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Hormone Replacement Therapy

Controversy over hormone replacement therapy:

Estrogen replacement therapy (ERT), the use of estrogen to supplement that which is no longer being produced by the body, and hormone replacement therapy (HRT), in which estrogen and progestin (a synthetic progesterone) are used in combination, have been the subject of great controversy over the years. And, because there is a risk versus benefit ratio in the supplementation or replacement of these hormones, the debate still continues. In addition, the high doses of estrogen therapy given when ERT began being used 50 years ago, gave hormone replacement therapy a bad reputation.

Today, however, much more is known about administering the right combination of these hormones to provide the desired benefits while lowering the undesirable risks. Hormone replacement therapy is something every woman should consider when approaching menopause. However, every woman should also become informed first and discuss all possible options with her physician before making any decisions that will affect her health.

What is hormone replacement therapy?

When a woman reaches menopause, the production of estrogen and progesterone decreases significantly. HRT is a means of replacing these hormones that are no longer being produced by the body. This type of therapy is usually commenced at menopause or may be started while a woman is in the perimenopausal phase, nearing menopause. Many physicians recommend that women take HRT for the rest of their lives to realize the maximum benefits. In many cases, HRT can provide long-term health benefits, such as minimizing the risk of osteoporosis and cardiovascular disease, as well as reducing the symptoms of menopause.

HRT is available in pills, skin patches, and creams, and by prescription only. Women should discuss which method is most appropriate for them with their physicians.

What are the benefits and risks of HRT?

It is important that each woman discuss the benefits and risks of HRT with her physician in the context of her medical history. Together, you can make an informed decision about whether or not HRT is appropriate for you.

potential benefits Entering menopause places women at a significantly higher risk for coronary heart disease, stroke, and osteoporosis because of the decrease in estrogen in the body. Probably the biggest benefit of HRT is that it may counteract these risks by restoring the estrogen supply.
  • Research has suggested that HRT provides protection against cardiovascular disease by cutting a woman's risk by as much as 50 percent. HRT seems to raise levels of HDL cholesterol, the "good" cholesterol that helps to prevent blockages from occurring in the arteries, while lowering levels of LDL cholesterol, or "bad" cholesterol, which causes blockage of the arteries.
  • Research has suggested that HRT protects against osteoporosis by slowing the rate of bone loss and improving bone density in the hips and spine. It has been shown that women who take HRT have a decreased risk of hip fractures.
  • Research has suggested that HRT provides relief from many of the symptoms associated with menopause including hot flashes, sweating, sleep disturbances, increased urinary tract infections, vaginal dryness, and vaginal itching and burning.
  • Research has suggested that HRT may delay the onset of symptoms of Alzheimer's disease. One particular study found that women taking estrogen had a 40 percent lower incidence of Alzheimer's disease. In addition, those women taking estrogen who did develop the disease seemed to have a milder form of the disease. However, it is too early to conclude that HRT can reduce the risk of Alzheimer's disease.
potential risks Although for many women hormone replacement is very beneficial, it is not appropriate for every woman, nor is it free of potential risks. The following potential risks should be considered before starting hormone replacement therapy:
  • Research has suggested that taking estrogen alone may increase the risk for uterine cancer. However, this risk may be counteracted with the addition of a synthetic progesterone, or progestin, which may actually enhance protection against uterine cancer. Most women take both estrogen and progestin, in combination. In addition, women who have undergone a hysterectomy and no longer have a uterus can take estrogen alone, since they are not at risk for uterine cancer.
  • Studies regarding the link between estrogen and breast cancer have shown mixed results; some show a link, while others do not. One recent study has shown a slight increase in the incidence of breast cancer in women taking a combination of estrogen and progestin HRT. It is important for women with a history of breast cancer (or those at an increased risk for developing the disease) to consult their physicians about their individual medical condition as well as their personal risk/benefit ratio before starting HRT.
  • HRT may cause women to experience menstrual-type "withdrawal" bleeding and some premenstrual symptoms. Some women experience breast tenderness and water retention, however, it is uncommon to have menstrual cramps. Other side effects of HRT may include headaches and nausea. Some women consider these to be a major drawback of HRT, while others see it as only a minor inconvenience.

Who is not a good candidate for hormone replacement therapy?

Women who have had a history of any of the following conditions may not be good candidates for HRT:

  • breast cancer
  • blood clots
  • liver disease
  • gallbladder disease
  • seizures
  • migraine headaches
  • coronary heart disease

Women with one or more of these conditions should discuss their options with their physician. Some women are able to use estrogen patches rather than oral medications and still gain some of the benefits of HRT.

How is hormone therapy replacement administered?

According to the American Medical Association, HRT can be administered in a variety of methods, including the following:

estrogen pills Estrogen pills can either be taken every day or for 25 days each month. Women who have had a hysterectomy can take estrogen alone, while those who have not may take a combination pill (estrogen and progestin) to minimize their risk of uterine cancer.
estrogen/progestin pills There are two methods - the continuous method and the cyclic method - for taking estrogen and progestin. In the continuous method, a pill that contains both estrogen and progestin is taken daily. Occasionally, irregular bleeding may occur.

The cyclic method involves taking estrogen and progestin separately - with estrogen taken either every day or daily for 25 days of the month and progestin taken for 10 to 14 days of the month. This may cause monthly "withdrawal" bleeding.
estrogen and estrogen/progestin skin patches Using this method, a patch is applied to the skin of the abdomen or buttocks for 3 Ω or 7 days. The patch is then discarded and a new one is applied. The patch can be left on at all times, even while swimming or bathing, and either the estrogen, or estrogen/progestin combination is delivered through the skin into the bloodstream. Progestin can be taken in a pill form with the patch. The patches may cause monthly bleeding.

While estrogen patches help to relieve menopausal symptoms and protect against bone loss, they may not improve HDL and LDL cholesterol levels, which help protect against heart disease. However, estrogen patches may be an option for women who cannot take estrogen in the pill form.
estrogen cream Estrogen cream is inserted into the vagina or used locally around the vulva to help with vaginal dryness and urinary problems. However, estrogen creams do not provide the same long-term health benefits as some of the other hormone replacement methods.
raloxifene Raloxifene is an estrogen-like drug (sometimes called "designer estrogen") that is part of a new class of drugs called selective estrogen receptor modulators (SERMs).

Raloxifene helps prevent osteoporosis, however, it has only minimal protection against heart disease. In addition, research has suggested that raloxifene does not pose the same uterine cancer risks as estrogen-based medications. Further, some studies have shown that it may reduce a woman's risk of invasive breast cancer. However, while there is no monthly bleeding with raloxifene, it does not help to relieve the hot flashes often experienced during menopause.

For many women, HRT can be customized to provide the most benefits with the least side effects. It is important to talk with your physician about any discomfort or menstrual symptoms you experience with HRT, as treatment approaches and dosages can be adjusted.

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