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Determining Candidates for Hormone Replacement Therapy

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The first thing you should know about hormone therapy is that it’s no longer referred to as hormone replacement therapy. Jan Shifren, M.D., immediate past president of the board of the North American Menopause Society and associate professor of obstetrics, gynecology and reproductive biology at Harvard Medical School, explains it’s an important distinction.

“When you say ‘replacement,’ it gives a false sense of security that you’re replacing something,” Shifren said. But in reality, post-menopausal women are no longer producing estrogen so to say you’re replacing estrogen, or estrogen and progestin, is a misnomer.

The second important point Shifren wants women to understand is there are two types of hormone therapy: systemic hormone therapy and low-dose vaginal estrogens. Systemic hormone therapy is used to treat bothersome hot flashes.

They raise blood hormone levels to where they were before menopause. As an added benefit, they do a good job preserving bone density and significantly reduce fracture risk – while in use.

“Women will lose bone density very quickly when they come off systemic hormone therapy,” Shifren said. If a woman chooses systemic hormone therapy but does not have a uterus, she will use only estrogen.

But if she also has a uterus she will be given estrogen plus progestin. “The progestin is given to protect the lining of the uterus from overgrowth of endometrial tissue caused by estrogen,” Shifren explained.

Low-dose vaginal estrogens do not raise blood hormone levels and are often used to treat vaginal dryness. “I let women know that while hot flashes go away eventually, vaginal dryness just gets worse,” Shifren said.

“Most physicians would be comfortable using them for women who have had heart disease or stroke,” said Cynthia Stuenkel, M.D., a clinical professor of medicine, endocrinology and metabolism at the University of California, San Diego School of Medicine, about low-dose vaginal estrogen use.

And just to clarify, systemic estrogens can also be delivered through the vagina. Those doses do raise blood hormone levels and are not the same as low-dose vaginal estrogens.

The best candidate for hormone therapy, according to Shifren, is a healthy woman in her early 50s with bothersome hot flashes. General risks include a slight increase in the risk of heart disease, as well as leg and lung clots, but not until age 60.

“It’s very, very small,” Shifren says of the clot risk. Ditto that for the very small risk of stroke.

What has gotten perhaps the most press is an elevated risk of breast cancer, but Shifren points out that risk doesn’t emerge until after four to five years of hormone therapy, and a woman may need treatment for less time than that to get her through the worst of her hot flash symptoms. To mitigate these risks, Shifren advocates the standard “lowest dose for the shortest time that meets treatment goals.”

Those women deemed unsuitable candidates for hormone therapy include: those with breast, endometrial or uterine cancer; cardiovascular disease, including stroke, heart attack or blood clots; or those with liver disease. Stuenkel says women who have had uterine or endometrial cancer, as well as diabetics, are in a gray area, with opinions on the safety of hormone therapy varying by doctor.

“It’s important that women know that any post-menopausal bleeding needs to be reported even if they think it’s just from intercourse,” Shifren added.

Another sideshow of the menopause main stage is mood. “For many of the women it’s because they’re having bothersome hot flashes or not sleeping well,” Shifren said, pointing out that it’s not unlike the exhaustion and complications that go with the sleeplessness of raising a newborn. “That’s pretty much the menopause transition. You just don’t have the baby to show for it.”

However, Shifren is quick to point out mood issues that aren’t solved with improved sleep patterns should be dealt with separately from hormone therapy. “There are some very good studies that the time of menopause transition is a time of mood transition,” Shifren said. “The good news is that beyond the menopause transition women typically go back to baseline.”

Stuenkel says the use of hormone therapies in women who don’t need them for bothersome hot flashes is the last great debate on the subject. Should women be given hormone therapy for prevention? Some doctors and scientists believe it could offer an improvement in heart health.

“Most groups have said ‘not at this time.’ No groups have really embraced this,” she said. For now, hormone therapy remains the treatment for hot flashes and vaginal dryness.

“Even if women want to give it a shot, I think within two or three months women are going to know whether it’s working,” said Stuenkel, who chaired the Endocrine Society’s clinical practice guidelines statement on treatment of symptoms of menopause.


Jan Shifren, M.D., via phone interview. August 11, 2015. http://www.massgeneral.org/doctors/doctor.aspx?id=16440

Cynthia Stuenkel, M.D., via phone interview August 14, 2015. https://endo.confex.com/endo/2015endo/webprogram/Person140277.html

Global Consensus Statement on Menopausal Hormone Therapy. Endocrine Society. Retrieved August 18, 2015. http://www.endocrine.org/news-room/press-release-archives/2013/global-consensus-statement-on-menopausal-hormone-therapy

Santen RJ et al. Postmenopausal Hormone Therapy: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab. 2010 Jul;95(7 Suppl 1):s1-s66. doi: 10.1210/jc.2009-2509. Epub 2010 Jun 21. Full Text: http://press.endocrine.org/doi/10.1210/jc.2009-2509?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

Reviewed August 18, 2015
by Michele Blacksberg RN

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We value and respect our HERWriters' experiences, but everyone is different. Many of our writers are speaking from personal experience, and what's worked for them may not work for you. Their articles are not a substitute for medical advice, although we hope you can gain knowledge from their insight.



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