Hormone Therapy in Menopause
Written by Dr. Michael Nielsen

Menopause is the name of the condition woman experience when their ovaries stop producing estrogen. Pre-menopause or the perimenopause is the time before the menopause when the ovaries still produce estrogen but on an inconsistent basis. Menopause is defined by the absence of menstruation and is often accompanied by symptoms such as hot flashing, night sweats, and vaginal dryness. These changes can vary from mild to severe and last from a few months to many years. Since estrogen affects
most areas of our bodies, the onset of menopause effects many changes within us, such as loss of bone, progression of heart disease, and skin changes.

Replacing estrogen at time of menopause is very controversial and unfortunately associated with fear and misunderstanding. The purpose of this article is to try to put things in perspective, explain risks and benefits, and hopefully help you make an informed decision regarding what is best for you.

Hormone therapy means replacing both female hormones (estrogen and progesterone) if you have a uterus, and replacing just estrogen if you have had a hysterectomy. Hormones can be replaced in numerous ways including
pills, patches, creams and lotions, vaginal rings, vaginal creams and tablets, implants, and injections. The transdermal and vaginal routes have safety advantages but also several drawbacks, including skin irritation, invasiveness, and cost. Most women use the oral (pill) route, but individual choice is usually the determining factor.

In discussing risks and benefits, it is important to keep things in perspective. While hormone therapy may be important, other factors may have much greater impact on your health; these include health factors such as weight, exercise, diet, smoking, alcohol, and other drug use. In general, the benefits associated with hormone therapy will be less than those associated with a healthy life style, and the associated risks of hormone replacement are frequently over estimated.

A review of benefits includes:

1) Vasomotor Symptoms: Estrogen or estrogen plus progesterone are highly effective for alleviating hot flashing and night sweats. For severe symptoms, estrogen is much more effective than other advocated and/or advertised alternatives.
2) Sexual Difficulties: Estrogen is effective for treating the vaginal dryness and atrophic (aging) changes that impact sexual function. Vaginal and oral routes are effective. Lubricants help but do not treat the actual
atrophic changes.
3) Skin: Estrogen may increase collagen content and skin thickness and reduce wrinkling in non- sun exposed areas.
4) Genitourinary Tract: Local estrogen may decrease urinary tract infections and improve symptoms of atrophic vaginitis. Estrogen does not improve urinary incontinence.
5) Depression: Some woman find that estrogen prevents depression, but estrogen in not used for primary treatment of depression.
6) Cognition: Estrogen seems to help the ‘thinking' process in some woman. It does not prevent or treat dementia. The timing of when estrogen is replaced may play a role both in risk and benefit.
7) Osteoporosis: The thinning of bones is a major health risk in some postmenopausal women. This risk increases with age. Estrogen is effective in preventing and treating osteoporosis and may be used as first line treatment and/or prevention in some circumstances. Estrogen does decrease the risk of fractures.

A review of risks includes:

1) Breast Cancer: Evidence from a major study showed that estrogen plus progesterone increased the risk of breast cancer. The absolute risk remains low (an additional 20 cases per 10,000 women over 5 years) but the risk does increase. The same study showed that estrogen alone did not increase the incidence of breast cancer. On balance, multiple studies have shown an increased risk, but many studies do not confirm this risk.
2) Thromboembolic Disease: Hormone therapy increases the risk of venous thromboembolism by 2- fold. The risk of pulmonary embolism (a clot going to the lung) is also increased. These risks are highest in the first year, then decrease significantly. Transdermal estrogen seems to decrease or eliminate this risk.
3) Stroke: Studies show a small but consistent increase in stroke, mainly in woman older than 65.
4) Pancreatitis and Cholecystitis: Inflammation of the pancreas is a rare but serious risk of estrogen therapy. Woman with high triglyceride levels are at risk. Estrogen increases the risk of gallstones and subsequent surgery.

Neutral for risk/benefits:

1) Weight and Diabetes: Hormone therapy does not cause weight gain or make diabetes
better or worse.
2) Arthritis: Hormone therapy has no effect on common types of arthritis.
3) Other Cancers: Long term (more than 10 years) estrogen therapy may increase the risk of ovarian cancer. Combined estrogen and progesterone therapy decreases the risk of uterine cancer. Hormone therapy reduces the risk of colon cancer.

Questions and answers:

What is new in hormone therapy?
The latest look at the information available shows that not all age groups respond the same to hormone therapy. There is a "window of opportunity" in newly menopausal woman in which hormone therapy decreases cardiovascular risks. Waiting 5 years or longer and then starting therapy may have an opposite effect. This information may be particularly reassuring to woman who are newly menopausal and who are having significant symptoms.

Who should be on hormone therapy?
There is often no right or wrong answer to this question. The severity of menopausal symptoms, family history, medical conditions, age, and personal choice are all major factors in you making the right choice. Yes or no should be an individual choice after education and consultation with your health care provider. Most women who experience premature menopause, either from premature ovarian failure or surgery, should go on hormone therapy to prevent early osteoporosis, heart disease, and to prevent sexual dysfunction.

Which estrogen should I use?
The concept that ‘bioidentical estrogen' is the best estrogen to use is not based on reliable scientific information. Many of the FDA approved products fit the definition of bioidentical. There is ongoing concerns that compounded products vary in content and/or purity. Compounded products are not subject to oversight testing and may vary significantly in content and dosage. While there are theoretical reasons one type of estrogen may be superior to another, there is limited scientific evidence to prove this claim. The right estrogen for you is probably the one you choose.

How reliable is the information that is available and how reliable will a decision be that is based on this information?
Every year the knowledge base increases and becomes more reliable, but there is a great amount of information that is not available, and probably will not be available for many years. Any recommendation made by your provider and any decision you make should be based on the best information available at this time in connection with your needs and desires. As more information becomes available, and as needs change, recommendations and decisions will also change.

How long should I take hormone therapy?
This becomes an individual choice with no absolute time frame. As long as the benefits exceed the risks in both your and your provider's opinion, there is a reason to continue the therapy.

What side effects should I expect?
As a general rule, you should feel normal on replacement therapy. Like almost any form of therapy, some people experience unusual or rare side effects. These should be discussed with your provider. In general, breast tenderness or continued menopausal symptoms should be discussed so adjustments can be made.

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