Hormone Replacement Therapy
Hormone replacement therapy (HRT) is one of the most controversial approaches to the management of menopausal symptoms. HRT literally replaces the hormones that a woman's body no longer produces. There are two primary types of HRT: estrogen replacement therapy (ERT) and combination estrogen/progesterone therapy. Other hormones less commonly used in HRT include androgens, specifically testosterone, and dehidroepiandrosterone (DHEA).
 ©2006 Publications International, Ltd. Some doctors will recommend hormone replacement therapy for extreme menopause symptoms. |
Some doctors think that menopause is a "failure of the ovaries" and that estrogen should be given indefinitely to almost every woman going through menopause. But most doctors think that HRT should be used only for a short period of time to alleviate severe symptoms of menopause.
Clinical Studies
Doctors have learned quite a bit since HRT was first introduced. In the l940s, scientists discovered how to make estrogen that could be taken in a pill. The first orally active estrogen was made from pregnant mares' urine, hence the familiar brand name, Premarin. Premarin and other forms of estrogen became very popular in the l950s. In the 1960s, reports appeared that women taking estrogen supplements had an increased risk of endometrial (uterine) cancer. Further research revealed that as long as estrogen was balanced with a second hormone, progesterone or a synthetic "progestin'" the combination -- which is also used in oral contraceptives -- did not cause endometrial cancer.
By the 1980s, combination estrogen/progestin therapy was widely used to manage menopausal symptoms in women who had a uterus, but it was not usually used to treat women who had hysterectomies, as they do not need protection from endometrial cancer. At the time, many thought that the combination therapy might protect women against heart disease and Alzheimer's disease as well, but this has never been proven.
In the 1990s, the federal government funded clinical trials to evaluate the safety of HRT. The Women's Health Initiative conducted two studies: the estrogen-alone study of women who had hysterectomies and the combination estrogen/progestin study of women with a uterus. Conclusions from both studies showed that HRT increases women's risk of stroke and blood clots. The estrogen-alone study indicated no increased risk for heart attack or colorectal cancer and a decreased risk of fractures, but effects on breast cancer were uncertain.
However, the combination estrogen/progestin study indicated an increased risk of heart attack and breast cancer and a decreased risk of colorectal cancer and fractures. As a result of the studies, the Food and Drug Administration (FDA) recommends that women who use HRT take the lowest effective dose for the shortest amount of time possible, that health care providers consider prescribing topical products to address vaginal symptoms, and that non-estrogen medications be considered first to treat women at risk for osteoporosis.
Why would a woman use HRT? There are several benefits. Estrogen helps to preserve bone mass and prevent fractures, alleviates thinning of the vaginal wall and bladder, and effectively treats hot flashes. Many women also feel better on HRT; they sleep more soundly, have more energy, and feel less fatigue and irritability. And many find that their skin seems moister and less prone to wrinkling.
Additional Precautions
Recently, products advertising that they are "natural" or "bioidentical" have been gaining popularity. The term "natural" is primarily a marketing term and is commonly used to describe herbal and over-the-counter nutritional supplements aimed at treating menopausal symptoms. "Bioidentical" hormones are chemically identical to those the human body produces. No large-scale, long-term clinical trials have been conducted to evaluate the safety of these products.
When taking estrogen, taking progesterone protects against endometrial cancer. But estrogen can also be combined with another hormone, testosterone. Although usually thought of as a male hormone, testosterone is, in fact, produced in small amounts in women's ovaries. Some women notice a decrease in libido and general well-being after menopause (particularly surgical menopause) but find that taking testosterone supplements improves their sex drive. However, side effects include facial hair, thinning scalp hair, acne, and deepening of the voice. Furthermore, most of the products on the market are for males and use in women is "off-label." There have been no long-term safety studies of testosterone use in women.
Another hormone, DHEA, which is normally made in the adrenal glands, is available in over-the-counter supplements, and some studies indicate it can improve libido and well-being. Since the FDA has classed it as a dietary supplement and it is available over the counter, DHEA is not as tightly regulated as are prescription pharmaceuticals, and as a result, products may vary in potency. No long-term safety studies have been done.
Side effects of HRT are common; many women experience vaginal spotting and bleeding, fluid retention, and breast tenderness. Many blame midlife weight gain on HRT, although aging and slowing metabolic rate are probably the culprits.
Lifestyle Considerations
Personal and family history can play a role in helping you to decide whether to take HRT. Here are some factors to consider:
- Family history of osteoporosis: If your ancestors are similar to you in body build and lifestyle and had problems with bone fractures from minor injuries as they aged, you may be at increased risk for bone loss and may want to consider estrogen for it bone benefits. However, ask your doctor about non-estrogen treatments first.
- Personal and family history of breast or endometrial cancer: Women with a strong family history of female tumors should talk with their doctors before taking HRT. Women with a personal history of breast or endometrial cancer will likely be advised against HRT, particularly estrogen alone, but topical or low-dose therapy may be recommended for specific conditions.
- Family or personal history of blood clots: It is known that HRT increases the risk of blood clots. Women with a family or personal history of blood clots should be carefully assessed by a doctor before taking HRT.
- Are you sedentary? Physical activity and exercise help develop strong bones. Sedentary women, on the other hand, have a higher risk of osteoporosis. If you can't or won't change your lifestyle, the benefits of estrogen may be great. Women who are disabled, in particular, may require the bone-protecting benefits of HRT.
- Do you smoke? Smokers go through menopause several years earlier than nonsmokers, increasing their risk of osteoporosis. Although HRT may protect against osteoporosis, smokers may not be able to take it due to their increased risk of developing blood clots.
- Are you obese? Obese women have a greater risk of breast and endometrial cancer but may have a lower risk of osteoporosis.
- Are you a health nut? If you eat a nutritious, varied diet, exercise regularly, and avoid items that you do not consider "natural," you may prefer not to take HRT on philosophic grounds. Fortunately, your diet and exercise regimen will help to protect you against heart disease and osteoporosis, but you may still benefit from HRT's ability to stave off bone loss.
- Are you stressed? Many women find that hormonal fluctuations during perimenopause lead to sleep loss, fatigue, mood swings, and irritability -- contributing factors for stress. Some women on HRT experience improved sleep and less irritability. However, HRT does not treat major depression or other significant biochemical mood disorders. Women suffering from these conditions should seek medical attention from a mental health professional.
Only you can piece all these factors together for your own well-being. Above all, try to keep in mind that HRT is not a replacement for other health habits. You should decide about HRT at the same time you are working on increasing exercise, eating a healthier diet, and quitting smoking--not instead of making these vital changes. You, too, must do your part.
If you or you doctor decides that hormone replacement therapy is right for you, your next biggest decision will be what type of hormone you take. In the next section, we will help you make an informed choice.
This information is solely for informational purposes. IT IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. Neither the Editors of Consumer Guide (R), Publications International, Ltd., the author nor publisher take responsibility for any possible consequences from any treatment, procedure, exercise, dietary modification, action or application of medication which results from reading or following the information contained in this information. The publication of this information does not constitute the practice of medicine, and this information does not replace the advice of your physician or other health care provider. Before undertaking any course of treatment, the reader must seek the advice of their physician or other health care provider.
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