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What is HRT?

Hormone therapy is used to treat menopausal symptoms, such as hot flashes, mood swings and vaginal symptoms that occur from fluctuating levels of natural hormones in the body, particularly estrogen, as the ovaries are gearing down. Hormone replacement therapy (HRT) is a misnomer, since it doesn't replace anything. A woman's body continues to make hormones during and after menopause.

In its early days, HRT was actually only ERT - estrogen replacement therapy. Studies found that estrogen alone increased the risk of endometrial cancer, so a progestin - a natural or synthetic form of progesterone - was added to keep the endometrium from thickening. This significantly reduces the risk of endometrial cancer, a cancer of the lining of the uterus.

Doctors generally prescribe a combination of estrogen and a progestin for women who still have a uterus. This combination is referred to as HRT. You may also hear the term progestogen, which is often used interchangeably with progestin. A progestogen is any agent capable of producing effects similar to those of progesterone, although it doesn't have to contain progesterone. For example, a progestogen can be a synthetic derivative from testosterone, another hormone that women's bodies produce.

There are various HRT regimens. They include the following:

• Cyclic HRT provides estrogen for 25 days each month, adding a progestogen on the last 10 to 14 days, followed by three to six days of no therapy. This "cycling" regimen isn't as popular as it once was, because of uterine bleeding each month when the progestogen cycle ends and the possibility of hot flashes returning during the therapy-free interval.

• Continuous-cyclic HRT (sometimes called sequential HRT) provides estrogen every day, with a progestogen added for 10 to 14 days each month. With this treatment, uterine bleeding occurs in about 80 percent of women when the progestogen cycle ends each month.

• Continuous-combined HRT provides both hormones every day. The daily dose of a progestogen is much lower than the daily doses used in the cyclic treatment, resulting in a lower cumulative dose over a month's time. Uterine bleeding occurs in about 50 percent of women. However, it often stops after several months of therapy. Many women in the United States choose this option.

• Intermittent-combined HRT is a new regimen that provides estrogen every day, and then adds a progestogen intermittently in cycles of three days on, three days off. The cumulative monthly dose of a progestogen is half that of continuous-combined HRT. Bleeding is similar to that of a continuous-combined treatment.

Progestogens come in different forms - as a pill, injection, IUD (intrauterine device), cream, vaginal gel or capsules suspended in peanut oil. They are available either alone or in combination with estrogen.

What is ERT?

Estrogen replacement therapy refers to the use of estrogen alone (called unopposed estrogen). ERT is the standard HRT for women who have had their uterus surgically removed in a hysterectomy.

The most commonly prescribed ERT in the United States includes mixtures of several forms of estrogen that come from the urine of pregnant mares. These are called conjugated estrogens sold under trade names such as Premarin®. Estrogen manufactured in the lab, which is less potent than conjugated estrogens, are also sometimes used, such as estradiol (estrace and Estraderm®), estropipate (Ogen®) and esterified estrogens (Estratab®).

Estrogen can be administered in different forms - the pill or tablets, vaginal creams, vaginal ring insert, implants or shots. There are also patches that stick to the skin.

Are there other hormone therapies?

Androgens

Male-type hormones also have been given to women who have a waning sex drive and whose hot flashes may not be relieved by ERT. Just as men's bodies manufacture small amounts of estrogen, women's bodies produce androgen, secreted by the ovaries and adrenal glands as testosterone and and rostenedione. As a woman ages, she produces more androgen which is converted in her fat, muscles, brain and breasts into estrogen. Women who have had hysterectomies and some women who have undergone natural menopause produce less androgen as well as estrogen.

Several short-term studies suggest small amounts of androgen added to ERT can restore sexual desire, improve energy and also prevent bone loss. As of yet, no long-term safety data exists on the use of testosterone. Observational studies, however, have suggested that it may increase breast cancer probably because it is converted to estrogen in the breast. Too much androgen may cause feelings of agitation, aggression and/or depression. Higher dosages also can cause facial and body hair growth, acne, an enlarged clitoris, a lowered voice and muscle weight gain - side effects that may not go away after therapy.

Women who take androgens do not take them alone. Androgen therapy is only appropriate when a woman is also taking estrogen.

Currently, the only androgen-containing product approved in the United States for use in women is Estratest®, a prescription oral tablet containing an androgen (methyltestosterone) and an estrogen (esterified estrogens). Estratest is approved for treating hot flashes that are unresponsive to ERT alone. It is not approved for boosting sex drive, although some women report an improved libido when taking Estratest.

Women must not use androgen products approved for men, because these contain doses that would be harmful to women.

Birth control pills

Low-dose oral contraceptives containing estrogen and progestin are sometimes prescribed during perimenopause to help regulate periods, improve sleep and level mood swings even though they aren't approved for that use. Oral contraceptives provide significantly more hormone than standard HRT regimens. Since estrogen levels are already very high during perimenopause, in some women they actually make symptoms worse. In addition, their safety in this age group has not been determined. Oral contraceptives increase blood clots and may increase breast cancer just as HRT does. Some women switch from oral contraceptives to HRT after menopause is reached. However, if you take birth control pills you will continue to have uterine bleeding even after menopause, making it difficult to determine if you've reached menopause.

What are the side effects?

Both HRT and ERT can have side effects. They include:

• Uterine bleeding (spotting or returning of monthly periods for a few months or years)
• Breast tenderness
• Cramping
• Abdominal bloating and/or fluid retention (estrogen does not cause weight gain, but it may result in a temporary weight gain because of these side effects)
• Changes in the shape of the cornea of the eye (which may affect wearers of contact lens)
• Headache
• Dizziness
• Increased breast density (making mammograms more difficult to interpret)

Progestogens can cause some medical conditions to worsen, such as asthma, heart failure, epilepsy, depression and migraine headache. Natural progesterone tends to have fewer side effects.

Sometimes the side effects are temporary as a woman adjusts to the hormonal changes. Unless side effects are severe, your doctor may recommend a three-month trial of therapy to see if side effects disappear. Your doctor may be able to control these side effects by changing the amount of hormone, the way it is taken, or the timing of the dose.

What are the benefits?

• Alleviates hot flashes, night sweats, vaginal dryness and other menopausal symptoms.
• Prevents bone loss (as long as a woman is on HRT), although it has not been demonstrated to decrease fractures
• Improves cholesterol levels

What are the risks?

• May increase the risk of breast cancer (particularly in long-term users of hormone therapy)
• Increases risk of stroke in women who have already had a stroke
• Increases risk of heart attack
• Increases triglycerides
• Increases incontinence and uterine prolapse
• Increases risk of ovarian cancer
• Increases risk of blood clots
• Slightly increases risk of developing gallstones

Who would be a candidate for HRT?

Whether you are a candidate for HRT depends on your health, the severity of your symptoms and your willingness to tolerate side effects. Other treatments should also be considered.

You may be a candidate if your symptoms, such as hot flashes, disturbed sleep, mood changes, vaginal dryness and urinary problems, significantly interfere with your ability to function day to day and are unrelieved by alternative therapies.

You may be a candidate if you do not have a history of or high risk factors for breast cancer, blood clots, stroke or heart disease.

Generally, ERT/HRT is used for a limited time (three to five years) to help women manage the temporary symptoms of menopause. Then women should taper off. The current data do not support long-term use of HRT for prevention of the diseases of aging. There are other drugs, which have been proven to be beneficial in the prevention of heart attacks and fractures that are better alternatives for the women at risk.

Who should not use HRT?

You should not take hormone replacement therapy if you have the following:

• Known or suspected pregnancy
• History of breast or endometrial cancer
• Unexplained uterine bleeding
• History of blood-clotting disorders
• Liver disease
• History of a heart attack or stroke

Talk to your doctor

Only you alone, advised by your doctor, can decide if the benefits of HRT outweigh the risks of using it for symptom relief. Discuss your symptoms with your doctor and talk about all of the treatment strategies, including medical and non-medical choices, before deciding what is best for you. (You should also be evaluated for your risk of getting breast cancer, osteoporosis and heart disease.) Most menopausal symptoms, such as hot flashes, night sweats, and vaginal dryness, disappear on their own, although some women can have them for years without treatment.

For  More   Information:  Please  consult  your   physician  on  your  next  visit.