every day and progestin is given for a few days each month. This is essentially mimicking the normal menstrual cycle and is very similar to the types of regimens given to provide contraception. The HRT can also be given continuously where you are always taking both estrogen and progestin—the combination HRT. Breakthrough bleeding and irregular bleeding can occur and can take up to a year to get more regular. If you are post-menopausal (and haven’t had a period in at least a year) and you experience menstrual-like bleeding, it is very important that you contact your healthcare professional. Bleeding may be a sign of endometrial cancer and you need to be thoroughly checked out. (!)

Local Hormone Replacement Therapy

Local HRT may be used for women whose major concerns are vaginal dryness, thinning or discomfort during sexual activity. In this case, often a local estrogen is prescribed. This can be a low-dose vaginal ring, low dose vaginal tablet or a low dose vaginal cream. The ring is left in the vagina for 3 months and then replaced—it does not have to be removed during any sexual activity. The tablets and creams are used daily for a while and then used 2-3 times a week after some symptom relief has been achieved.

Benefits and Risks

Benefits

  • Well, of course the first potential benefit is symptom relief. You are the only one who can determine if your symptoms really need to be treated and you are the only one who can say that that relief has been achieved.
  • There are studies indicating that combined HRT and estrogen alone can lower the risk of osteoporosis, or rapid bone loss. These therapies can also lower the risk of spine and hip fractures. 1
  • Estrogen alone appears to decrease the risk of breast cancer somewhat (but remember that if you still have a uterus, estrogen alone will increase the risk of endometrial cancer—also, see the list of risks for estrogen-alone HRT)

Risks

  • Estrogen alone HRT increases the risk of endometrial cancer, stroke, gallbladder disease, urinary incontinence (a leaky bladder) and the risk of deep vein thrombosis (DVT). DVT is a condition where blood clots form (often in the legs) and can lead to stroke, heart attack and difficulty breathing or a pulmonary embolism (a blockage in the lungs caused by a clot).
  • Neither estrogen-alone or combination (estrogen + progestin) HRT reduces the risk of heart disease.
  • Combination HRT is associated with an increased risk of stroke, breast cancer, DVT, gallbladder disease and urinary incontinence.

The currently recognized recommendations

You should NOT use HRT if you have any of the following conditions:

  • A history of DVT, blood clots in the lungs, cardiovascular disease, stroke, breast cancer, liver disease
  • Abnormal uterine bleeding

Otherwise, if you are healthy and have determined you have symptoms that really do need relief (but please try alternative treatments like diet and lifestyle changes first), talk to your healthcare professional and determine the lowest dose needed—and take that for the shortest time possible. 2

Don’t forget to read the articles on alternative treatments and on bioidentical HRT.

Notes:

  1. Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause (10723714) 2010;17:242-55.
  2. Alexander IM. The History of Hormone Therapy Use and Recent Controversy Related to Heart Disease and Breast Cancer Arising from Prevention Trial Outcomes. Journal of Midwifery & Women’s Health 2012;57:547-57.

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