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Hormone Replacement Therapy (HRT) i



Over the past decades, menopausal women have been encouraged to use hormone replacement therapy (HRT) for its apparent health- and youth-preserving benefits. It is true that HRT lowers the risk of osteoporosis and possibly colon cancer.1, 2 But, compared to women not taking hormones, women taking HRT have slightly higher rates of breast cancer, ovarian cancer, heart attack, stroke, blood clots, and Alzheimer’s disease as well as other forms of dementia.2, 3, 4


Although HRT risks are not high for most women, on average, the small risks outweigh the small benefits. As a result, women’s health experts now recommend that, for most women, HRT use should be limited to one or both of the following:


* Short-term menopausal symptom relief.

* Severe osteoporosis risk (when nonhormonal treatments have been considered and/or tried first).


This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor’s recommendation.


Key points in making your decision

Consider the following when deciding whether to start or continue taking hormone replacement therapy (HRT):


* The risks of short-term HRT use are small but significant, particularly for women with preexisting risk factors:5, 2

o After 1 year’s use, HRT is linked to changes on mammograms in 40 out of 1,000 women. These changes aren’t diagnosed as cancer but require further testing.3

o After 5 years’ use, HRT is linked to breast cancer in 4 to 6 out of 1,000 women. This risk increases with prolonged HRT use.2, 5

o The risk of blood clots in the legs or lungs is greatest during the first 2 years, affecting about 6 out of 1,000 women.

* Heart disease is the number one killer of women, and HRT use causes heart disease in a small number of women.6

* Heart risk from HRT does not seem to affect women in their first 10 years after menopause.7, 8 Review your personal heart risk profile versus possible HRT benefits as part of your treatment decision process.

* For perimenopausal symptoms, consider non-HRT treatments, including breathing-for-relaxation exercises; certain antidepressants, low blood pressure medicines, and black cohosh for hot flashes; and vaginal lubricant or vaginal estrogen (cream, ring, or tablet) for dryness and irritation.9

* If you decide to use HRT for symptom relief, use the lowest effective dose for the shortest possible time, and see your doctor regularly to reevaluate your personal benefits and risks.

* HRT helps prevent bone loss and osteoporosis. If you are at high risk for osteoporosis, HRT is one of several treatments you can consider.


Medical Information


What is menopause?


After several years of fluctuating hormone levels and irregular menstruation in your 40s or 50s, your estrogen and progesterone levels begin to decline. After 6 months to 1 year of decline, your estrogen level drops past a certain point, and your menstrual cycle ends. Menopause is the point in time when you’ve had no menstrual periods for 1 year.


During the first year or so after menopause (postmenopause), estrogen levels continue to decline, which can cause perimenopausal symptoms like hot flashes and insomnia or make them worse. After your hormone levels reach a stable low point, these symptoms are likely to subside. This typically takes 1 to 2 years. But some women continue with symptoms for years, perhaps because their estrogen levels are lower than average.


Low estrogen is part of the healthy, natural state of the postmenopausal phase of life—it is tailored to the way your body is meant to function after your childbearing years. Low estrogen is good for you in the sense that it lowers your hormone-related cancer risk. But because estrogen also plays an important role in skin and bone health, low estrogen creates some health concerns for the postmenopausal woman.


* Following years of gradual decline in bone density and strength, low estrogen after menopause speeds up bone loss, which increases your risk of osteoporosis.

* Low estrogen leads to low collagen, a building block of skin and connective tissue. As a result, the vaginal lining and the lower urinary tract also thin and weaken. This condition, called genitourinary atrophy, can make sexual relations difficult and can increase the risk of vaginal and urinary tract infection.


What other treatments are available for perimenopausal symptoms?


Although the perimenopausal transition itself is a natural body change that doesn’t require treatment, severe symptoms can disrupt a woman’s life and sense of well-being. The first and best approach to reducing your perimenopausal symptoms (and long-term health risks related to aging) is to lead a healthy lifestyle—avoid excess caffeine, alcohol, and stress; eat well; and exercise regularly.


If you need additional relief, you have several non-HRT treatment options to choose from. Slow, rhythmic breathing exercises may help you manage hot flashes and emotional symptoms. Vaginal lubricants (such as Astroglide or K-Y Jelly) are useful for vaginal dryness, and vaginal estrogen (cream, ring, or tablet) can help with vaginal dryness and irritation. Certain types of antidepressants or blood pressure medication (clonidine) may reduce hot flashes. Black cohosh may help with hot flashes and other hormone-related symptoms.


Before menopause, you can also consider low-dose estrogen-progestin birth control pills for perimenopausal symptoms and pregnancy prevention, as long as you have no risk factors for heart disease or breast cancer and you do not smoke.


What is hormone replacement therapy (HRT)?


Estrogen replacement therapy (ERT) refers to the daily use of estrogen to increase a woman’s hormones to premenopausal levels. Women with a uterus who take estrogen also need the hormone progestin to prevent the estrogen from affecting the uterine lining (endometrium), which can lead to endometrial cancer. The combination of estrogen and progestin is called hormone replacement therapy (HRT). Women with a uterus take HRT. Women who have had a hysterectomy to remove the uterus take ERT.


The U.S. Food and Drug Administration (FDA) has updated its HRT recommendations and now only approves estrogen-progestin HRT for:


* Short-term treatment of perimenopausal symptoms. Women who do decide that HRT benefits outweigh their risks are advised to use the lowest effective dose for as short a time as possible, not exceeding 3 or 4 years.

* Osteoporosis prevention and treatment, in select, severe cases. Most experts recommend that HRT only be considered for women with significant risk of osteoporosis that outweighs their risks from taking HRT.10 Women are now encouraged to consider all possible osteoporosis treatments and to compare their risks and benefits.11 For more information, see the topic Osteoporosis.


The FDA is reviewing its ERT recommendations, based on March 2004 stroke risk information from the Women’s Health Initiative ERT study.12 Other low-dose ERT research is currently in progress.


What are the benefits of taking estrogen?


When taken as ERT or HRT, estrogen: 2, 1


* Helps prevent osteoporosis after menopause by slowing bone loss and promoting some increase in bone density.1

* Reduces hot flashes and sleep problems in most, but not all, women.1

* Maintains the lining of the vagina, reducing irritation.

* Maintains skin collagen levels, which decline as estrogen levels decline. Collagen is responsible for the stretch in skin and muscle.

* Increases the amount of HDL (“good”) cholesterol and decreases the amount of LDL (“bad”) cholesterol in the blood.

* Reduces the risk of dental problems, such as tooth loss and gum disease.

* May reduce the risk of colon cancer.2


What are the risks of hormone replacement therapy?


HRT increases   the risks of breast cancer, ovarian cancer, blood clots, heart disease, stroke, and dementia. Estrogen alone (ERT) is also linked to increased stroke, ovarian cancer, dementia, and possible breast cancer risk.13, 5, 14 No particular form or dosage of ERT or HRT has been proved safer than another.15


Among the women using HRT in the recent Women’s Health Initiative trials, most did not develop major health problems. But after the first 1 to 4 years of using HRT, a small yet significant number of women did develop signs of cancer, blood clots, heart disease, stroke, and dementia.2, 3, 4


* Within the first 2 years, HRT use slightly increased the risk of blood clots in the lungs (pulmonary embolism) and legs (deep vein thrombosis) in all healthy postmenopausal women regardless of risk factors.16

* During the second year, HRT use began to slightly increase heart attack and stroke risk in all healthy postmenopausal women, regardless of risk factors. Early signs of heart disease first became apparent during the first year of use.16, 6 Heart disease risk does not increase for women in the first 10 years after menopause.17, 7, 8

* After 1 year, HRT use increased the number of abnormal mammograms by approximately 4% each year. Daily estrogen-progestin increased breast density compared with estrogen alone or placebo. Although the abnormal mammograms required additional medical evaluation, they were not linked to an early increase in breast cancer. Studies are ongoing to learn more about breast density change from HRT.3

* After 4 years of use, HRT-related breast cancers first became apparent. The number of HRT-related breast cancers increased with each additional year of HRT use. Women taking HRT generally had larger, more advanced tumors than women who developed breast cancer while taking a placebo treatment.2 (But some of these cancers may respond more favorably to treatment.)18


by Robin Parks, MS


Natural hormone replacement therapy (HRT) – Menopause