Hormone Replacement Therapy: A Look at the Options
Hormone replacement therapy (HRT) is sometimes used on a short-term basis for the relief of unpleasant menopausal symptoms such as hot flashes, vaginal dryness, and irritability. On a long-term basis, some women have used HRT based on doctors’ assumptions that it would reduce the risk of ]]>osteoporosis]]> and ]]>heart disease]]>. However, results of studies on estrogen replacement therapy (ERT) and estrogen plus progestin suggest that the risks of long-term HRT may outweigh the benefits for many women.
Along with information about the risks of HRT, there are also a number of options. So if you and your doctor decide that HRT may be right for you in the short- or long-term, how do you decide which therapy would be best?
HRT can include the hormones estrogen or progesterone, or a combination of both. If you're considering HRT for the first time, or want to talk to your doctor about changing the regimen you're presently on, here's a rundown of options.
Estrogen Only (ERT)
Therapies containing just estrogen are commonly referred to as estrogen replacement therapy, or ERT. Because of the increased risk of ]]>endometrial cancer]]> (lining of the uterus), long-term ERT is usually only offered to women who have had their uteruses removed through ]]>hysterectomy]]>.
ERT can be administered in a variety of ways. Systemic ERT delivers estrogen so that it circulates throughout the body, whereas local ERT delivers estrogen to a particular area of the body, such as the vagina to treat vaginal dryness or vaginal atrophy.
Forms of systemic ERT include:
- Oral medication: ]]>Premarin]]>, ]]>Cenestin]]>, ]]>Estratab]]>, ]]>Menest]]>, Ortho-Est, ]]>Ogen]]>, ]]>Estrace]]>
- Skin patch: Alora, Climara, Esclim, Vivelle, Vivelle-Dot, Estraderm
- Pellet implanted under the skin
- Spray: ]]>Evamist]]>
These medications may help to reduce hot flashes and vaginal dryness and may reduce your risk of osteoporosis. Even low doses of estradiol (given as a skin patch) may help with vaginal dryness and pain during sexual activity. Evamist, which is a spray, is another type of low-dose estradiol that may reduce the number of hot flashes.
Forms of local ERT include:
- Vaginal creams: Premarin Vaginal Cream, Ogen Vaginal Cream, Estrace Vaginal Cream
- Vaginal rings: Estring Vaginal Ring
- Vaginal tablets: Vagifem Vaginal Tablet
Because only a small amount of estrogen circulates in the body with local ERT, these products typically only help with local symptoms, such as vaginal dryness. They are usually not helpful in controlling other symptoms of ]]>menopause]]>, such as hot flashes, or in preventing osteoporosis.
Potential Side Effects of Systemic ERT
- Uterine bleeding (if uterus is present)
- Breast tenderness
- Nausea or abdominal bloating
- Fluid retention in extremities
- Changes in the shape of the cornea of the eye, which sometimes makes contact lenses uncomfortable
- Headache (sometimes ]]>migraine]]>)
- Increased breast density, which makes ]]>mammograms]]> harder to interpret
Potential Risks of Systemic ERT
- ]]>Ovarian]]> and ]]>breast cancer]]>
- Enlargement of benign uterine tumors (]]>fibroids]]>)
- Worsening of ]]>endometriosis]]>
- Endometrial cancer (if progesterone isn't taken with ERT)
- Gallbladder problems, including ]]>gallstones]]> (for orally administered ERT)
- ]]>Pancreatitis]]> in women with high triglyceride (fat) levels in the blood
- Blood clots
- Heart disease
Estrogen Plus Progesterone (HRT)
Hormone replacement therapy (HRT) is treatment that combines ERT (estrogen only) with a form of the hormone progesterone. This may consist of natural progesterone or a synthetic progesterone, called progestin. Both forms are also called progestogens.
There are several HRT schedules and methods of delivery available, including:
- Cyclic HRT—This treatment provides estrogen for 25 days each month, adding progesterone on the last 10-14 days out of 25, followed by 3-6 days of no therapy. This way, both hormones are "cycled." Cyclic HRT may cause uterine bleeding (a menstrual period) when the progesterone cycle ends. Hot flashes are also more likely to return on the days when no hormones are taken.
- Continuous-Cyclic HRT—This treatment provides estrogen every day, with progesterone added 14 days of each month. Like cyclic HRT, the main side effect is uterine bleeding (in the form of a period). This form of HRT is available in oral medication (]]>Premphase]]>).
- Continuous-Combined HRT—This treatment provides both estrogen and progesterone every day. The daily dose of progesterone is much lower than the daily dose in cyclic therapy, which may result in a lower total dose over the course of the month. Breakthrough uterine bleeding occurs in some women on this schedule, but usually stops within the first six months of therapy. The regimen is available as oral medication (]]>Prempro]]>, ]]>Femhrt]]>, ]]>Activella]]>) or skin patch ( ]]>CombiPatch]]>).
- Intermittent-Combined HRT—This treatment provides estrogen every day, with progesterone added intermittently in "on-off" cycles. The cumulative monthly dose of progestogen is about half of that of a continuous-combined pattern. This is available as oral medication (Ortho-Prefest).
Potential Risks of HRT
Potential side effects and risks of HRT are basically the same as those listed for ERT. Long-term HRT may slightly, but significantly, increase the risk of ]]>strokes]]>, blood clots, heart attacks, and invasive ]]>breast cancer]]>, gallstones, gallbladder disease, and ovarian cancer. Adding progesterone, however, eliminates the increased risk of endometrial cancer caused by estrogen alone. This applies to women who have not had their uteruses removed.
Weighing Your Options
If you are currently taking estrogen or combined estrogen and progesterone or were thinking about starting, talk to your doctor before making any final decisions about what to do.
American Congress of Obstetricians and Gynecologists
Menopausal Hormone Therapy Information
The Canadian Women's Health Network
The Society of Obstetricians and Gynaecologists of Canada
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9/16/2008 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Huang A, Yaffe K, Vittinghoff E, et al. The effect of ultralow-dose transdermal estradiol on sexual function in postmenopausal women. Am J Obstet Gynecol. 2008;198:265.e1-7.
11/19/2008 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Buster JE, Koltun WD, Pascual ML, Day WW, Peterson C. Low-dose estradiol spray to treat vasomotor symptoms: a randomized controlled trial. Obstet Gynecol. 2008;111:1343-1351.
Last reviewed June 2010 by ]]>Brian Randall, MD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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