Hormone Therapy

While there are several treatment options for menopause, hormone therapy (HT) is the most well known and the most efficacious and the only FDA-approved treatment. Every year researchers find out more and more about the effects of HT – some good news, some bad news. Despite the questions surrounding HT, doctors continue to prescribe the therapy because it offers so many women substantial relief from many menopausal symptoms, such as hot flashes and vaginal dryness and protects the bones from osteoporosis.

What is hormone therapy?
Hormone therapy is a treatment that is used to supplement the body with either estrogen alone or estrogen and progesterone combination. Estrogen and progesterone are hormones that are produced by a woman's ovaries. When the ovaries no longer produce adequate amounts of these hormones (as in menopause), HT can be given to supplement the body with adequate levels of estrogen and progesterone.

Why does the body need estrogen and progesterone?
Estrogen and progesterone together thicken the lining of the uterus, preparing it for the possible implantation of a fertilized egg. Estrogen also influences how the body uses calcium, an important mineral in the building of bones, and helps maintain healthy levels of cholesterol in the blood (although standard HT in older, postmenopausal women has not been shown to reduce most chronic disease risks).

As menopause nears, the ovaries reduce most of their production of these hormones. Lowered or fluctuating estrogen levels cause menopause symptoms such as hot flashes, osteoporosis, and other conditions. Hormone therapy helps to replenish the estrogen, relieving some of those symptoms and preventing osteoporosis.

Why is progesterone taken?
When taken without progestin (a progestin-synthetic progesterone), estrogen increases a woman's risk for cancer of the endometrium (the lining of the uterus). During a woman's reproductive years, endometrial cells are shed during menstruation. When the endometrium is no longer shed, estrogen can cause an overgrowth of cells in the uterus, a condition that can lead to cancer.

Progesterone reduces the risk of endometrial cancer by making the endometrium shed each month. As a result, women who take progesterone have monthly bleeding. Monthly bleeding can be lessened and, in some cases, eliminated by taking progesterone and estrogen together continuously. Women who have had a hysterectomy (removal of the uterus through surgery) usually do not need to take progesterone.

What are the types of hormone therapy?
There are two main types of hormone therapy:

Estrogen therapy: Estrogen is taken alone. Doctors most often prescribe a low dose of estrogen to be taken as a pill or patch every day. You should take the lowest dose of estrogen needed to relieve menopause symptoms and/or to prevent osteoporosis.

Progestin-estrogen therapy: Also called combination therapy, progestin-estrogen therapy combines doses of estrogen and progesterone (progestin is a synthetic form of progesterone). Estrogen and a lower dose of progesterone also may be given continuously to prevent the regular, monthly bleeding that occurs when progesterone is taken alone. Taking the lowest dose of hormone therapy for the shortest time consistent with the reason the woman is taking the therapy is the current recommendation.

What menopause symptoms can estrogen relieve?
Estrogen is prescribed to relieve:

• Hot flashes
• Vaginal dryness that can result in painful intercourse
• Osteoporosis (other options are available for osteoporosis prevention and treatment)

Other benefits of taking HT include:

• Reduced risk of developing osteoporosis and reduced risk of bone breakage
• Improvement of mood and overall sense of mental well being in some women
• Decreased tooth loss
• Lowered risk of colon cancer

What are the risks of taking HT?
While HT helps many women get through menopause, the treatment is not risk free. Known health risks include:

• An increased risk of endometrial cancer (if a woman still has her uterus and is not taking progesterone along with estrogen)
• Increased risk of blood clots and stroke
• Increased risk of breast cancer in women taking estrogen-progestin therapy for over four years. Estrogen alone has not been shown to increase the risk of breast cancer in the estrogen alone arm of the WHI.

Possible health risks are:

• Increased risk of heart disease
• Increased risk of stroke
• Increased risk of gallbladder disease
• Increase in blood pressure in some women
• Increased risk of memory loss in older women who take HT several years after menopause

Every day doctors are learning more and more about HT.

What are some commonly used postmenopausal hormones?
The following charts list the names of some, but not all, postmenopausal hormones.

Estrogen Types:

Brand Names:

Pills

Cenestin, Estinyl, Estrace, Menest, Ogen, Premarin

Cream

Estrace, Ogen, Ortho Dienestrol, Premarin

Vaginal ring

Estring, Femring

Vaginal tablet

Vagifem

Patch estradiol

Alora, Climara, Esclim, Estraderm, Vivelle, Vivelle-Dot

Progestin Types:

Brand Names:

Pills/Capsules

Amen, Aygestin, Curretab, Cycrin, Megace, Prometrium, Provera—medroxyprogesterone acetate

Vaginal Gel

Prochieve progesterone gel 4%, 8%

Combination Types:

Brand Names:

Pills

Activella, femhrt, Ortho-Prefest, Premphase, Prempro, low-dose Prempro

Patch

CombiPatch

Climara-Pro

Who shouldn’t take HT?
HT is not usually recommended for women who have:

• Active or past breast cancer
• Recurrent or active endometrial cancer
• Abnormal vaginal bleeding
• Recurrent or active blood clots
• Liver disease
• Known or suspected pregnancy
• Stroke

HT may not be advisable for some women who have:

• Endometriosis
• Fibrocystic breast disease
• Uterine fibroids
• Gallbladder disease
• High risk for blood clots
• Migraine headaches
• Epilepsy

Cigarette smokers should consider stopping tobacco use before taking HT.

What are the side effects of HT?
Like almost all medications, HT can have side effects. The most common side effects are:

• Monthly bleeding
• Irregular spotting (which stops permanently for most women within 6-9 months)
• Breast tenderness

Less common side effects of HT include:

• Blood clots and stroke (rare but the most serious risk)
• Fluid retention
• Headaches (including migraine)
• Dizziness
• Skin discoloration (brown or black patches)
• Increased breast density making mammograms more difficult to interpret
• Skin irritation under estrogen patch

How can I reduce these side effects?
Adjusting either the dosage or the form of the medication you are taking can often reduce side effects of HT. However, you should never make changes in your medication or stop taking it without first consulting your doctor.

How can I know if HT is right for me?
There are many factors to consider when deciding whether to take HT, including your current health status and your past medical history. Discuss your risk factors and medical history with your doctor. You should also weigh the risks and benefits of HT and consider other treatments.

How long should I take HT?
Since research on HT is ongoing, women should revaluate their treatment plans each year. Discontinue HT (under your health care provider’s guidance) if you develop a medical condition that would make it unsafe for you.

Can HT prevent heart disease?
Results from the Women’s Health Initiative (WHI) study revealed that the overall rate of heart disease events, in postmenopausal women on estrogen-progestin or estrogen alone with established heart disease, was not reduced. The results showed that the therapy actually increased the risk of blood clots and stroke.

Based on the WHI study results, should I stop taking HT?
It’s important that you do not make any abrupt changes to your HT without consulting your doctor. He or she can discuss with you the benefits and risks of HT based on your individual circumstances.

The National Heart, Lung and Blood Institute (NHLBI), which sponsored the study in collaboration with other units of the National Institutes of Health (NIH), has the following recommendations for women who may have questions about the long-term use of HT:

• First, the therapy should not be continued or started to prevent heart disease. Women should consult their doctor about other methods of prevention, such as lifestyle changes, and cholesterol- and blood pressure-lowering drugs.
• Second, for osteoporosis prevention, women should consult their doctor and weigh the benefits against their personal risks for heart attack, stroke, blood clots, and breast cancer. Alternate treatments also are available to prevent osteoporosis .
• Third, women should keep up with their regular schedule of yearly mammograms and breast self-examinations.
• Finally, while short-term use was not studied, women taking HT for relief of menopausal symptoms may reap more benefits than risks. Women should talk with their doctor about their personal risks and benefits.