Whether or not to use hormone replacement therapy (HRT) is a complex issue and should be discussed with your physician. The following is a list of topics covered in this discussion. Click to go to a specific entry.
- effects of low estrogen
- benefits of HRT
- risks of HRT, or not
- contraindications to HRT
- exactly what is HRT
- different types of HRT
- alternatives to HRT
Hormones are chemicals produced by glands in the body that control many aspects of normal bodily function. In addition, scientists have made a variety of synthetic hormones. The major “female hormones” are estrogen and progesterone. These hormones are produced by the ovaries, and in small amounts by the adrenal glands (that are located on top of the kidneys). Small amounts of the male sex hormones called androgens are also produced by the ovaries and adrenal glands.
Significant amounts of estrogen and progesterone are produced in most women during the reproductive years. The gradual decline in estrogen production is something that all women eventually experience. This decline in female hormone production, or the perimenopause, usually begins around age 45 and ends by age 55, but may occur earlier or later. The menopause is technically your last menstrual period. On occasion, the ovaries may be surgically removed before natural menopause, resulting in a “surgical menopause.”
Even before the menopause, other conditions may cause a woman to produce inadequate amounts of estrogen.
Extreme weight loss from a nervous condition called anorexia nervosa may drop the total body fat content to a level that results in low estrogen production by the ovaries. Excessive exercise without adequate caloric intake may do the same thing and cause the monthly menses to stop. This is sometimes seen in dancers and gymnasts who are compulsive about their desire to be thin. These young women can themselves be at increased risk for bone fractures.
The decrease in female hormone production causes changes that vary from woman to woman. You may notice hot flashes (also called hot flushes) that wake you up in the middle of the night, vaginal dryness and irritation, and possibly even short-term memory loss. In addition to these symptoms, the decline in estrogen production increases a woman’s risk of heart disease and osteoporosis (brittle bones) with the possibility of fractures. To reduce the likelihood of these problems, many women choose hormone replacement therapy (HRT). As with any medication, there are potential side effects in addition to the benefits. This information will help you decide if you want to take HRT or not.
Your own Hormones
What are the effects of low estrogen?
Hot Flashes – Help!
Change in mood is common
Vaginal dryness, along with irritation and itching, is a common problem. These symptoms are sometimes confused with those of vaginal infection. Pain with intercourse is not uncommon. Similarly, pain or discomfort on urination as a result of inadequate estrogen may mimic a bladder infection. Of course, a woman who is estrogen deficient may also have vaginitis or a urinary tract infection.
What About Alzheimer’s
Eye and other concerns
Studies have shown that HRT may reduce the risk of age-related macular degeneration (the leading cause of blindness in the older population) and tooth loss. Further study is also needed to confirm these findings.
Should you take estrogen?
What are the benefits and the risks?
As with any therapy, the benefits should clearly outweigh any potential risks. Hormone replacement therapy (HRT) is not risk free. The benefits are prevention or reduction of the effects of low estrogen. You and your doctor should decide what is best for you.
Benefits of HRT
Benefits of HRT may include:
- reduction of hot flashes and night sweats
- reduction of mood swings
- reduction of osteoporosis
- reduction of vaginal dryness and pain with sex
- reduction of dry skin
- reduction of heart disease
Risks of HRT
Risks of HRT may include:
- heart disease
- blood clot, stroke, and pulmonary embolus
- breast cancer
- uterine (endometrial) cancer
- uterine fibroid enlargement
- ovarian cancer
- gall bladder disease
- increase in impaired liver function
The Risks Associated with HRT should be considered before taking this medication(s).
A number of medical studies have raised concerns about risks of HRT, but the landmark study was the Women’s Health Initiative Study that began releasing data in July 2002. The first part of the study involved 16,608 women ages 50 to 79 years with an intact uterus (no hysterectomy). In women taking estrogen plus progestin (Prempro®), the study demonstrated an increased risk of invasive breast cancer, coronary heart disease, stroke, and pulmonary embolism (blood clots in the lungs). On the positive side, the study found a decrease in hip fractures and colon cancer in women taking this combination of hormones. More Recent data from the study (2004) showed no increase in the risk of heart attack and breast cancer on estrogen alone but did demonstrate an increased risk of stroke as see with the estrogen plus progestin.
Estrogens have been reported to increase the risk of endometrial cancer (cancer of the lining of the uterus or womb). Women who have had a hysterectomy (removal of the uterus) do not have to worry about this. If you still have a uterus, taking a progestin or progesterone reduces this risk. In fact if you are taking both estrogen and progestin or progesterone, your risk of uterine cancer seems to be less than if you are on no hormones at all.
Breast Cancer Scares Me!
At a recent symposium sponsored by the San Antonio Cancer Institute, Dr. Hakan Olsson reported the findings of a large prospective cohort study on nearly 30,000 women aged 25-65 in Sweden. Hormone Replacement Therapy (HRT) that included progestin markedly increased the risk of breast cancer.
However, estrogen-only HRT did not significantly increase a woman’s breast cancer risk.
The overall cancer risk was not increased in all HRT users. The increased risk of breast cancer in women using estrogen plus progestin was balanced by a decreased risk of other tumor types, especially colon and smoking-related cancers. This suggests that the tumor sites are shifted but with no overall increased risk of cancer. Combined (estrogen plus progestin) continuous HRT use for 1 to 48 months increased the risk of breast cancer 1.37 times over women never taking HRT. When used more than 48 months, there was a 4.6-fold increased risk of breast cancer. If the progestin was taken sequentially (usually 10-14 days each month), the risk of breast cancer was 2.23 times increased over never-users. What do these numbers mean for the individual woman? A 50-year-old Swedish woman who never used HRT or used estrogen-only HRT has a 2% chance of developing breast cancer over the next 10 years. If this woman used a progestin-containing HRT on a daily basis for at least 4 years, she would have a 7% chance of developing breast cancer over the next 10 years. The author commented that a low-dose progestin-releasing IUD might be an option for the woman who has not had a hysterectomy and needs HRT. This, at least in theory, should reduce the risk of progestin-related disease. Other medications are being studied that may provide lower-risk alternatives to traditional HRT in the future. Tibolone is a synthetic steroid with beneficial effects on bone and menopausal symptoms but apparently without any affect on breast cancer. The drug is being used in Europe and is under review by the Food and Drug Administration in the United States.
Gall Bladder Disease
Women taking HRT may have a greater chance of developing gall bladder disease which could make it necessary to have the gall bladder surgically removed.
Estrogens may cause breast tenderness, fluid retention and swelling, mood changes, nausea, and pelvic cramping. Estrogens may cause fibroid tumors of the uterus (usually benign muscle tumors) to enlarge and to cause bleeding. Estrogens should be used with caution in women who have impaired liver function. Although we do not large studies regarding, liver disease and HRT, transdermal estrogen may be safer because it does not make a first-pass through the liver like oral estrogen does.
The relationship between HRT and Alzheimer’s disease and dementia is still under investigation. As noted under Benefits of HRT (see above), a recent study showed an increased risk of Alzheimer’s and dementia in older women taking combination estrogen plus progestin. It is not yet known whether estrogen alone or estrogen plus progesterone have similar effects, or whether they may be beneficial. Some data suggests that women started on HRT around the age of the menopause may have improved brain function and those women started on HRT at an older age may have a decline in brain function.
Contraindications to Hormone Replacement Therapy
Many women may benefit from hormone replacement therapy, but not every woman can take it safely. If any of the following apply to you, HRT should be avoided.
- Known or suspected cardiovascular disease (CVD) – it is not yet known what effect estrogen alone, especially using the transdermal route (thepatch) will have on existing CVD.
- Known or suspected pregnancy.
- Known or suspected breast cancer except in appropriately selected patients.
- Known or suspected estrogen-dependent cancers such as cancer of the uterus.
- Abnormal uterine bleeding that a cause has not yet been identified.
- Active thrombophlebitis or thromboembolic disease (inflammation with or without blood clots in the veins or lungs) – if you have a history of previous thrombophlebitis or thromboembolic disease, therapy must be individualized by your physician.
Hormone Replacement Therapy
If you stop HRT, your body returns to a “menopausal” state.
Whether you have had a hysterectomy or not, some women also take small amounts of male hormone, called androgens. An FDA Panel denied a request for approval of an androgen patch for treatment of sexual function problems. It acknowledged the patch showed some benefit but was concerned about long-term effects such as cardiovascular and breast cancer risk. Some women say they feel better when taking a small amount of androgen, but caution is appropriate.
Options for HRT
- Estrogen is still most commonly taken in the form of a pill, either on a continuous or cyclic basis. If continuous therapy is chosen, you will take one pill every day. Estrogen pills increase the risk of blood clots.
- Transdermal estrogen (the patch) may be a safer route of administration due to reduced chance of thrombophlebitis (blood clots). The patch is usually applied once or twice a week.
- Estrogen rings may be a good choice for some women. These devices are flexible synthetic rings that are inserted into the vagina by the patient and release estrogen continuously. Potential advantages include insertion every three months rather than daily ingestion of medication or application of a patch once or twice a week. Also, the estrogen levels in the tissues are more constant. There are two different rings available. Estring® delivers a low dose of estrogen and is appropriate for treating vaginal dryness and other symptoms of estrogen deficiency localized to the pelvis (female organs). Femring® delivers a higher dosage of estrogen and can treat systemic estrogen deficiency. It can treat hot flashes and night sweats and reduce the risk of osteoporosis. Until proven otherwise, we have to assume Femring® has the same risks as other forms of estrogen. If you have not had a hysterectomy, a progestin or progesterone must be used along with the ring to reduce the risk of cancer of the uterus. There appears to be no increase risk of blood clots.
- Vaginal estrogen suppositories or cream – depending on the specific product chosen, the effect may be systemic (absorbed into your body) or more localized in the vagina and pelvis. There appears to be no increased risk of blood clots.
- Estrogen injections are usually taken every 3-4 weeks and appear to cause no increased risk of blood clots.
A progestin or progesterone should also be taken with the estrogen if you have not had a hysterectomy. A recent medical study suggests that women who still have one or both ovaries should take progestin with estrogen or not take hormones at all (see ovarian cancer above). The WHI Study demonstrated a number of risks as a result of taking estrogen plus progestin continuously. The most common schedules for administration of progestin or progesterone include:
- one pill every day – after the first several months on this schedule, you should not have any bleeding.
- one pill a day, 12 days each month
- one pill a day for 14 days every three months
- Progestin may also be given with the progestin IUD or with a patch that has both estrogen and progestin.
Designer Hormones, also called Bio-identical and Compounded Hormones
Are there any alternatives to HRT if I cannot, or do not want to, take hormones? The answer depends on what desired effect of the therapy is. For instance, do you want to treat or prevent osteoporosis, reduce hot flashes or night sweats, or limit vaginal dryness and pain?
Please go to the section on osteoporosis if you are most interested in reducing bone degeneration. I cannot over-emphasize how important it is to discuss your options with your physician
Some women choose botanical (plant) medicines to supplement or replace prescription medicine when treating the menopause.
Soy products contain phytoestrogens (plant estrogens) which have weak estrogen activity. Soy products contain isoflavones that are structurally similar to estrogen. Some patients report that soy helps relieve estrogen deficiency symptoms such as hot flashes. Soy products do not seem to increase the risk of blood clotting like oral estrogen does. The standard amount of soy protein recommended is 40 grams per day (contains 118 mg of isoflavones).
Many other botanicals have been used for treatment of menopausal symptoms. Some of these include:
- Black cohosh – thought to have estrogen-like effects but recently shown to couple to and block estrogen receptors – may cause stomach upset
- Dong quai – a type of angelica – a recent medical study showed it has no more estrogen-like effect than a placebo (a medicine with no active ingredients that works by the power-of-suggestion) – may cause toxicity due to blood-thinning properties
- Evening primrose – contains gamma linolenic acid which has been shown in one study to reduce night-time hot flashes of the menopause
- Ginkgo biloba – improve concentration and memory by increasing blood flow to the brain
- Ginseng – indicated for fatigue, lack of stamina, and inability to concentrate
- St John’s Wort – mild anti-depressant, sedative, and anti-anxiety agent – similar action to prescription anti-depressants
- Valerian root – has been shown to be mildly effective for treating nervousness and insomnia with no side effects
- Wild yam extract – contain saponins which are similar in structure to progesterone but have no demonstrable progesterone activity in humans – some women report relief of some menopausal symptoms
Vitamin supplements help some women with menopausal symptoms but should not be viewed as a replacement for a healthy diet. In addition to a good multivitamin, vitamin B6 200 mg and vitamin E 400 units daily are sometimes helpful with premenstrual-like symptoms (moodiness, irritability, fluid retention, and breast tenderness). Other vitamin and mineral supplementation may be beneficial.
- Do not take HRT to prevent cardiovascular disease, although there is evidence HRT begun at the menopause may reduce cardiovascular disease.
- Use as low of a dosage as possible to get the desired effects.
- Consider limiting treatment to 5 years or less. As more information is gained regarding risks and benefits, this recommendation appears to be changing.
- Transdermal HRT (“the patch”) reduces the risk of thrombophlebitis (blood clotting problems). It appears that all forms of estrogen therapy other than the pill reduce blood clot risk when compared to the pill.
- If progesterone/progestin is needed, natural progesterone appears to be safer than synthetic progestins.
- Consider transvaginal estrogen to treat local pelvic problems such as vaginal dryness.
The approach to the menopause and hormone replacement therapy (HRT) has changed dramatically since 1999. Although concerns have been raised by the Women’s Health Initiative, long-term benefits and risks associated with HRT are still under evaluation. It is important to individualize therapy based on personal and family history. Choice of therapy should be an individualized one discussed with your physician.
The information provided by Advanced Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes only. As each woman is unique, do not rely on this information for diagnosis and treatment. We cannot guarantee the accuracy of the content and advise that you see a qualified Health Care Professional for individual needs and care.Advanced Healthcare for Women 5354 Reynolds Street, Suite 518 Candler Professional Building Savannah, Georgia 31405 Telephone 912-355-7717 Fax 912-355-0979 firstname.lastname@example.org