Hormone Therapy - Menopausal Care
Making Sense of Postmenopausal Hormone Therapy: Is It Right For Me?
This is a question you need to discuss with your health care provider. Every individual patient has different health issues, intensity of symptoms and family health history. Whether to start or continue hormone therapy is not a "one size fits all" decision. The purpose of this web page is to help you understand all the confusing information about hormones.
Hormone Therapy Overview
If you have stopped menstruating, are in menopause and don't have any troubling symptoms, the risks of taking hormones generally outweigh any health benefits. If you are having symptoms such as hot flashes, night sweats, difficulty sleeping, vaginal dryness, painful sex, or lack of desire, you may be a candidate for hormones.
Prior to menopause, your ovary made two important hormones, estrogen and progesterone. As you age, levels of these hormones decrease, your menstrual cycles may become irregular, and intermittent hot flashes or vaginal dryness may occur. This transition time is called perimenopause.
Menopause occurs with your final menstrual period and is confirmed by 12 months in a row without a period. The average age at which menopause occurs is 51-52, but menopause can occur any time between ages 45-55. About 2-3 women out of 100 will be older or younger than this age range when they go through menopause. Postmenopause is all the years after your final menstrual period.
Types of Hormone Therapy
Menopausal women who are experiencing vaginal dryness, burning, itching or painful intercourse will benefit from vaginal estrogen preparations. They are used locally in the vagina, and can be administered as a cream, a vaginal ring or a vaginal tablet. Doses used are much lower than the dose prescribed to treat hot flashes, and the risks of estrogen therapy are usually seen with higher "systemic" doses, not with the low doses to treat vaginal symptoms.
Hormones prescribed to relieve symptoms such as hot flashes, night sweats, and sleep disturbances are prescribed in higher doses that elevate blood levels and circulate throughout the body. Women who have not had a hysterectomy are prescribed estrogen and a progestin. The progestin protects the uterine lining. Women who no longer have a uterus are prescribed estrogen alone. Estrogens and progestins are available in a variety of forms. The estrogen may be prescribed as an oral tablet, a skin cream, gel or lotion, a patch, or a vaginal ring (higher dose than the ring used for vaginal dryness). Progestins are available in a patch or pill combined with estrogen, a pill containing just progestin, or an IUD or vaginal gel (the IUD and gel are not approved for use in menopausal women in the US, but are used in Canada and Europe).
Bio-equivalent or Bio-identical Hormones
These terms are often used interchangeably and refer to hormone formulations that contain the same form of estrogen and progesterone that your ovary made, 17-beta estradiol and progesterone. Many patients think of these as "natural hormones"; however, all hormones, even if they come from a plant, must go through chemical processes to be extracted. There is no scientific evidence to date showing that these hormone formulations are safer or have less risk than "synthetic hormones." Research is still being conducted to see whether different hormonal products and the way the hormones are taken (oral, patch, skin lotion, etc.) have any safety advantages. You should discuss your preferences with your health care provider.
Benefits of Hormone Therapy
Hormone therapy relieves menopausal symptoms such as hot flashes, night sweats, interrupted sleep, vaginal dryness, painful intercourse and reduced sex drive. It can also reduce the risk of osteoporosis and increase bone density. If estrogen is started within a few years of menopause, it can reduce the risk of heart disease and colorectal cancer.
Risks of Hormone Therapy
Most of the studies conducted on risks and benefits of hormone therapy used higher doses than are commonly prescribed today. Studies show that estrogen plus progestin therapy increases the risk of blood clots (venous thromboembolism), stroke, and breast cancer. If estrogen plus progestin is started 10 or more years after menopause, it increases the risk of heart disease.
Since 2002, more than 13,000 articles have been published in the consumer literature. Patients have been flooded with a sea of confusing information. Surveys have shown that health care professionals are the most important source of information for women considering hormone therapy. The scientific literature is changing as more studies are conducted. Research is ongoing looking at different doses of estrogen, different combinations of hormones, different ways to administer estrogen, and alternatives to estrogen therapy.
The Women's Health Initiative Study (WHI): Understanding the Risks
The Women's Health Initiative, or WHI, was a major study funded by the U.S. government involving 160,000 women. Because this was such a large study, the results received a lot of publicity. The number of women who had either a positive or negative effect was so small, that the study cannot be used to determine what would happen to an individual woman. The average age of women in this study was 63, about 10 years post menopause, much older than women who usually start hormones to relieve symptoms.
The study was not designed to measure the effects of hormones on menopause symptoms, since many of the women in the study were not having symptoms. It was designed to look at other risks and benefits of hormones. The best type of scientific study compares women who take a medication to other women who don't take the medication, but receive an identical appearing dummy pill (placebo). The person in the study doesn't know if they are getting the medication or the dummy pill.
In one section of the WHI study, approximately 16,000 postmenopausal women were prescribed estrogen with progestin or placebo (identical looking dummy pill). The second section of the WHI study involved women who had a hysterectomy and included 10,739 women who took estrogen only or placebo. What did they find?
The results of the WHI showed small increases in the chance of developing breast cancer, heart disease, blood clots or stroke in women who take estrogen plus progestin, and small decreases in the chances of developing hip or spine fractures, and colorectal cancer.
In women taking estrogen alone, it found small increases in the risk of stroke, blood clot, and colorectal cancer and small decreases in the risk of heart disease, breast cancer, and vertebral or hip fractures. In both of these studies, the chance for an individual woman having any of the risks or benefits was less than 0.2 percent per year.
Any of these risks may be increased or decreased by your health status, co-existing medical conditions and family history. The decision whether to start or continue hormone therapy is complex and should also consider the severity of your symptoms and the impact of these symptoms on your quality of life. It is important to discuss the issue fully with your health care provider.