Risks And Benefits Of Hormone Therapy: Focus On Cardiac Health
In 2002, the Women’s Health Initiative clinical trial was published, causing patients and physicians to question the safety of menopausal hormone therapy.3 Before this study, many patients took hormones in an attempt to improve overall health, prevent future cardiac disease, and treat menopausal symptoms, in part because results of observational studies showed apparent protection from cardiac disease. The WHI study compared a combined oral regimen consisting of conjugated equine estrogen and medroxyprogesterone acetate with placebo, and found that the combined regimen increased the risk of coronary artery disease, breast cancer, stroke, and venous thromboembolism . This large study of approximately 16,000 women also found a decreased risk of colorectal cancer, hip fractures, and total fractures.3
Critics of the 2002 WHI trial believe it is not appropriate to generalize results to all menopausal women, because the population studied may not represent women who typically use hormone therapy. Specifically, the average age of participants was 63 years, more than a decade older than the average age of the menopausal transition , when women are more likely to start hormone therapy.
Who Can Take Hrt
Most women can have HRT if they’re having symptoms associated with the menopause.
But HRT may not be suitable if you:
- are pregnant it’s still possible to get pregnant while taking HRT, so you should use contraception until 2 years after your last period if you’re under 50, or for 1 year after the age of 50
In these circumstances, alternatives to HRT may be recommended instead.
Forms Of Hormone Therapy
HT comes in different forms. You may need to try different types before finding one that works best for you.
Estrogen comes in:
- Pills or tablets, taken by mouth
- Skin gel
- Skin patches, applied to the thigh or belly
- Vaginal creams or vaginal tablets to help with dryness and pain with sexual intercourse
- Vaginal ring
Most women who take estrogen and who still have their uterus also need to take progestin. Taking both hormones together lowers the risk of endometrial cancer. Women who have had their uterus removed cannot get endometrial cancer. So, estrogen alone is recommended for them.
Progesterone or progestin comes in:
- Pills
- Vaginal suppositories
- Intrauterine device or intrauterine system
The type of HT your doctor prescribes may depend on what menopause symptoms you have. For example, pills or patches can treat night sweats. Vaginal rings, creams, or tablets help relieve vaginal dryness.
Discuss the benefits and risks of HT with your provider.
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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.
There are various ways of delivering hormone therapy, and the different types 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.
Hrt After Premature Early And Surgical Menopause
While most women experience natural menopausearound the age of 50, some women reach menopause much earlier or after surgery.In these cases, HRT should typically be started immediately.
Menopause that happens before the age of 40 is known as premature menopause, while between 40 and 45 it is known as early menopause. Women who experience premature or early menopause can have the same symptoms as women who experience typical menopause, but may also be at greater risk for psychological distress and a number of serious physiological health conditions. Meanwhile, women who undergo oophorectomysurgical removal of one or both ovariesprior to natural menopause can experience even more severe symptoms due to the extreme and sudden drop in hormones as well as significant long-term health risks. For all women who experience premature, early, or surgical menopause these risks include cardiovascular disease, osteoporosis, neurological disease, mood disorders, and premature death.
Due to these risks, it is typically recommended that women who experience premature, early, and surgical menopause start hormone replacement therapy as soon as possible. As the American Society For Reproductive Medicine, mincing no words, said of bilateral oophorectomy patients:
In these cases, there is little doubt that HRTis the right choice and should be initiated immediately.
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Added Benefits Of Hrt
HRT reduces the risk of various chronic conditions that can affect postmenopausal women, including:
- diabetes taking HRT around the time of menopause reduces a womans risk of developing diabetes
- osteoporosis HRT prevents further bone density loss, preserving bone integrity and reducing the risk of fractures, but it is not usually recommended as the first choice of treatment for osteoporosis, except in younger postmenopausal women
- bowel cancer HRT slightly reduces the risk of colorectal cancer
- cardiovascular disease HRT has been shown to reduce cardiovascular disease markers when used around the time of menopause.
When May Female Bhrt Be Most Beneficial
Bioidentical hormone replacement therapy for women may help any woman whose hormones are out of balance. However, the most common time women seek bioidentical hormone replacement therapy is when theyre experiencing menopause. There are three stages of menopauseperimenopause, menopause, and post menopause. There are also rare instances regarding women who have never had balanced hormones, often causing excessively uncomfortable menstrual cycles and extreme mood swings. The Biote Method of bioidentical hormone replacement therapy for women may help address the cause of these issues.
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What Are The Benefits Of Hormone Replacement Therapy
HRT is a safe and effective treatment for most healthy women with symptoms, who are going through the menopause at the average age in the UK . The risks and benefits of HRT will vary according to your age and any other health problems you may have. Your doctor will be able to discuss any potential risks of HRT to you in detail.
Conditions That May Cause Low Hormone Levels
Hormones naturally decline as you continue aging. However, there are certain conditions that may cause unusually low levels of sex hormones that may need treatment. These conditions include:
Menopause
Menopause is the time when you have been period-free for one year without being pregnant, breast-feeding, sick, or taking certain medications. It is a natural occurrence as a result of aging.
In the years before menopause, the ovaries shrink and the amount of hormones fluctuates. This can create symptoms like hot flashes and vaginal dryness that many people find difficult.
Surgical removal of ovaries
If your ovaries are removed before age 45, you may not have enough estrogen that helps protect against heart disease, osteoporosis, stroke, dementia, certain types of cancer, or mood changes. You may pursue HRT to prevent these conditions.
Early menopause
If you experience menopause before age 45, you may not have enough estrogen that helps protect the body. You may need hormone replacement therapy to prevent disease.
Primary ovarian insufficiency
This is a condition where the ovaries lose normal function. If this occurs before age 45, you may not have enough estrogen and you may need hormone replacement therapy.
Other hormone conditions
Hormone replacement therapy may be used to treat other conditions like breast cancer, infertility, and endometrial hyperplasia, which is the overgrowth of the lining in the uterus.
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Signs You Need Hormone Replacement Therapy
Hormone replacement therapy is not for everyone, but some people find the treatment provides relief from the symptoms of menopause.
Signs that you may need hormone replacement therapy include:
Other conditions caused by hormone deficiency may also benefit from hormone replacement therapy.
How You Will Take Hormones
When taking estrogen and progesterone together, your doctor may suggest one of the following schedules:
Cyclic hormone therapy is often recommended when you start menopause.
- You take estrogen as a pill or use it in patch form for 25 days.
- Progestin is added between days 10 and 14.
- You use estrogen and progestin together for the remainder of the 25 days.
- You don’t take any hormones for 3 to 5 days.
- You may have some monthly bleeding with cyclic therapy.
Combined therapy is when you take estrogen and progestin together every day.
- You may have some unusual bleeding when starting or switching to this HT schedule.
- Most women stop bleeding within 1 year.
Your doctor may prescribe other medicines if you have severe symptoms or have a high risk of osteoporosis. For example, you may also take testosterone, a male hormone, to improve your sex drive.
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Does Hrt Cause Cancer
Some older research linked HRT to endometrial, breast, and ovarian cancer. However, this research did not look at all aspects of HRT.
The American Cancer Society point out that the risk may depend on the type of treatment and the type of cancer.
They report that while one type of HRT may increase the risk of breast cancer slightly, another type may reduce the risk.
Anyone who is thinking of using HRT should talk to their doctor about the specific risks and benefits.
Who Can Use It
You can begin hormone replacement therapy as soon as you start experiencing menopausal symptoms.
The average age for women to experience the menopause in the UK is 51. However, some women have the menopause when they are in their 30s, 40s or 60s. There is no way of predicting exactly when the menopause will happen.
Some women have menopausal symptoms, such as hot flushes and vaginal dryness, in the 3 to 4 years before the menopause. This is known as the peri-menopause.
The peri-menopause occurs because levels of the female sex hormones, oestrogen and progesterone, fall when the number of remaining eggs drops below a certain level. This means you may experience menopausal symptoms even when you are still having periods.
In most cases, HRT can be used without taking a test to confirm you are starting the menopause. A test for the menopause is usually only necessary if you are under 40 years old or have unusual bleeding patterns during your period.
Testing can help rule out other conditions that may cause similar symptoms, such as having an overactive thyroid gland . You should have regular smear tests for cervical cancer.
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Hormone Therapy For Prostate Cancer
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Hormone therapy is also called androgen suppression therapy. The goal is to reduce levels of male hormones, called androgens, in the body, or to stop them from fueling prostate cancer cells.
Androgens stimulate prostate cancer cells to grow. The main androgens in the body are testosterone and dihydrotestosterone . Most androgen is made by the testicles, but the adrenal glands as well as the prostate cancer itself, can also make a fair amount. Lowering androgen levels or stopping them from getting into prostate cancer cells often makes prostate cancers shrink or grow more slowly for a time. But hormone therapy alone does not cure prostate cancer.
Menopausal Symptoms Usually Ease
This can make a big difference to quality of life in some women:
- HRT works to stop hot flushes and night sweats within a few weeks.
- HRT will reverse many of the changes around the vagina and vulva usually within 1-3 months. However, it can take up to a year of treatment in some cases.
- This means that HRT can:
- Improve symptoms of vaginal dryness.
- Improve discomfort during sexual intercourse as a result of this vaginal dryness.
- Help to reduce recurrent urine infections.
- Improve any increased frequency of passing urine.
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How To Get Started On Hrt
Speak to a GP if you’re interested in starting HRT.
You can usually begin HRT as soon as you start experiencing menopausal symptoms and will not usually need to have any tests first.
A GP can explain the different types of HRT available and help you choose one that’s suitable for you.
You’ll usually start with a low dose, which may be increased at a later stage. It may take a few weeks to feel the effects of treatment and there may be some side effects at first.
A GP will usually recommend trying treatment for 3 months to see if it helps. If it does not, they may suggest changing your dose, or changing the type of HRT you’re taking.
Waiting 5 Years To Start Hormone Replacement Therapy Offers Less Risk
Many studies have shown a link between increased breast cancer risk and hormone replacement therapy to treat bothersome menopausal symptoms. While the results of all the studies aren’t exactly the same, there is good evidence that:
- HRT increases the risk of being diagnosed with invasive breast cancer
- breast cancer risk increases within the first several years of HRT use risk appears to increase the longer a woman uses HRT
- combination HRT increases breast cancer risk more than estrogen-only HRT
- high-dose HRT increases risk more than low-dose HRT
A study found that breast cancer risk was higher in women who used HRT during the first 5 years after menopause started compared to women who waited more than 5 years to start HRT.
This research is part of the very large Million Women Study. The Million Women Study included nearly 1.3 million women in the United Kingdom and was designed to identify links between diet and lifestyle factors and health problems such as cancer. The women, who were about 57 years old, started the study between 1996 and 2001.
More than half of the women had used some form of HRT at some time in their lives and 35% were using HRT when the researchers did the analysis. The researchers recorded 15,759 breast cancers diagnosed in the 1.3 million women.
More than 60% of the breast cancers were diagnosed in women who had used HRT at some point 45% of the breast cancers were diagnosed in women using HRT when the cancer was diagnosed.
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The Critical Window Theory Of When To Start Hrt
Menopause comes at different times for different people. While the average age of menopause in the United States is 51, many factors can impact when menopause occurs, including racial and ethnic differences and overall health. But regardless of when menopause starts, the hormonal changes that lead to the end of your reproductive cycle actually begin years earlier.
So when should you start hormone therapy? In part, it depends on your symptoms. For many women, perimenopausewhich can begin as many as 10 years before menopause can be an uncomfortable and distressing experience. The symptoms of perimenopause can include irregular periods, mood disturbances, sleep disturbances, increased anxiety, and vasomotor symptoms like hot flashes, any of which benefit from HRT treatment. However, some women worry that their symptoms are not severe enough to warrant hormone therapy, particularly if they are relatively young. Others erroneously believe that they are too young for HRT even while experiencing severe perimenopause symptoms.
While its common to assume that its too earlyto start hormone replacement therapy, research suggests that there may bemeaningful benefits to starting HRT earlier rather than later. In fact, agrowing body of evidence indicates that there is a critical window ofopportunity for HRT to confer significant long-term health benefits.
Counseling Patients About Hormone Therapy And Alternatives For Menopausal Symptoms
D. ASHLEY HILL, MD, Florida Hospital Graduate Medical Education Program, Orlando, Florida
SUSAN R. HILL, MD, Orlando, Florida
Am Fam Physician. 2010 Oct 1 82:801-807.
Patient information: See related handout on treating menopausal symptoms, written by the authors this article.
Menopause is a normal, physiologic transition when a woman stops producing eggs and ovarian function diminishes, sometimes causing bothersome symptoms such as hot flashes or vaginal dryness. The media attention to recent clinical trials of treatments for menopausal symptoms has provided women with a large amount of information, some of it contradictory. This makes it challenging for patients to understand which treatment options are available, effective, and safe. In the past, physicians typically prescribed hormone therapy for menopause, whereas now they increasingly prescribe medications to treat specific symptoms. The U.S. Food and Drug Administration issued a boxed warning for hormone preparations and, with the American College of Obstetricians and Gynecologists , advises that hormone therapy be prescribed at the lowest effective dosages and for the shortest possible duration.1,2 Dozens of medications, dominated by hormone formulations, are available to treat menopausal symptoms. When counseling menopausal patients, physicians should understand the benefits and risks of hormone therapy and alternative treatments, and the key differences among the various delivery systems.
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What Are The Risks Of Taking Hormone Therapy
While hormone therapy helps many women get through menopause, the treatment is not risk-free. Known health risks include:
- An increased risk of endometrial cancer .
- Increased risk of blood clots and stroke.
- Increased chance of gallbladder/gallstone problems.
- Increased risk of dementia if hormone therapy is started after midlife. HT started during midlife is associated with a reduced risk of Alzheimers disease and dementia.
- Increased risk of breast cancer with long-term use.