Estrogen therapy is the most effective prescription drug for treating menopausal symptoms.
Hormone therapy (HT) refers to estrogens or estrogen / progesterone combination therapy.
And in light of recent research, it remains safe and effective for many women when used for less than five years.
Estrogen therapy reduces or eliminates various symptoms of menopause, such as hot flashes, disturbed sleep as a result of hot flashes, and vaginal dryness.
There are other safe and effective non-hormonal medications to address a woman’s concerns regarding osteoporosis .
The use of estrogen therapy without progesterone (progestin) is associated with an increased risk of uterine cancer (endometrial cancer, cancer of the lining of the uterus).
Treatment with progesterone along with estrogen substantially reduces the risk of uterine cancer (endometrial cancer).
So the risk of developing this type of cancer is equivalent to that of women not taking estrogen.
Users of oral hormone therapy (HT) for more than five years have a slightly higher risk of breast cancer, heart disease, and stroke than those who do not use it.
The term “hormone therapy” or “HT” is used to replace the outdated terminology “hormone replacement therapy” or “HRT.”
What is menopause?
Menopause is the stage in a woman’s life when menstruation stops and she can no longer have children. During menopause, the body produces less female hormones, estrogen, and progesterone.
After menopause, lower hormone levels cause monthly menstrual periods to stop and gradually eliminate the possibility of getting pregnant.
These fluctuations in hormone levels can also cause troublesome symptoms, such as hot flashes (a sudden feeling of heat, sometimes associated with flushing) and sleep disturbances.
Sometimes women experience other symptoms, such as vaginal dryness and mood swings.
While many women experience little or no problems during menopause, others experience moderate to severe discomfort.
Does menopause cause bone loss?
Lower menopausal estrogen levels can lead to progressive bone loss that is especially rapid in the first five years after menopause.
Some bone loss in both men and women is normal as people age.
The lack of estrogen after menopause adds another strain on the bones in addition to the usual age-related bone loss.
When bone loss is severe, a condition called osteoporosis weakens bones and makes them susceptible to breakage.
Some of the symptoms of menopause can actually start years before menstrual periods stop occurring.
Doctors generally use the term “perimenopause” to refer to the period of time from before menopause to the first year after menopause.
Menopause itself is defined as having 12 consecutive months without a menstrual period.
Menopause symptoms begin gradually as the ovaries continue to function and a woman still has menstrual periods.
These symptoms can begin as early as the fourth decade of life (when a woman is in her 30s) and can persist for years until menopause occurs.
Symptoms occur early because the levels of hormones produced by the ovaries (estrogen and progesterone) slowly decrease over time.
The severity and duration of symptoms vary widely between people.
Some women may experience only minimal symptoms for a year or two, while others may experience at least some of the symptoms for several years.
While most women will experience a gradual transition to menopause with a slow onset of symptoms, some women will experience early menopause.
A common cause of immediate symptoms is “surgical menopause” after surgical removal of functional ovaries.
The symptoms of menopause can be perceived as physical problems, emotional disorders, or problems associated with sexual functioning.
What are estrogen therapy and hormone therapy (HT)?
Estrogen, in pill, patch, or gel form, is the most effective therapy for suppressing hot flashes. The term estrogen therapy, or ET, refers to estrogen given alone.
Because ET alone can cause cancer of the uterus (endometrial cancer), a progestin is given along with estrogen in women who have a uterus to eliminate the increased risk.
Therefore, the term estrogen / progestin therapy, or EPT, refers to a combination of estrogen and progestin therapy, as given to a woman who still has a uterus.
This method of prescribing hormones is also known as combination hormone therapy.
The term hormone therapy (HT) is a more general term that is used to refer to both the administration of estrogen alone, and combined estrogen / progestin therapy (women with a uterus).
All forms of hormone therapy (HT) that are FDA approved for the treatment of hot flashes are equally effective in suppressing hot flashes.
What are the side effects and risks of hormone therapy?
Women can experience side effects during hormone therapy; These can be divided into more minor side effects and more serious side effects.
Minor side effects are more common than serious side effects, and are generally perceived by women as “bothersome.” These symptoms include: headaches, nausea, breast pain.
It is still controversial which of these side effects are due to the estrogen component compared to the progesterone component.
Therefore, if side effects persist for a few months, the doctor will often alter the progesterone or estrogen part of the hormone therapy.
Recent research has confirmed that women taking commonly prescribed doses of hormone therapy are no more likely to gain weight than women not taking hormone therapy.
This is probably because menopause or aging itself is associated with weight gain, regardless of whether or not a woman is taking hormone therapy.
The most serious health concerns for women on hormone therapy include:
It increases the risk of venous clots in the legs (deep vein thrombosis) and blood clots in the lungs (pulmonary embolism) by about 2-3 times.
However, it is important to remember that these conditions are extremely rare in healthy women. Therefore, the true increase in risk for healthy women is minimal.
Women with a personal or family history of these blood clots should review this topic when considering hormone therapy (HT).
Uterine cancer (endometrial cancer)
Research shows that women who have their uterus and use estrogen only are at risk for endometrial cancer. Today, however, most doctors prescribe the combination of estrogen and progestin.
Progestin protects against endometrial cancer.
If there is a particular reason why a woman with a uterus cannot take some form of progesterone, her doctor will take a tissue sample from the uterus.
Women without a uterus (women who have had a hysterectomy) are not at risk for endometrial cancer.
Recent research indicates that hormone therapy (HT) and especially EPT increase the risk of breast cancer, although the increase in risk is very small.
The increased risk of breast cancer associated with hormone therapy (HT) probably increases with the duration of use and especially increases with five or more years of use.
Although hormone therapy (HT) lowers bad LDL cholesterol and raises good HDL cholesterol, hormone therapy (HT) increases the risk of heart attacks in women who already have heart disease.
Hormone therapy (HT) does not prevent heart attack based on recent research from the Women’s Health Initiative.
Abnormal vaginal bleeding
Women on hormone therapy (HT) are more likely than other postmenopausal women to experience abnormal vaginal bleeding. What is called “abnormal bleeding” depends on the type of hormone therapy (HT).
With cyclical therapy, in which monthly bleeding is expected, bleeding is abnormal if it occurs when it is not expected or is excessively heavy or long-lasting.
With continuous daily therapy, irregular bleeding can last from six months to a year, therefore, irregular bleeding that lasts for more than a year is considered abnormal.
When abnormal bleeding occurs, a doctor usually takes a sample of the lining of the uterus (endometrial biopsy) to rule out an abnormality or cancer in the uterus .
This procedure is usually done in the office. After the evaluation is done, if nothing is found wrong, hormone therapy (HT) doses will often be adjusted to minimize abnormal bleeding.
Hormone therapy (HT) slightly increased the risk of stroke in women studied in the Women’s Health Initiative.
The WHI predicted that there were 8 additional strokes for every 10,000 women who took hormone therapy (HT) for one year, compared to women who took a placebo (sugar pill).
Due to the potential for increased risks of breast cancer, stroke, and heart disease, women who do not have significant menopausal symptoms may choose to avoid hormone therapy (HT).
The effects of other types of hormone therapy (HT) (in addition to the Women’s Health Initiative types) on breast cancer risk are still unclear.
How is hormone therapy prescribed?
Doctors generally prescribe hormone therapy (HT) as a combination of estrogen and another female hormone, progesterone. Synthetic progesterone compounds are known as progestins.
Long-term use of estrogens without progesterone increases the risk of uterine cancer (endometrial cancer), while the addition of progesterone counteracts this risk.
Therefore, estrogen without progestin is generally only recommended for women who have had their uterus removed (hysterectomy).
Estrogen is available in the form of pills, tablets, patches, creams, mist sprays, or vaginal preparations (vaginal rings, vaginal tablets, or vaginal cream).
The choice of estrogen preparation recommended by the doctor depends on the woman’s symptoms.
For example, vaginal creams, vaginal tablets, and vaginal rings are used for vaginal dryness, while pills or patches are used to relieve hot flashes.
Estrogen pills are also helpful for vaginal dryness and are sometimes used in conjunction with vaginal creams, tablets, or rings.
Although progestin is generally taken in pill form, it is also available, along with estrogen, in patch form. Doctors can prescribe different times to take hormone therapy (HT).
The treatment and hormone therapy (HT) schedule for each woman should be individualized based on her particular situation.
Sometimes continuous daily therapy can cause unexpected and irregular vaginal bleeding during the first few months of treatment, especially in younger women entering menopause.
For these women, and for some other women, planned cyclical bleeding is more acceptable. In these women, progesterone is usually added to estrogen during the first 12 calendar days of the month.
Patches and mists (transdermal therapy)
Hormone therapy (HT) skin patches must be worn continuously. Newer patches should be changed once or twice a week.
Combination estrogen / progesterone patches are available to women who have not had a hysterectomy to prevent uterine cancer.
The patches are as effective as oral hormone therapy (HT) in controlling hot flashes.
Spray mists for ET are available as a transdermal spray that is used once a day.
Vaginal tablet rings and creams
Vaginal estrogen tablets and creams are usually prescribed in the evening for 2 weeks, then reduced to twice a week as a long-term “maintenance therapy.”
There is a low level of estrogen absorption in the body with the use of vaginal preparations as directed.
Circulating blood levels of estrogen increase slightly with the use of vaginal estrogens, and the long-term safety of vaginal estrogen rings, creams, and tablets has not been clearly established.
For this reason, the occurrence of vaginal bleeding during any type of vaginal estrogen use should be promptly assessed.
Vaginal estrogen rings are approved to treat genital dryness and irritation that can occur due to a lack of estrogen in women after menopause.
The vaginal ring remains in place for 12 weeks, after which it can be changed by the woman herself or by her doctor.
The long-term safety of the estrogen rings is still unclear, but there is a low level of absorption of the hormone into the bloodstream with the use of the vaginal estrogen ring.
Bioidentical Hormone Therapy
There has been a growing interest in recent years in the use of so-called “bioidentical” hormone therapy for perimenopausal women.
Bioidentical hormone preparations are drugs that contain hormones that have the same chemical formula as those that occur naturally in the body.
Hormones are created in a laboratory by altering naturally occurring compounds derived from plant products.
Some of these bioidentical hormone preparations are approved by the US FDA.
And made by pharmaceutical companies, while others are made in special pharmacies called compounding pharmacies, which make preparations on a case-by-case basis for each patient.
These individual preparations are not regulated by the FDA because the composite products are not standardized.
Who should take hormone therapy?
Women with hot flashes, especially when they are causing sleep disturbances, may consider hormone therapy (HT).
Short-term estrogen is the most effective treatment for hot flashes.
Women with vaginal dryness or itching due to menopause may consider HT. Oral pills, skin patches, gel, or vaginal forms of estrogen can be used.
Women who only have vaginal menopausal symptoms and who do not experience hot flashes should take a vaginal form of estrogen.
Sometimes if a woman has both vaginal hot flashes and symptoms, both oral and vaginal forms of ET will be prescribed, especially if vaginal symptoms do not improve with oral ET alone.
It is recommended that women who choose to take hormone therapy take the lowest effective dose for the shortest period of time possible.
Who Shouldn’t Take Hormone Therapy?
Contrary to the common myth, women with drug-controlled high blood pressure can take hormone therapy (HT) because hormone therapy (HT) does not cause significant elevations in blood pressure.
An important medical reason for not taking hormone therapy (HT) is a personal medical history of breast or uterine cancer.
Women with abnormal vaginal bleeding should undergo an evaluation before starting hormone therapy (HT) to exclude the presence of uterine cancer.
Similarly, routine mammograms and breast exams are important to exclude the presence of breast cancer.
While hormone therapy (HT) can be used in women with migraines or liver disease, certain types of hormone therapy (HT) may be chosen to try to prevent these conditions from worsening.
Women with a personal history of deep vein thrombosis (blood clots in the veins) should avoid hormone therapy (HT).
Women with phosopholipid antibodies, including cardiolipin antibodies or anticoagulant lupus, should not take HT due to the added risk of blood clotting and thrombosis.
What medical check-ups are recommended for women on hormone therapy?
All women who receive hormone therapy (HT) must have a medical check-up every year.
At that time, the doctor or nurse will do a breast exam and order a mammogram (a special x-ray image of the breasts) to look for breast lumps that may be cancerous.
At or even before these check-ups, a woman should discuss her bleeding pattern with her doctor to make sure it is within the expected pattern for her specific type of hormone therapy (HT).
Other routine screening evaluations can also be done at this annual checkup.
What if a woman decides not to use hormone therapy (HT)?
If a woman chooses not to use hormone therapy (HT), there are other ways to treat menopausal symptoms.
Although hormone therapy (HT) is far superior to other medications in relieving hot flashes, other non-hormonal prescription medications can also reduce hot flashes.
Similarly, personal lubrication products, such as a water-soluble jelly (not petroleum jelly) can be applied to the vagina to reduce dryness.
A woman may also want to ask her doctor about prescription non-hormonal osteoporosis medications. These new treatments appear safe and effective in preventing fractures.