Dr. Sarrel explains what women can expect when starting hormone replacement therapy.
If after a proper evaluation has been done, your healthcare provider is suggesting that you start a hormonal treatment program, there are some things that are important to know.
First, what to expect when you begin? Let’s say that you presented the most common of problems–sleep disturbance, fatigue, and hot flushes. That’s the triad that presents most frequently.
If you start on a proper estrogen replacement, I usually advocate starting on a lower dose to see if that works for a month, and I ask my patients, keep a diary of your symptoms so you would keep track of those three symptoms. And let’s say at the beginning you are having a lot of hot flushes; it was really a problem to you, so you would have regarded it as a level 4, which is severe.
And the same might be said for fatigue, and the same might be said for a problem of sleep disturbance. Remember, zero is you don’t have the symptom; 1 is it’s only a little; 2 is it’s moderate, but it’s enough to affect your function; 3 is it’s quite a bit and 4, it’s severe. And you have said it’s severe right across the board, but you are going to keep a daily diary.
Here is what you are going to find and what you need to expect. In the first week, everything gets better. We tell all of our patients that everything will get better in the first week. We think that’s actually a placebo effect, not a hormone effect.
In the second and the third week, in half of all the women receiving proper treatment, the symptoms come back, and they may actually be worse. Do not be discouraged because it’s a well-known phenomenon. Your body is readjusting to the new level of the hormone, and by the fourth week it’s going to get better, and besides which we are going to see you at the end of the fourth week to be sure that it’s better.
So what to expect–in the first week it’s fine. You think we are great doctors. In the second and third week, you think we don’t know what we are doing, and by the fourth week, “Maybe these guys are right and they have got the right thing for me.” Why am I emphasizing this? Because 25 percent of all women who start hormone therapy stop in the first month, and they haven’t been told ahead of time what to expect.
There is something else that you need to know. Estrogen, but also androgens, act in arteries, and what they do is to cause the blood vessels to dilate. This is why they are so helpful in a coronary artery to keep it open and prevent chest pain in women with low estrogen. But the dilation occurs throughout your body, and it happens that the arteries that are most sensitive to estrogen treatment are the arteries to your breasts.
In pregnancy that’s very important. You got to have a lot of blood flow to your breasts to provide a lot of milk. That’s good, but if you are a menopausal woman who is starting on estrogen and if it’s working, it’s highly likely you are going to get breast tenderness. It’s going to be toward the outside of your breast, and it’s due to a good effect of the hormone. You are not developing breast cancer; you are not developing cysts; don’t be frightened by that. It’s a sign that the system is responsive to what you are using.
But those are the two most important things to know about in that first month, that the flushes will respond and then stop, and then come back and respond again, and the breast tenderness which will occur will gradually dissipate. It won’t be a permanent condition, but it will occur in more than half of all of the women.
Then when you come back at the end of a month you can describe, bring your diary and you can show your doctor, “Well, here were my hot flashes at level 4. They were really severe. Now I still get them, but they are level 2. They are moderate. They are having a little bit of effect on my ability to function.”
For example, you are a doctor and in the operating room, occasionally, I get a hot flush. Well, let’s say your biggest issue was a problem with short-term memory, and you happen to be a psychotherapist, a social worker, or psychiatrist, and your complaint was, “I can’t remember what the patient just said in the office, and now I can remember it.” That’s a big effect of the hormone in a very short period of time.
But the complaint that you have is real and the response to it should be real, too, but you’ve got to keep track of it and bring that data to the follow-up visit.
Don’t accept a prescription for hormone therapy and the recommendation, “Come back in a year, and I will see how you are doing. If you are having any problem, contact my office.” That’s not adequate care. Don’t accept that.
About Dr. Sarrel, M.D.:
Philip M. Sarrel, M.D., completed his medical education at New York University School of Medicine, his internship at the Mount Sinai Hospital, and his residency at Yale New Haven Hospital. In addition to his many years on the faculty of the Departments of Obstetrics and Gynecology and Psychiatry at Yale University School of Medicine, Dr. Sarrel has also been a Faculty Scholar in the department of psychiatry at Oxford University, Visiting Senior Lecturer at King’s College Hospital Medical School at the University of London, Visiting Professor in Cardiac Medicine at the National Heart and Lung Institute in London, and Visiting Professor in the Department of Medicine at Columbia University College of Physicians and Surgeons in New York. He is currently Emeritus Professor of obstetrics, gynecology, and psychiatry at Yale University.