HEALTH & WELLNESS

All About Hormone Replacement Therapy By Lisa Sousou

While menopause - the complete cessation of menstrual periods - can be a welcome milestone in a way for many women, the years leading up to menopause, or peri-menopause, can be less welcomed. During these years, estrogen levels decline, leading to irregular menstrual periods. Also during this time, some women will begin to experience symptoms such as hot flashes, night sweats, sleep disruptions, mood changes or depression, and/or vaginal dryness, while others will experience few problematic symptoms at all. These symptoms can be short-lived, or can last for several years to a decade, even after menopause occurs, and into postmenopause (the time after menopause occurs).

For some women, these symptoms are mild and tolerable. For others, they can be severe. For women who have life-disrupting symptoms, sometimes medication can help. One of the most helpful therapies is often hormone replacement therapy, or HRT.

Hormone replacement therapy is used to boost the declining estrogen levels enough to help relieve distressing symptoms. Women who have a uterus and who take estrogen must take a second hormone, called progestin, along with it. This reduces the risk of cancer of the uterus, which can occur if estrogen is taken alone. Women who have had their uterus removed (a hysterectomy) can take estrogen alone.

What are the options for forms of hormone replacement therapy, and what are their benefits?

HRT can be taken as a pill, a patch, a vaginal ring, or even a gel or a spray to use on the skin. All of these forms are absorbed into the bloodstream and boost the estrogen levels throughout the body. These medications can help reduce symptoms like hot flashes, insomnia, and mood changes, as well as vaginal dryness and pain with intercourse. Some contain both estrogen and progestin; others only contain estrogen, in which case women with a uterus may need to take a separate progestin medication.

Although HRT is not prescribed for this specifically, it also helps lower the risk of bone fractures from osteoporosis (low bone density).

Estrogen alone can also be used in the form of vaginal creams, vaginal inserts, or a different, lower-estrogen vaginal ring. These forms only boost estrogen levels in the vagina, helping to relieve vaginal symptoms. They only provide a small dose of estrogen, and do not help with other perimenopausal symptoms. Their benefit is that they avoid systemic (whole-body) hormone dosing, which can have some associated risks.

What are the risks of hormone replacement therapy?

Many women may have concern about risks associated with HRT based on the Women’s Health Initiative (WHI) study, which initially released news in the early 2000s. This study did find an increase over time in breast cancer, heart attacks, strokes, and blood clots in postmenopausal women who took HRT containing estrogen and progestin. The risk of heart attacks increased more in women 60 and older. Oral medications may have more associated risk of clots than non-oral medications.

In women who took estrogen only, the risk of blood clots and stroke were also increased, but the risk of blood clots was not as high as with estrogen-progestin HRT. No increase in breast cancer

or heart attacks was found - in fact, in women in their 50s, risk of coronary heart disease decreased.

With these risks in mind, the current recommendations for women who want to take HRT for their menopausal symptoms are to take the smallest dose that relieves symptoms for the shortest amount of time needed. A general recommendation is often for five years or less. Within this short timeframe, the risks are low. Beyond this time period, a discussion of your personal benefits versus risks with your health care provider is a good idea.

Is there anyone who should not take HRT?

Women who have, or have had, breast cancer, heart disease, stroke, blood clots, or a blood disorder that increases their risk of blood clots should avoid HRT. Women who may be at increased risk for these conditions - for example, BRCA gene mutation, or family history of breast cancer - should discuss their personal benefits vs. risks with their health care provider.

If I have menopausal symptoms, but cannot take HRT or do not want to, what are my alternatives?

Soy-containing foods or soy-based over-the-counter supplements contain phytoestrogens, which are similar to estrogen, and may help with menopause-related symptoms in some women. An herbal supplement called black cohosh is also commonly used for hot flashes. Because these are considered supplements, they are not regulated like medications are. Some antidepressants have been shown to help with hot flashes and may also help with mood changes and depression associated with perimenopause or menopause. An antiseizure drug (gabapentin) and a blood pressure medication (clonidine) can also help with hot flashes, and an oral medication called ospemifene can help with vaginal dryness and pain with intercourse. (Ospemifene may actually cause or increase hot flashes, and may increase risk of blood clots and cancer of the uterus; it has not been studied in women who have had, or are at high risk for, breast cancer.)

The bottom line

Hormone replacement therapy is a highly effective treatment f or many perimenopausal/menopausal symptoms and poses low risks to most women who are under 60 and within 10 years of menopause when taken for five years or less. If perimenopausal symptoms are causing distress, discuss with your health care provider whether HRT is a good choice for you. SWM

For more information: The North American Menopause Society (NAMS): menopause.org The American College of Obstetricians and Gynecologists (ACOG): acog.org

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Pictured left to right are: Lisa Sousou, PA, Dinah Olson, PA and Heather Shannon, NP.

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