Hormone Replacement Therapy For Menopause

Oestrogen And Progesterone Therapy

Oestrogen is the main hormone prescribed to relieve menopausal symptoms, and for women who have had a hysterectomy, this may be all they need.

In women who still have their uterus, oestrogen alone can overstimulate the cells lining the uterus, causing an increased risk of endometrial cancer .

To remove the risk of overstimulation, women who have not had a hysterectomy need to take progesterone, or a synthetic form known as ‘progestin’, together with the oestrogen. ‘Progestogens’ is the name used to refer to both the natural form of progesterone and the synthetic form, ‘progestin’.

Possible Side Effects Of Mht

You may or may not have any of these side effects when you take MHT.

Hormone Therapy And Cardiovascular Disease

The incidence of cardiac disease is heightened in postmenopausal women. This finding has been linked to a causative pathogenic role of ovarian hormone deficiency.

When the concept of HT was initially introduced, it was believed that replacing ovarian hormones would reduce the observed increase in the risk of cardiovascular disease. However, this expected result has not been unequivocally demonstrated in various trials over the years.

The WHI study revealed an increased annual risk of heart attacks of 7 per 10,000 women who took combined therapy as opposed to women who took estrogen alone, in whom no significant difference was noted. Subsequent re-analysis showed similar results for breast cancer, demonstrating no increased risk in the fifth decade, though the risk rose with advancing age.

Two important clinical trials have been conducted to examine the relationship between cardiac disease and HT: the Postmenopausal Estrogen/Progestogen Interventions Trial and the Heart and Estrogen-Progestogen Replacement Study .

PEPI investigators looked at the effect of estrogen alone and combination therapies on bone mass and key risk factors for heart disease. They found generally positive results, including a reduction in low-density lipoprotein cholesterol and an increase in high-density lipoprotein cholesterol by both types of therapy.

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Transitioning From Contraception To Hormone Therapy

Transitioning from contraception to hormone therapy may be challenging because oral contraceptives have higher dosages than typical hormone therapy regimens. Also, measuring follicle-stimulating hormone levels after stopping oral contraceptives can be inaccurate during perimenopause.26 One small study found that a rise in follicle-stimulating hormone level without a change in estradiol levels two weeks after stopping oral contraceptives is evidence that it is safe to transition to hormone therapy.26 Others suggest discontinuation of contraception when women are in their mid-50s because spontaneous conception is rare at this age.27

What Is Topical Hormone Therapy

Topical hormone therapy is usually a low-dose estrogen cream applied directly to the vagina. It relieves vaginal dryness but does not help with other symptoms, such as hot flashes. It also is available as a vaginal ring, insert, and gel. The risks of topical hormone therapy are different from the risks of menopausal or hormone replacement therapy.

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How Long Do You Take Mht

Current guidelines recommend women who take MHT for menopausal symptoms take the lowest effective dose to alleviate symptoms for as long as is needed. For the treatment of symptoms, women can stay on MHT for as long as is required to relieve their symptoms. Current thinking is that the benefits of MHT far outweigh the risks in healthy women within 10 years of the menopause or between 50 and 60 years of age. MHT does not need to be discontinued after five years because:

• the mean duration of menopausal symptoms is approximately eight years
• 20â25% of women will have bothersome symptoms in their 60s and 70s
• 10% of women will have bothersome symptoms for 10 years or more.

Every year, it is important to have a discussion with your doctor about management of your menopausal symptoms. Some women can take MHT safely for many years, but this must be assessed on an individual basis and be supported with annual reviews by your doctor.

In women with premature menopause, MHT is prescribed in high doses and recommended to continue until the age of expected menopause, about 50-52 years.

As a general rule when using MHT in midlife:

• start low
• review often

What Are The Types Of Hormone Therapy

There are two main types of hormone therapy :

• Estrogen Therapy: Estrogen is taken alone. Doctors most often prescribe a low dose of estrogen to be taken as a pill or patch every day. Estrogen may also be prescribed as a cream, vaginal ring, gel or spray. You should take the lowest dose of estrogen needed to relieve menopause symptoms and/or to prevent osteoporosis.
• Estrogen Progesterone/Progestin Hormone Therapy : Also called combination therapy, this form of HT combines doses of estrogen and progesterone .

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What Are Some Commonly Used Postmenopausal Hormones

The following list provides the names of some, but not all, postmenopausal hormones.

Estrogen

• Pills, Brand names: Cenestin®, Estinyl®, Estrace®, Menest®, Ogen®, Premarin®, Femtrace®.
• Creams, Brand names: Estrace®, Ogen®, Premarin®.
• Vaginal ring, Brand names: Estring®, Femring® .
• Vaginal tablet, Brand names: Vagifem®. Imvexxy®
• Patch, Brand names: Alora®, Climara®, Minivelle®, Estraderm®, Vivelle®, Vivelle-Dot®, Menostar®.
• Spray, Brand name: Evamist®.

• Modest improvement in joint pains.
• Lower death rate for women who take hormone therapy in their 50s.

Cardiovascular Disease And Hrt

Women over 60 have a small increased risk of developing heart disease or stroke on combined oral HRT. Although the increase in risk is small, it needs to be considered when starting HRT, as the risk occurs early in treatment and persists with time.

Oestrogen used on its own increases the risk of stroke further if taken in tablet form, but not if using a skin patch. Similarly, tibolone increases the risk of stroke in women from their mid-60s.

Women who commence HRT around the typical time of menopause have lower risks of cardiovascular disease than women aged 60 or more.

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What Are The Risks Of Hrt

Breast cancer risk differs depending on the type of HRT and a womans personal history of breast cancer.

Based on results from the very large Womens HealthInitiative studies, combination HRT increases breast cancer risk and this increase in risk lasted for more than 10 years after the women stopped taking HRT.

Higher-dose combination HRT increases breast cancer risk more than lower-dose combination HRT.

Combination HRT also increases the likelihood that the cancer may be found at a more advanced stage. Combination HRT is linked to increased breast density, which can make it harder for mammograms to detect breast cancer.

Breast cancer risk appears to be higher with daily progesterone than with less frequent progesterone .

This increase in risk applies to bioidentical and natural hormone products as well as synthetic hormones. Bioidentical means the hormones in the product are identical to the hormones your body produces. Bioidentical hormones are derived from plants, so theyre sometimes called natural. Synthetic hormones are made in a lab and are also chemically identical to thehormones in your body. It’s important to know that many herbal and bioidentical HRT products fall outside the jurisdiction of the United States Food and Drug Administration and so aren’t subject to the same regulations and testing that medicines are.

Ht Indications Contraindications And Adverse Effects/risks

Indications

Indications for hormone therapy can be symptomatic or preventive. However, the application of HT to prevent sequelae of menopause is controversial, although some consensus has been reached regarding the use of HT to relieve symptoms.

The following are common clinical indications for prescribing HT:

• To relieve vasomotor symptoms

• To improve urogenital symptoms

• To prevent osteoporosis

Contraindications

No absolute contraindications of HT have been established. However, relative contraindications exist in certain clinical situations, such as patients with the following findings:

• A history of breast cancer*

• A history of endometrial cancer*

• Porphyria

• Endometriosis

• Fibroids

* Note that many clinicians do not prescribe HT for women with a previous history of breast or endometrial cancer.

Adverse effects and risks

Possible transient adverse effects are as follows:

• Nausea

• Bloating, weight gain , fluid retention

• Mood swings

• Breakthrough bleeding

• Breast tenderness

Potential risks of HT in postmenopausal women include the following:

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Shortage Of Some Hrt Products

There are ongoing supply problems with some HRT products. For some products this is because of irregular supply while for others it’s a longer-term shortage. There are lots of different reasons why medicines can be in short supply. Work is happening with the pharmaceutical manufacturers who make the medicines to help the situation.

If your pharmacy cant supply the specific HRT product you’ve been prescribed, they may supply an alternative product. This will usually have the same ingredient, but may be made by a different manufacturer. Your pharmacy might also reduce the amount they provide you with to help ensure that as many woman as possible can get access to their required medication.

Disruptions in the availability of HRT will be worrying if it has been prescribed for you. However, there are always alternative options. If you are concerned about this contact your GP, pharmacist or specialist doctor to discuss the best treatment options for you.

Are There Alternatives For Women Who Choose Not To Take Menopausal Hormone Therapy

Women who are concerned about the changes that occur naturally with the decline in hormone production that occurs during menopause can make changes in their lifestyle and diet to reduce the risk of certain health effects. For example, eating foods that are rich in calcium and vitamin D or taking dietary supplements containing these nutrients may help to prevent osteoporosis. FDA-approved drugs such as alendronate , raloxifene , and risedronate have been shown in randomized trials to prevent bone loss.

Medications approved by the FDA for treating depression and seizures may help to relieve menopausal symptoms such as hot flashes . Drugs that have been shown in randomized clinical trials to be effective in treating hot flashes include venlafaxine , desvenlafaxine , paroxetine , fluoxetine , citalopram , gabapentin , and pregabalin .

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Information For Your Doctor To Read Includes Ams Information Sheets:

If you have any concerns or questions about options to manage your menopausal symptoms, visit your doctor or go to the Find an AMS Doctor service on the AMS website.

NOTE: Medical and scientific information provided and endorsed by the Australasian Menopause Society might not be relevant to an individuals personal circumstances and should always be discussed with their own healthcare provider. This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by Australasian Menopause Society Members, other health professionals and their patients for clinical practice is permissible. Any other use of this information must be agreed to and approved by the Australasian Menopause Society.

Who Should Avoid Hrt

Estrogen replacement therapy should be avoided by women who have not had their uteruses removed in a hysterectomy. This is because estrogen stimulates the growth of the uterine lining, increasing the risk for cancer.

Moreover, women with a history of certain health conditions should also avoid hormone replacement. These include breast, ovarian, and endometrial cancer unexplained vaginal bleeding blood clots liver disease or strokes or heart attacks.

Keep in mind that taking hormone therapy may increase the risk of aforementioned health conditions – breast cancer, strokes, heart attacks, and blood clots – as well as gallbladder disease.

Speak with your doctor to discuss the risks and benefits of HRT depending on your specific medical history and symptoms experienced.

However, because studies have shown that hormone replacement for women can cause serious side effects, many women pursue alternative ways to treat the hormonal imbalance at fault for their pesky symptoms.

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Does It Cause Weight Gain

Some people worry that hormone treatment might lead to weight gain, but there is no evidence to support this.

Eating a healthful diet and getting plenty of exercise can help manage the weight gain that commonly affects both females and males in midlife.

provide different combinations and amounts of hormones.Common types include:

Estrogen-only HRT: A doctor may recommend this if a person has had their uterus and ovaries removed, in which case progesterone is not necessary.

Cyclical, or sequential, HRT: This may be a good option if symptoms occur before menopause the dosage can align with the menstrual cycle.

Continuous HRT: After menopause, a doctor may prescribe a continuous combination of estrogen and progesterone.

Local estrogen: Vaginal tablets, creams, or rings can help with urogenital symptoms, including vaginal dryness and irritation.

The doctor will prescribe the lowest possible dosage that addresses the persons symptoms, and arriving at this dosage may take some trial and error.

Ways of delivering HRT include:

• tablets
• vaginal rings
• skin patches

When a person no longer needs the treatment, the doctor will describe how to stop it gradually.

Various lifestyle adjustments can help manage the symptoms of menopause.

They include:

Also, it is a good idea to ask the doctor about nonhormonal treatment options.

Always speak to a doctor before using any supplements.

Risks And Benefits Of Hormone Therapy

In 2002, the first Women’s Health Initiative clinical trial was published, causing patients and clinicians to question the safety of menopausal hormone therapy.1 Before this study, many patients took hormones to improve overall health, prevent cardiac disease, and treat menopausal symptoms. The large study of approximately 16,000 women compared a combined oral regimen consisting of conjugated equine estrogen and medroxyprogesterone with placebo, and found that the combined regimen increased the risk of coronary artery disease, breast cancer, stroke, and venous thromboembolism . The study also found a decreased risk of colorectal cancer, hip fractures, and total fractures with combined hormone therapy.1 Critics of the study believe it is not appropriate to generalize results to all women going through menopause, partly because the average age of participants was 63 years.

The timing hypothesis suggests that starting hormone therapy early in menopause may be cardioprotective because of estrogen’s apparent ability to slow the progression of atherosclerosis in younger women.3,4 Although the evidence suggests that beginning hormone therapy near the start of menopause decreases the risk of cardiac disease, further study is needed. Current guidelines recommend against using hormone therapy to prevent or treat cardiac disease.5 Further, the American Academy of Family Physicians recommends against using hormone therapy for the prevention of chronic conditions.6

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Important Questions To Ask About Menopause Hormone Medicines

• Are hormones right for me? Why?
• What are the benefits?
• What are the serious risks and common side effects?
• How long should I use hormone therapy?
• What is the lowest dose that will work for me?
• Are there any non-hormone medicines that I can take?

Want more information about menopause? Check the FDA website at: www.fda.gov/menopause

The drug and risk information in this booklet may change. Check for the latest facts on each product listed in this booklet.

Types Of Hormone Replacement Therapy

Estrogen-only hormone therapy and combination hormone therapy are the two main types of hormone replacement therapy. If you still have your uterus, your doctor will suggest combination therapy because progesterone reduces your risk of endometrial cancer.

If you have had a hysterectomy and no longer have a uterus, you typically will not need progesterone. This is important to know because taking estrogen alone has been shown to have fewer long-term risks compared to combination hormone therapy.

There are two ways a woman can receive hormone replacement therapy systemically or locally:

• Systemic hormone therapy is mainly taken in a pill, injection, or patch. It works by releasing hormones into the bloodstream and reaching the organs and tissues that need them. This type of therapy can help systemic symptoms like hot flashes, vaginal dryness, and mood changes.
• Local hormone therapy is a cream, ring, or suppository used on a localized area and doesn’t get into the bloodstream. It’s mainly used to help women suffering from vaginal dryness due to the loss of estrogen by rebuilding the vaginal lining and promoting lubrication. Fewer risks are associated with localized hormone therapy, but it does not help prevent or alleviate systemic symptoms like hot flashes.

here to get a closer look at the main hormones within a womans body and their important roles.

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Other Treatments For Menopausal Symptoms

Studies have shown that some prescription medications can reduce hot flushes and sweats. These treatments may be an option if HRT cannot be used for health or other reasons, and should be discussed with a doctor.

The herbal medicine, black cohosh, may take the edge off hot flushes and sweats, but there is no data to support long-term use. There is also a rare liver condition that may be associated with the use of black cohosh.

Other complementary and alternative medicines have not been shown to be effective for menopausal symptoms when compared with dummy or placebo treatment in research studies.

Commercially available vaginal moisturisers may reduce vaginal dryness if used regularly. Consult your doctor about what will work best for you.