Menopause and Hormone Replacement Therapy (HRT)

Pills are an option

Hormone replacement therapy can be either estrogen alone (called estrogen replacement therapy, or ERT), or estrogen and progesterone combined. This combination is referred to as hormone replacement therapy (HRT). HRT can be prescribed to treat hot flashes, vaginal dryness, insomnia, and other symptoms of menopause. It is available in several forms, including pills, patches, and creams. While once widely used, HRT now has a more limited role because of concerns about its safety.

The hormones provided with HRT are meant to replace the natural hormones that a woman's body no longer produces after menopause. Estrogen is involved in many functions in the body, and therefore, HRT is believed to provide the following benefits:

• Reduce the symptoms of menopause
• Helps to slow or prevent the bone loss that occurs with aging and increases after menopause, in order to help delay osteoporosis
• Helps to reduce the risk of colorectal cancer

Read more details about Hormone Replacement Therapy (HRT).

HRT may be prescribed in any of its various forms either to control existing symptoms of menopause or to prevent the onset of diseases that are believed to be caused by lowered estrogen levels in the body.

Research on Estrogen and Progesterone

From 1993 to 1998, the Women’s Health Initiative studied the preventive effects of HRT, specifically the combination of estrogen and progesterone. The subjects were 161,809 healthy, ethnically diverse postmenopausal women. Throughout the trial, 42% of participants ended HRT treatment due to a conflicting medical condition or advice from their doctor.

The primary outcome measured was

• Coronary Heart Disease risk
  • Rate of CHD events was 29% higher in treatment group relative to placebo

The secondary outcomes measured were

• Bone fracture
  • Rate of bone fractures decreased 23-24%
• Invasive breast cancer
  • Rate of invasive breast cancer was 26% higher in HRT group
  • Estrogen and progesterone together increased risk of breast cancer more than estrogen therapy alone
• Stroke
  • Rate of stroke was 41% higher in treatment group relative to placebo
• Colorectal cancer
  • rate of colorectal cancer reduced by 37%
• Deep Vein Thrombosis (DVT)
  • Two-fold greater rates of DVT compared with placebo

Endometrial cancer (cancer of the lining of the uterus) incidence, lung cancer, and total cancer incidence was not affected.

Given the favorable outcomes on colorectal cancer and fractures due to osteoporosis, the Women’s Health initiative supports the use of HRT for peri or postmenopausal women ONLY when the balance of potential risks and benefits are favorable for that individual woman, keeping in mind that no single trial data can be extrapolated to all women.

Research on Estrogen Therapy (Post-Hysterectomy)

A 2010 study compared Conjugated Equine Estrogen (CEE) treatment with a placebo. The participants who completed the trial were 1,717 women who had had hysterectomies between the ages of 50 and 79. They answered surveys about symptoms before treatment, after one year of using the hormone replacement therapy, and about a year after stopping treatment. One third reported moderate to severe symptoms before the trial began.

After discontinuing treatment, women were more likely to experience hot flashes and night sweats, even if they had never had these symptoms before treatment.

The influence of the hormone replacement therapy CEE on symptoms after one year were as follows:

• Vasomotor symptoms (i.e. hot flashes and night sweats)
  • Significantly reduced
  • Those with no reported vasomotor symptoms at baseline were 7.2% more likely to report them after treatment.
• Vaginal dryness
  • Significantly reduced -Breast tenderness
  • Increased both in women who reported this symptom at the baseline survey and those who did not.
• Pain and stiffness
  • Reduced marginally

The treatment had no effect on mood swings or sleep disturbances.

The following side effects may disappear over time as your body adjusts to taking HRT. Also, your doctor may be able to change the amount of hormone you receive, the way it is taken, or the timing of the dose, in order to help minimize these effects:

• Bloating
• Breast tenderness
• Cramping
• Irritability
• Depression
• Return of monthly periods
• Swelling of feet and lower legs
• Rapid weight gain

HRT can also cause some very serious side effects. You should discuss your specific health status and risks with your doctor when deciding whether or not to use HRT.

Research findings support the general recommendation not to initiate hormone replacement therapy in women who do not have serious symptoms of menopause. The exception to this is the possible preventive effect against osteoporosis. If HRT is started and then stopped, symptoms that did not exist before may appear.

Long-term use of HRT may significantly increase women's risks of breast cancer, strokes, heart attack, and blood clots. ERT may also increase the risk of ovarian cancer. HRT has been associated with an increased risk of gastroesophageal reflux disease (GERD)

For many women the risks of HRT—especially when used long-term—may outweigh the benefits, so the decision to use HRT should be carefully considered and discussed with your healthcare provider.

Women with the following conditions are usually advised not to use HRT:

• Unexplained vaginal bleeding
• Liver disease
• Kidney disease
• High levels of triglycerides (a type of fat in the blood)
• History of blood clots in the veins
• History of breast or ovarian cancer
• History of cardiovascular disease
• History of stroke
• Many other conditions
  • Ask your doctor if any of your medical conditions increase the risks of taking HRT

Combinations and Categories of HRT

• Conjugated (equine) estrogens
  • Synthetic conjugated estrogens
  • Conjugated/Equine Estrogens and Medroxyprogesterone
• Esterified Estrogens
  • Esterified Estrogens and Methyltestosterone
• Estradiol
  • Drospirenone/Estradiol
  • Estradiol and Levonorgestrel
  • Estradiol and Norgestimate
  • Systemic Estradiol

Estrogen is most commonly prescribed in these forms

• Pill or tablet
• Vaginal cream
• Vaginal ring insert
• Patch
• Topical gel

Progesterone is available in these forms

• Pill (can be combined with estrogen)
• Intrauterine device (IUD)
• Vaginal capsule
• Injection
• Implant
• Topical gel

American College of Obstetricians and Gynecologists website. Available at: http://www.acog.org .

Brunner, Robert et al. “Menopausal symptom experience before and after stopping estrogen therapy in the Women’s Health Initiative randomized, placebo-controlled trial,” Menopause: The Journal of The North American Menopause Society 17, no 5 (2010): 946-954.

Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke . 2010 October 21. Available at: http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181f7d043v1 . Updated October 21, 2010. Accessed November 2, 2010.

Hormonal replacement therapy. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Updated November 2010. December 14, 2010.

Hormones and menopause. National Institue on Aging website. Available at: http://www.nia.nih... . Updated December 2009. Accessed December 13, 2010.

Hormone replacement therapy and breast cancer risk. American Medical Women's Association website. Available at: http://www.amwa-doc.org.

Patsner, Bruce (2008). "Pharmacy Compounding of Bioidentical Hormone Replacement Therapy (BHRT): A Proposed New Approach to Justify FDA Regulation of These Prescription Drugs" ExpressO Available at: http://works.bepress.com/bruce_patsner/1

Writing Group for the Women’s Health Initiative. “Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial,” JAMA no 288 (2002):321-333.

9/30/2008 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Jacobson BC, Moy B, Colditz GA, Fuchs CS. Postmenopausal hormone use and symptoms of gastroesophageal reflux. Arch Intern Med. 2008;168:1798-1804.