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    Hormone therapy

    HRT; Estrogen replacement therapy; ERT; Hormone replacement therapy

    Hormone therapy (HT) uses one or more female hormones, commonly estrogen and progestin and sometimes testosterone, to treat symptoms of menopause.

    Symptoms of menopause include hot flashes, vaginal dryness, mood swings, sleep disorders, and decreased sexual desire. Hormone therapy comes as a pill, patch, injection, vaginal cream, tablet, or ring.

    Information

    Hormone therapy may help relieve some of the bothersome symptoms of menopause, such as hot flashes, vaginal dryness and pain with intercourse. The hormone estrogen protects against thinning of the bones ( osteoporosis).

    However, taking hormones may also increase your risk for:

    • Blood clots
    • Breast cancer
    • Heart disease
    • Stroke

    You and your doctor should decide whether hormone therapy is right for you. The key is to weigh the risks of taking hormone therapy against the benefits that you might have from taking these hormones. Every woman is different. Your doctor should be aware of your entire medical history before prescribing hormone therapy.

    At this time, short-term use (up to 5 years) of hormone therapy at the lowest possible dose to treat the symptoms of menopause still appears to be safe for many women.

    BENEFITS OF HORMONE THERAPY

    Perhaps the largest benefit women receive from hormone therapy is relief from:

    • Hot flashes
    • Night sweats
    • Sleep difficulties
    • Vaginal dryness
    • Anxiety

    Usually, hot flashes and night sweats are less severe after a couple of years, especially if hormone therapy is slowly reduced.

    A woman's body produces less estrogen during and after menopause, which may affect her bone strength. Hormone therapy may also prevent the development of osteoporosis. For information on treating bone loss, see: Osteoporosis.

    Studies have not been able to clearly show that hormone therapy helps with urinary incontinence, Alzheimer's disease, or dementia.

    RISKS OF HORMONE THERAPY

    BLOOD CLOTS

    Doctors have long known that taking estrogen increases a person's risk for blood clots. Generally, this risk is higher if you use birth control pills, which contain high doses of estrogen. Your risk is even higher if you smoke and take estrogen. The risk is not as high when estrogen skin patches (transdermal estrogen) are used.

    CANCER

    Breast cancer: Woman who take estrogen therapy for a long period of time have a small increase in risk for breast cancer. Most guidelines currently consider hormone therapy safe for breast cancer risk when taken for up to 5 years.

    Endometrial/uterine cancer: The risk for endometrial cancer is more than five times higher in women who take estrogen therapy alone, compared with those who do not. However, taking progesterone with estrogen seems to protect against this cancer. Endometrial cancer does not develop in women who do not have a uterus.

    CARDIOVASCULAR DISEASE

    Heart disease: Estrogen may increase the risk of heart disease in older women, or in women who began estrogen use more than 10 years after their last period. Estrogen is probably the safest when started in women under age 60, or within 10 years after the start of menopause.

    Deep venous thrombosis (DVT or blood clot in a vein) and pulmonary embolus (PE or blood clot in the lungs) are more common in women who take oral estrogen, regardless of their age.

    Stroke: Women who take estrogen have an increased risk for stroke.

    Women who also smoke, have heart disease, or are at higher risk for heart disease and stroke are less likely to be given estrogen hormones.

    GALLBLADDER DISEASE

    Several studies have shown that women who take estrogen/progestin therapy have an increased risk for developing gallstones.

    SIDE EFFECTS OF HORMONE THERAPY

    As with all medicines, side effects are possible. Some women taking hormone therapy may have:

    • Bloating
    • Breast soreness
    • Headaches
    • Mood swings
    • Nausea
    • Water retention

    Changing the dose or form of hormone therapy may help reduce these side effects.

    Some women have irregular bleeding when they start taking hormone therapy. Changing the dose often eliminates this side effect. Close follow-up with your doctor is important when you have any unusual bleeding.

    FORMS OF HORMONE THERAPY

    Hormone therapy is available in various forms. You may need to try more than one form before finding the one that works best for you.

    Estrogen comes in the following forms:

    • Nasal spray
    • Pills or tablets, taken by mouth
    • Skin gel
    • Skin patches, which are applied to the thigh or belly area
    • Vaginal creams or vaginal tablets, to help with dryness and pain with sexual intercourse
    • Vaginal ring

    Most women who take estrogen and who have not had their uterus removed also need to take progesterone. Taking these medicines together helps reduce the risk of endometrial (uterine) cancer.

    Progesterone or progestin comes in the following forms:

    • Pill
    • Skin patch
    • Vaginal cream

    When estrogen and progesterone are prescribed together, your doctor will recommended one of the following schedules:

    • Cyclic hormone therapy is often recommended when a woman is starting menopause. With this therapy, estrogen is taken in pill or patch form for 25 days, with progestin added somewhere between days 10 - 14. The estrogen and progestin are used together for the remainder of the 25 days. Then, no hormones are taken for 3 - 5 days. There may be monthly bleeding with cyclic therapy.
    • Continuous, combined therapy involves taking estrogen and progestin together every day. Irregular bleeding may occur when starting or switching to this therapy. Most women stop bleeding within 1 year.

    Additional medications may be recommended for some women with severe symptoms from menopause, or women who are at very high risk for osteoporosis or heart disease. One of these supplemental drugs might be testosterone, a hormone that is more plentiful in males, to improve sex drive. Nonhormonal medications are sometimes used either in addition to, or instead of, hormone therapy.

    HEALTHY LIFESTYLE

    In addition to hormone therapy, a woman can take other steps to adjust to the changes in life during menopause. Eating healthy foods and getting regular exercise will help decrease bone loss, improve balance, and maintain healthy heart muscle.

    CALLING YOUR HEALTH CARE PROVIDER

    It is important to have regular checkups with your health care provider when taking hormone therapy. If you have vaginal bleeding or other unusual symptoms during hormone therapy, call your health care provider.

    References

    American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 420. November 2008: hormone therapy and heart disease. Obstet Gynecol. 2008;112:1189-1192.

    Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010;17:25-54; quiz 55-56.

    North American Menopause Society. Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010;17:242-255.

    National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Jan. 2010. Accessed Dec. 15, 2011.

    Col NF, Fairfield KM, Ewan-Whyte C, Miller H. In the clinic. Menopause. Ann Intern Med. 2009;150:ITC4-1-15.

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            Review Date: 9/13/2011

            Reviewed By: David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine.

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