Hormone replacement therapy

Menopause is the end of menstruation, which usually occurs after several years of decline in normal hormone levels. Perimenopause is the time around menopause when a woman's body adjusts from normal ovulation to menopause. Hormone replacement therapy (HRT) can help reduce or eliminate the symptoms and long-term effects of perimenopause and menopause by restoring certain hormones to premenopausal levels. HRT usually refers to taking the hormone estrogen by itself or along with the hormone progesterone. When estrogen is taken by itself, it may also be called estrogen replacement therapy (ERT).

Despite the advantages, there are some potential risks involved with HRT. Take the decision seriously, and seek information from reliable medical sources.


General information
Estrogen and progesterone are female hormones produced mainly by the ovaries. These hormones regulate sexual development, menstruation and reproduction. Estrogen offers protection from certain diseases, including osteoporosis (bone density loss that leads to brittle bones). Estrogen also helps regulate levels of cholesterol and other fats in the blood.
Natural menopause, which typically occurs between ages 40 and 58, happens when the ovaries stop producing estrogen and progesterone. For premenopausal women, early or premature menopause can also result from surgery or various medical treatments.


Purpose
Again, hormone replacement therapy can help reduce or eliminate some symptoms and long-term effects of perimenopause and natural or premature menopause. The sudden hormone loss after surgical removal of the ovaries (oophorectomy) often causes intense menopause symptoms, and estrogen is typically prescribed to help alleviate them. HRT also helps prevent fractures due to osteoporosis. In the past, HRT was also taken to help prevent heart disease, but researchers have learned that it does not prevent heart disease and it's no longer recommended for this purpose. Today, the U.S. Food and Drug Administration (FDA) recommends that HRT be used only to treat the symptoms of menopause, and even then in the smallest effective dose for the shortest possible time.

Procedure
Depending on your symptoms and medical history, estrogen may be taken in pill or tablet form; as a vaginal cream, suppository or ring; a regular shot; or as a patch applied to the skin. When progesterone is taken along with estrogen, it's usually in pill or patch form. Dosages vary. HRT in the form of a patch uses a lower dose of hormone, which is absorbed directly into the bloodstream through the skin.

Benefits of HRT
Symptom relief
HRT may relieve some of the symptoms of perimenopause and menopause, including:

hot flashes
night sweats
mood changes
difficulty sleeping
vaginal dryness and uncomfortable intercourse
frequent urinary tract infections
fatigue
Fewer fractures from osteoporosis
More than 50 percent of all women eventually develop osteoporosis-related fractures. In the United States, osteoporosis accounts for more than several million hip, wrist and spine fractures a year. Hormone replacement therapy can significantly reduce the risk of these fractures. However, the protective benefits of HRT on bones does not continue once HRT is stopped. HRT increases the risk of breast cancer and heart disease, so alternative treatment for osteoporosis may need to be considered. Discuss your treatment options with your doctor.

Lowered risk of colorectal cancer
Research indicates that combination HRT may lower the risk of colorectal cancer. HRT is not prescribed as a preventive for colorectal cancer, however, because the risks from treatment are considered greater than the benefits. Other prevention options include limiting alcohol consumption and intake of animal fat, exercising regularly, maintaining a healthy body weight, and eating plenty of fiber, fruits and vegetables.

Other general benefits

HRT in the form of a skin patch has a lower risk of gallbladder problems and elevated triglycerides. (Triglycerides are fats in the blood that the body produces from sugar, alcohol or excess calories.)

Vaginal forms of estrogen have fewer side effects, since only a small amount of medication is absorbed into the bloodstream. They are helpful in treating urinary and vaginal symptoms.

Lower doses of HRT may have fewer risks and side effects.

Risks of HRT
General risks and side effects
Vaginal forms of estrogen may not stop hot flashes, improve cholesterol levels, or prevent osteoporosis. Lower doses of hormones may not be as effective in relieving symptoms and preventing the long-term effects of menopause.

Side effects from hormone replacement therapy may also occur. As your body adjusts to the medication, some of these may disappear, however. Depending on the dosage and type of therapy you take, possible side effects include:

uterine bleeding (especially during the first 12 months of treatment if progesterone and estrogen are taken every day)
nausea
abdominal bloating
gallbladder disease
headaches
dizziness
mood changes
breast swelling or tenderness
swelling or temporary weight gain due to fluid retention
Increased risk of heart disease and breast cancer with combination HRT
A leading cause of death in postmenopausal women is heart disease. When estrogen levels fall during menopause, high density lipoprotein (HDL or "good" cholesterol) also falls. In turn, low density lipoprotein (LDL or "bad" cholesterol) increases and raises the risk of heart disease.

Part of a large study on hormone replacement therapy conducted by the Women's Health Initiative (WHI) was stopped in July 2002 after finding that the combination therapy of estrogen and progestin does not prevent heart disease, as it was earlier thought. Instead, it actually appears to place women at greater risk for having a heart attack or developing breast cancer. The combination therapy (conjugated equine estrogens at 0.625 milligrams and medroxyprogesterone acetate at 2.5 milligrams -- brand name Prempro) was used in the study. The study did not investigate newer HRT combinations using different estrogens and progestins. Another part of the study found that estrogen therapy alone does not affect the risk of heart disease or breast cancer.

Increased risk of stroke with combination HRT and estrogen therapy
The 2002 WHI HRT study also found that combination therapy placed women at greater risk for having a stroke. Another part of the WHI study addressed the effects of taking estrogen alone. This study was stopped early when researchers found an increased risk of stroke in women taking estrogen therapy.

Increased risk of blood clots in the lungs and legs with combination HRT and blood clots in the legs with estrogen therapy
Both combination HRT and estrogen alone have been found to increase the risk of blood clots in the deep veins of the legs. There's also an increased risk of blood clots in the lungs with combination HRT.

Increased risk of dementia with combination HRT and estrogen therapy
Further analysis of the 2002 WHI HRT study found that women over age 65 taking the combination therapy of estrogen and progestin (Prempro) have twice the risk of developing dementia than those who do not use this therapy. Preliminary results of the WHI study that addressed the use of estrogen alone found a possible trend toward an increased risk of dementia or mild cognitive impairment in women over age 65 who take estrogen alone.

Increased risk of endometrial cancer with estrogen alone
If you still have a uterus, taking estrogen by itself increases the risk of endometrial cancer (cancer of the tissue that lines the uterus). Therefore, estrogen by itself is only recommended for women who no longer have a uterus. New research also shows that long-term estrogen use may increase the risk of developing ovarian cancer.


Considerations
Hormone replacement therapy may not be recommended if you have certain risk factors that may increase your chance of experiencing unwanted side effects. The risk factors include:
uterine bleeding from an unknown cause
a history of heart disease
a triglyceride level over 500
uncontrolled high blood pressure
a history of blood clots
liver disease
gallbladder disease
a personal history of cancer, especially breast or uterine cancer
risk factors for breast cancer, such as a family history
Again, because of the potential risks, the decision to take hormone replacement therapy should be taken seriously. Carefully review the options with your doctor and consider your medical history and risk factors, as well as your personal preferences. Remember, if you can't or choose not to take HRT, alternatives are available.


Senior-specific information
The risk of osteoporosis and heart disease increases as you age. If you think you may be approaching or have already experienced menopause, talk to your doctor about the benefits and risks of hormone replacement therapy and other treatment options.

Prevention
Although you can't prevent menopause, you can minimize the long-term negative effects.
If you smoke, quit. Smoking increases your risk of heart disease, osteoporosis and early onset menopause, and it can lead to lung and other cancers. (The earlier you go through menopause, the higher your risk of developing osteoporosis and heart disease.)

Eat a healthful, low-fat diet and lose weight if you're overweight to help prevent heart disease.

To help prevent osteoporosis, make sure your diet is high in calcium. If you don't have enough calcium in your blood, it will be taken from your bones. Unfortunately, the ability to absorb calcium and produce vitamin D, which is needed for calcium absorption in the intestines, decreases with age. Premenopausal women and postmenopausal women on hormone replacement therapy should consume at least 1,000 milligrams of calcium a day. Recommendations vary from 1,200 to 1,500 milligrams for postmenopausal women who are not taking estrogen. Women who have low bone mineral density should get 400 to 800 international units (IU) of vitamin D a day.
Excellent food sources of calcium include dairy products, canned salmon and sardines with bones, and dark green leafy vegetables such as broccoli, collard greens and dried beans. Calcium supplements can complement your diet without adding fat or calories. If necessary, your doctor may recommend calcium and vitamin D supplements.


To strengthen your bones and increase bone formation, try weight-bearing exercises such as walking. Regular exercise can also reduce your risk of heart disease.
In addition, it's important to practice preventive medicine. Many medical organizations believe it's important to do a monthly breast self-exam and have a yearly clinical breast exam. However, recent studies have shown that monthly breast self-exams do not appear to decrease the number of deaths due to breast cancer. The U.S. Preventive Services Task Force recently cited a link between breast self-exam and an increase in benign breast lump biopsies. They state that no evidence exists to recommend either for or against doing a breast self-exam or routine clinical breast exam alone to screen for breast cancer.

The debate on the timing of mammography also continues. Some health care professionals recommend regular mammograms every one to two years beginning at age 40 and annually beginning at age 50. The U.S. Preventive Task Force recommends mammograms every one to two years, with or without clinical breast examination, for women ages 40 and older.

Consult your doctor to find out if you need earlier or more frequent screenings or exams. Also see your doctor for regular pelvic exams to screen for vaginal, ovarian and cervical cancers. Your doctor may want to see you more often depending on your individual circumstances.