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Hormone Replacement Therapy (HRT) ii

Your risks It is impossible to know whether you will develop health problems from HRT. If you have no personal or family history of breast cancer, ovarian cancer, heart attack, stroke, blood clots, and dementia, your increased HRT risks are likely to be small. If you have a personal or family history of breast cancer, ovarian cancer, or heart disease, your HRT risks are likely to be higher than average, making the risks outweigh the benefits. If you have had breast cancer, which can be triggered or made worse by estrogen, taking HRT is not safe for you.   Low-dose Hormone Replacement Therapy (HRT) The typical HRT dose is 0.625 mg of estrogen plus 2.5 mg of progestin. In March 2003, the FDA approved a low-dose version of Prempro, containing 0.3 mg of estrogen and 1.5 mg of progestin. This low-dose version may help hot flashes and bone density and is hoped to reduce the risks related to higher-dose HRT, but it needs more study.   Low-dose estrogen for osteoporosis. Researchers are studying the effects of low-dose estrogen therapy. A small early study has shown that a low estrogen dose—0.25 mg per day—may keep the bones as strong as the higher dose.19 But the long-term risks of taking low-dose estrogen are not yet known.   How and when do I stop taking hormone replacement therapy? There is no way of knowing in advance whether you will have perimenopausal symptoms when you stop using HRT (or ERT). While some women have no symptoms, others are mildly affected, and some have moderate to severe symptoms. Most women find that their symptoms subside over time.   How to stop Hormone Replacement Therapy (HRT) There are currently no evidence-based guidelines for stopping HRT. Talk to your doctor about how you should stop HRT. Your doctor may want you to stop HRT right away or try tapering off. You may taper off by lowering your daily dose, increasing the time between dosages, or trimming back an estrogen patch over time.   When to stop Hormone Replacement Therapy( HRT) Ultimately, it is up to you and your doctor to decide how long you will take HRT. After weighing the risks, some women will continue to take HRT for years to come, while others stop as soon as they learn of the risks. If you have been taking HRT for many years, talk to your doctor about stopping HRT. There are currently no evidence-based guidelines for when to stop short-term HRT.15 But based on the risks, HRT use for 4 or more years is considered “long term.” If you develop symptoms when tapering or suddenly stopping HRT, consider how severe your symptoms are, what other treatment options are available for symptom relief, and how long you’ve been taking HRT. You can:   * Slightly increase your HRT dose until symptoms subside. After another 6 months to 1 year, try to taper off again. * Continue with your plan to stop HRT and see whether symptoms subside over a few months. * Continue with your plan to stop HRT and try another type of treatment.   More information, see the topic Menopause and Perimenopause.   Your Information   If you have decided that you are in need of symptom treatment after menopause or that you need to treat or prevent osteoporosis, your choices are:   * Use another treatment for perimenopausal symptoms or osteoporosis prevention. * Use low-dose hormone replacement therapy for the shortest time possible.   The decision about whether to take hormone replacement therapy takes into account your personal feelings and the medical facts.   Making a decision about Hormone Replacement Therapy (HRT)    Reasons to take Hormone Replacement Therapy (HRT) Low-dose, short-term HRT (up to 4 years). You have no risk factors for heart disease, blood clots, stroke, or breast or ovarian cancer, are willing to accept the small increase in risks of cancer and heart disease, and you:   * Have considered or tried other treatments. * Have moderate to severe perimenopausal symptoms that are disrupting your sleep and/or daily life.   Long-term Hormone Replacement Therapy (HRT). You are willing to accept the breast and ovarian cancer, blood clot, heart disease, and possible dementia risks of continuing HRT for longer than 4 years, and you:   * Are at high risk for osteoporosis and have considered or tried other osteoporosis therapies. * Have long-standing perimenopausal symptoms (such as hot flashes) that only HRT will relieve.   Are there other reasons you might want to take hormone replacement therapy?   Reasons to not take Hormone Replacement Therapy (HRT)   * You have not considered or tried other treatment options. * You are concerned about blood clot and stroke risk. * You are 10 or more years past menopause and are concerned about heart disease risk. * You have been taking HRT for longer than 4 years and are concerned about increased cancer and dementia risks. * You only have vaginal or urinary tract symptoms, which can be treated with vaginal estrogen (cream, ring, or tablet). * You need a preventive treatment for heart disease or stroke (HRT does not prevent these conditions).   Do not use Hormone Replacement Therapy (HRT) if you have   * A personal history of breast cancer, ovarian cancer, or endometrial cancer. * A personal history of pulmonary embolism, deep vein thrombosis, heart attack, or stroke. (Your risks may also be higher if you have a family history of these conditions.) * Vaginal bleeding from an unknown cause. * Active liver disease (oral estrogen stresses the liver; an estrogen patch or cream does not).   Are there other reasons you might not want to take hormone replacement therapy?   * Have considered or tried other treatments. * Have moderate to severe perimenopausal symptoms that are disrupting your sleep and/or daily life.   Long-term HRT. You are willing to accept the breast and ovarian cancer, blood clot, heart disease, and possible dementia risks of continuing HRT for longer than 4 years, and you:   * Are at high risk for osteoporosis and have considered or tried other osteoporosis therapies. * Have long-standing perimenopausal symptoms (such as hot flashes) that only HRT will relieve.   Are there other reasons you might want to take hormone replacement therapy?   * You have not considered or tried other treatment options. * You are concerned about blood clot and stroke risk. * You are 10 or more years past menopause and are concerned about heart disease risk. * You have been taking HRT for longer than 4 years and are concerned about increased cancer and dementia risks. * You only have vaginal or urinary tract symptoms, which can be treated with vaginal estrogen (cream, ring, or tablet). * You need a preventive treatment for heart disease or stroke (HRT does not prevent these conditions).   Do not use HRT if you have:20   * A personal history of breast cancer, ovarian cancer, or endometrial cancer. * A personal history of pulmonary embolism, deep vein thrombosis, heart attack, or stroke. (Your risks may also be higher if you have a family history of these conditions.) * Vaginal bleeding from an unknown cause. * Active liver disease (oral estrogen stresses the liver; an estrogen patch or cream does not).   Are there other reasons you might not want to take hormone replacement therapy?    References    Citations   1.          Speroff L, Fritz MA (2005). Menopause and the perimenopausal transition. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 621–688. Philadelphia: Lippincott Williams and Wilkins. 2.          Rossouw JE, et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288(3): 321–333. 3.          Chlebowski T, et al. (2003). Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: The Women’s Health Initiative randomized trial. JAMA, 289(24): 3243–3253. 4.          Shumaker SA, et al. (2003). Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. The Women’s Health Initiative memory study: A randomized controlled trial. JAMA, 289(20): 2651–2662. 5.          Million Women Study Collaborators (2003). Breast cancer and hormone-replacement therapy in the Million Women Study. Lancet, 362(9382): 419–427. 6.          Manson JE, et al. (2003). Estrogen plus progestin and the risk of coronary heart disease. New England Journal of Medicine, 349(6): 523–534. 7.          Prentice RL, et al. (2006). Combined analysis of Women’s Health Initiative observational and clinical trial data on postmenopausal hormone treatment and cardiovascular disease. American Journal of Epidemiology, 163(7): 589–599. 8.          Rossouw JE, et al. (2007). Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA, 297(13): 1465–1477. 9.          North American Menopause Society (2004). Treatment of menopause-associated vasomotor symptoms: Position statement of the North American Menopause Society. Menopause, 11(1): 11–33. 10.         National Heart, Lung, and Blood Institute (2007). Postmenopausal hormone therapy: Questions and answers about estrogen-plus-progestin hormone therapy. Available online: http://www.nhlbi.nih.gov/health/women/q_a.htm. 11.          American College of Obstetricians and Gynecologists (2003). Statement of the American College of Obstetricians and Gynecologists on hormone therapy for the prevention and treatment of postmenopausal osteoporosis. ACOG News Release. Available online: http://www.acog.com/from_home/publications/press_releases/nr10-07-03.cfm. 12.          U.S. Food and Drug Administration (2004). FDA plans to evaluate results of Women’s Health Initiative study for estrogen-alone therapy. FDA Talk Paper T04-06. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01281.html. 13.          Women’s Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701–1712. 14.          Beral V, et al. (2007). Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet, 369(9574): 1703–1710. 15.          North American Menopause Society (2007). Position statement: Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of the North American Menopause Society. Menopause, 14(2): 168–182. 16.          Wassertheir-Smoller S (2003). Effect of estrogen plus progestin on stroke in postmenopausal women. The Women’s Health Initiative: A randomized trial. JAMA, 289(20): 2673–2684. 17.          Grodstein F, et al. (2006). Hormone therapy and coronary heart disease: The role of time since menopause and age at hormone initiation. Journal of Women’s Health, 15(1): 35–44. 18.          Kerlikowske K, et al. (2003). Prognostic characteristics of breast cancer among postmenopausal hormone users in a screened population. Journal of Clinical Oncology, 21(23): 4314–4321. 19.          Prestwood KM, et al. (2003). Ultralow-dose micronized 17 B-estradiol and bone density and bone metabolism in older women. JAMA, 290(8): 1042–1048. 20.          Holmberg L, Anderson H (2004). HABITS (Hormonal replacement therapy after breast cancer—Is it safe?), a randomized comparison: Trial stopped. Lancet, 363(9407): 453–455.   by Robin parks, M.S.