Hormone replacement therapy: is it for you?

When does menopause typically occur?

Technically defined as the permanent cessation of menstrual function for 12 months, menopause signals the end of a woman's reproductive years. When this natural phase of aging occurs, the ovaries no longer release eggs or produce estrogen. The average American women enters menopause at age 50, although it can occur earlier as well as later.

Unless ovaries are surgically removed as part of a hysterectomy, menopause doesn't suddenly just happen. It comes on gradually, with symptoms often appearing as much as 10 years beforehand. This is usually referred to as perimenopause.

What can I expect?

Although most women don't consider the end of monthly bleeding, bloating, cramping, or concerns about becoming pregnant problematic, menopause often brings its own discomforts. The degree of distress varies widely. Some women barely notice the transition while others find their lives turned upside down by the hormonal flux.

Hot flashes, irregular sleeping patterns, vaginal dryness, night sweats, and mood swings are the most common symptoms. In the later years of menopause, osteoporosis—a loss of bone density—may make bones brittle and susceptible to breaking. However, replacing the hormones no longer produced by the ovaries can relieve these uncomfortable symptoms and offer long-term health benefits.

What is hormone replacement therapy?

Hormone replacement therapy (HRT) largely consists of two hormones: estrogen and progestin, a synthetic form of the female hormone progesterone. However, some research has shown testosterone therapy to be successful in treating symptoms of menopause, including decreased libido, decreased genital sensation and moodiness.

Estrogen and progesterone can be administered via pills, patches, creams, or vaginal creams. Pills are the most commonly prescribed way of taking HRT. The benefit of this method is that when estrogen in pill form is processed by the liver, it more readily increases the level of HDL (good) cholesterol.

The patches are thin pads that adhere to the skin and deliver estrogen directly to the bloodstream. They are placed on the buttocks or abdomen and changed once or twice a week. Unfortunately this method doesn't seem to have the same beneficial effects on HDL as oral estrogen.

Creams containing estrogen and progestin can be applied directly to the skin—usually over the abdomen, arms, or thighs. The cream is absorbed from the skin into the bloodstream. Creams allow for a balanced dose because they're administered daily. However, application can be messy, and you can inadvertently apply an improper amount. Creams can produce higher levels of estrogen than standard oral regimens or patches, so blood estrogen levels need to be carefully monitored.

Vaginal creams containing estrogen can be helpful for women who have only vaginal menopausal symptoms such as dryness or itching. Contrary to common belief, estrogen does enter the bloodstream when applied vaginally. Therefore, the same risks and benefits associated with other forms of estrogen also apply to vaginal creams.

What are the benefits of HRT?

According to Dr. Mitzi Krockover, medical director of the Iris Cantor-UCLA Women's Health Center, the most common reason women consider HRT therapy is to alleviate the hot flashes and vaginal dryness of perimenopause.

Another reason that women consider HRT is to protect against certain medical conditions, Krockover says. Estrogen provides protection against osteoporosis and cardiovascular disease. In later menopause, osteoporosis can lead to fractures of the spine, hip, or other bones.

Cardiovascular disease, comprising both stroke and coronary artery disease, is the leading cause of death of older women in the United States. "Estrogen is effective in protecting against cardiovascular disease, even in smokers and women with a history of stroke," reports Krockover.

What about the risks?

Although estrogen seems to be the workhorse of HRT, the progestin shouldn't be neglected. "Studies have shown that if you give estrogen by itself to someone who still has her uterus, she is at increased risk of endometrial cancer (cancer of the uterine lining)," says Krockover. The estrogen-progestin combination seems to reduce this risk. "A woman who has had a hysterectomy, doesn't need the progestin," she adds.

There is also evidence suggesting a link between estrogen use and breast cancer. "There are some studies suggesting that with long-term use (greater than five years), there may be an increase in breast cancer," Krockover acknowledges. But overall she feels that the data from existing studies are inconclusive.

Dosage

The most common prescription is an oral dose of 0.625 milligrams of estrogen and 5 milligrams of progestin. This is about one-sixth the amount of estrogen and progestin found in birth control pills.

You can discuss alternative doses of HRT with your doctor. Some women use low-dose HRT, such as 0.3 milligrams of estrogen and 2.5 milligrams of progestin. These low doses relieve symptoms but probably don't provide the same level of heart or bone protection. Therefore, low dose HRT may be appropriate for women who are not at risk for heart disease or osteoporosis but want relief from the symptoms of menopause.

What else should I know?

Hormone replacement therapy can bring on its own set of symptoms. Some side effects of estrogen include headache, nausea, breast tenderness or enlargement, enlargement of benign tumors of the uterus (fibroids), and retention of excess fluids. Some of the side effects wane with continued use.

If you're considering HRT, be sure to discuss any history of breast or uterine cancer, gall bladder disease, liver disease, or blood clots with your doctor. While these conditions don't automatically rule out HRT, they need to be figured into the equation. Before rushing into HRT, women should also make certain they're not pregnant—a very different cause of interrupted menstruation!

Are there other alternatives?

HRT is not the only treatment for menopausal symptoms. Vaginal dryness can be alleviated simply by using a lubricant. Hot flashes may be reduced or eliminated by identifying and avoiding what triggers them; alcohol or large meals are common culprits. An increased vitamin E intake has also helped to alleviate hot flashes in some women.

Exercise and diet play a significant role in protecting against osteoporosis and cardiovascular diseases. Regular weight bearing exercise helps to reduce bone loss and improve fitness. It also pays to avoid caffeine and smoking, which interfere with calcium absorption. If osteoporosis is a primary concern, physicians can prescribe one of several new drugs on the market that treat low bone density without estrogen.

In the end, the choice to use hormone replacement therapy is a personal decision. Some women take it only until the uncomfortable menopausal symptoms they are experiencing pass. For women seeking protection against osteoporosis and cardiovascular disease, therapy may continue indefinitely.

"It's an individual decision and you make that decision based on your individual risk profile," Krockover explains. Understanding the potential risks and benefits is a large step toward making an informed choice.