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Hormone Replacement Therapy

Hormone Replacement Therapy (HRT)

 

            Many women going through menopause have questions regarding hormones.  Here are some answers to frequently asked questions regarding this issue:

 

What are my hormones doing?

            During menopause the amount of estrogen produced by the ovaries begins to decrease.  In response, a hormone from the pituitary gland called the follicle stimulating hormone (FSH) begins to rise to stimulate the ovaries to produce more estrogen.  Sometimes the ovaries will respond to this increased stimulation and the FSH will level off until the estrogen level begins to drop.  The tug of war continues until the ovaries completely stop producing estrogen and then the FSH will begin fall back down.

           

Why do I feel different?

            As the body’s level of estrogen drop, women may begin to experience hot flashes, night sweats, mood swings, and vaginal dryness.  Another issue associated with the loss of estrogen is the loss of bone density which can lead to osteopenia and osteoporosis and increased risk for bone fractures.

 

What is hormone replacement therapy (HRT)?

            Hormone replacement therapy is exactly what is says.  A person takes a substance to replace the hormones that are lost during menopause.  HRT begins with replacing estrogen.  For any woman who still has her uterus, it is also necessary to replace progesterone (the second type of female hormone).

            Another hormone that can be supplemented is testosterone.  Although testosterone is naturally low in women, there can be some benefits to increasing its level.  These include increased energy and sex drive.

 

What is the purpose of HRT?

            Hormone therapy can be used to help relieve the symptoms of hot flashes and night sweat.  These are called vasomotor symptoms.  These symptoms vary in women during menopause from few and mild to frequent and severe.  The goal of HRT is to relieve symptoms that are interfering with a woman’s ability to work, sleep or enjoy her daily activities.

            Although HRT can help prevent bone loss, it should not be used for bone benefits alone.  The risks associated with HRT do not outweigh the benefit of maintaining bone density.  The American College of Obstetricians and Gynecologists (ACOG) does not advocate using HRT for this purpose alone. However, there are other types of medication available to increase bone density (i.e. Actonel, Boniva, and Fosamax).

 

What forms of HRT are available?

            Hormone replacement therapy can be provided in pill form by mouth, vaginally by creams, pills or rings or through the skin with creams, sprays or patches.  Additionally, some women choose hormone pellets that are placed in the fat tissue of the buttocks.  This can be done during an office visit.

 

What are bioidentical hormones (bio-HRT)?

            Bioidentical hormones are developed from estrogens that are taken from plants and then combined for therapy.  Although some prescription HRT medications do come from plants, most bio-HRTs come from a compounding pharmacy.  It is important to realize that bio-HRTs have the same risk factors as other HRT.  Additionally, bio-HRTs are not regulated by the Food & Drug Administration (FDA).  However, some women do feel that this is a good option for their needs. 

 

What are the risks of HRT?

            Estrogen carries several risks including blood clots, endometrial thickening and possibly increasing triglycerides. 

·         Blood clots can travel throughout the body and cause deep vein thrombosis (DVT in the legs), stroke (brain), heart attacks or pulmonary embolisms (PE in the lungs). 

·         Elevated triglycerides are noted more with oral HRT. Sometimes switching to a transdermal (patch or cream) form can help return triglycerides to a normal level. 

·         Estrogen in known to cause thickening of the endometrium (or lining of the uterus).  This thickening can lead to endometrial cancer.  In order to help prevent this, women who still have a uterus will need to also take progestin, which helps to thin the endometrium. 

·         Another side effect of HRT can be the return of bleeding or spotting like a period.

 

In the Women’s Health Imitative (WHI) study, it was found that women using combined HRT with both estrogen and progestin were also at increased risk for breast cancer. 

 

            Women using HRT for long terms are noted to have an increase of risks compared with women who use HRT for shorter durations.

 

            Vaginal estrogen creams or pills can be used to help with vaginal dryness which can cause pain or itching.  This is given in a lower dose and used at the site of needed treatment.  The side effects of vaginal estrogen alone are much less than full HRT. 

 

Who should not take hormones?

            Women with a personal history of breast or ovarian cancers should not use HRT, especially women with estrogen or progestin specific receptors.  Women who have a history of blood clots, stroke, or heart attack are at higher risk with HRT use.  Women with known high levels of triglycerides may need close supervision and transdermal forms of HRT.

 

Should I take hormones?

            This is a choice that each individual woman must make depending on the severity of her symptoms in menopause.  Women considering HRT should discuss their symptoms, personal history, family history and the risks and benefits of HRT with their health care provider.  ACOG recommends that if a woman chooses to start HRT, it should be used at the lowest dose to relieve her symptoms and for the shortest duration of time possible.

 

What type of follow-up should I have?

Women taking HRT should have annual exams.  Women who are having unexpected bleeding, pelvic pain, severe headache, leg pain or other side effects should contact their healthcare provider.

 

What other options are there?

            Sometimes a non-hormonal medication can help relieve symptoms of menopause such as antidepressants.  Also, herbal products may help relieve mild symptoms.  However, it is important to note that, like bio-HRT, herbal products are not regulated by the FDA.

 

The decision to take hormone replacement therapy is a person choice for each woman dealing with menopause symptoms.  Talk with your healthcare provider about your individual risks, benefits and options.

 

Written by Cyndi Ayoub, WHNP

September 23, 2009.  Updated March 5, 2010.

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