Hormone Therapy (HT)

Hormone Therapy is sometimes also called hormone replacement therapy, HRT.

Estrogen and progesterone are hormones that are produced by a woman's ovaries.

Why Does the Body Need Estrogen?

Estrogen thickens the lining of the uterus, preparing it for the possible implantation of a fertilized egg. Estrogen also influences how the body uses calcium, an important mineral in the building of bones, and helps maintain healthy levels of cholesterol in the blood. Estrogen also keeps the vagina healthy.

As menopause nears, the ovaries reduce most of their production of these hormones. Lowered or fluctuating estrogen levels may cause menopause symptoms such as hot flashes, and medical conditions such as osteoporosis.

What is Hormone Therapy?

Hormone therapy is a treatment that is used to supplement the body with either estrogen alone or estrogen and progesterone in combination. When the ovaries no longer produce adequate amounts of these hormones (as in menopause), HT can be given to supplement the body with adequate levels of estrogen and progesterone. Hormone therapy helps to replenish the estrogen, relieving some of the symptoms of menopause and helping to prevent osteoporosis.

Why is Progesterone Taken?

Progesterone is used along with estrogen in women who still have their uterus. In these women, if taken without progesterone, estrogen increases a woman's risk for cancer of the endometrium (the lining of the uterus). During a woman's reproductive years, cells from the endometrium are shed during menstruation. When the endometrium is no longer shed, estrogen can cause an overgrowth of cells in the uterus, a condition that can lead to cancer.

Progesterone reduces the risk of endometrial (uterine) cancer by making the endometrium thin. Women who take progesterone may have monthly bleeding, or no bleeding at all, depending on how the hormone therapy is taken. Monthly bleeding can be lessened and, in some cases, eliminated by taking progesterone and estrogen together continuously. Women who have had a hysterectomy (removal of the uterus through surgery) usually do not need to take progesterone. This is an important point, because estrogen taken alone has less long-term risks than hormone therapy that uses a combination of estrogen and progesterone.

What are the Types of Hormone Therapy?

There are two main types of hormone therapy:

1. Estrogen Therapy (ET): 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. This type of hormone therapy is used if a woman has had a hysterectomy.
2. Estrogen Progesterone/Progestin Hormone Therapy (EPT): Also called combination therapy, this form of HT combines doses of estrogen and progesterone (progestin is a synthetic form of progesterone). This type of hormone therapy is used as a woman still has her uterus.

What are the Benefits of Taking Hormone Therapy?

HT is prescribed to relieve:

• Hot flashes
• Vaginal dryness that can result in painful intercourse
• Other problematic symptoms of menopause, such as night sweats and dry, itchy skin

Other benefits of taking HT include:

• Reduced risk of developing osteoporosis and reduced risk of bone breakage
• Improvement of mood and overall sense of mental well-being in some women
• Decreased tooth loss
• Lowered risk of colon cancer
• Lowered risk of diabetes
• Modest improvement in joint pains
• Lower death rate for women who take hormone therapy in their 50s.

What are the Risks of Taking Hormone Therapy?

While HT helps many women get through menopause, the treatment (like any prescription or even non-prescription medicines) is not risk-free. Known health risks include:

• An increased risk of endometrial cancer (only if a woman still has her uterus and is not taking a progestin along with estrogen) .
• Increased risk of blood clots and stroke. However, in women within 5 years of menopause there was no statistically significant increase in stroke risk. Also, studies suggest that using estrogen delivered from the skin via a patch/cream might further lessen the risk of blood clots.
• Increased chance of gallbladder/gallstone problems.
• Increased risk of dementia if hormone therapy is started after a woman has been in menopause for 10 years. It is not yet known if it might be beneficial for women who start HT in their 50s.

Most of our understanding about the benefits and risks of hormone therapy on the heart and breast come from the WHI study (one of the largest studies done on hormone therapy).

HT and the Heart:

Recent analysis of WHI actually shows that the risk of heart disease may be related more to the advanced age of the participants as opposed to the HT. The study also found that HT given to younger women, at the onset of menopause, appeared to decrease the risk of heart disease.

More specifically, an increased risk of heart disease is only seen in women taking long-term estrogen-progestin combination therapy (EPT) if they start HT in their mid 60s. There does not seem to be an increased risk of heart disease when women in their 50s start EPT. Estrogen alone (ET) has not been shown to increase the risk of heart disease. Analysis of the age since menopause actually shows a decrease in the risk of heart disease when ET was started in younger women (those just beginning menopause).

Currently, it is not recommended to use hormone therapy solely for the purpose of preventing heart disease. However these studies give us reassurance that when women just newly approaching menopause need HT for a short time, it is safe to do so in terms of long term heart disease risk.

HT and Breast Cancer:

Diagnosis of breast cancer increases when combination EPT is used beyond 3-5 years. This means that out of 10,000 women who use estrogen progestin therapy for more than 5 years, there will be 8 additional breast cancers diagnosed. In contrast, the WHI study showed women who use estrogen alone had no increase in risk of breast cancer even after 11 years of use. In fact, less breast cancers were seen in the group taking estrogen alone, though this was not statistically significant. When a woman comes off of hormone therapy, any potential increase in her risk of breast cancer quickly goes back to her baseline norm. This is why hormone therapy can be a safe option for women in their 50s who are generally at lower risk for breast cancer compared to older women.

Does Starting HT Closer to the Time of Menopause Make it Safer?

One of the problems with the WHI study, which gave us much of our knowledge on the risks of HT, is that most women in the study were starting hormones in their mid 60s. Typically, women who need HT are newly menopausal, in their early 50s. Younger women in the WHI study had less risks and more benefits from HT. Newer studies are trying to understand the risks and benefits of HT in women in their 50s. One such study showed HT started early in postmenopausal women significantly reduced death rate, heart attacks and heart failure. These postmenopausal women who started HT early and used it for more than 10 years were not at increased risk of breast cancer or stroke.1

What are Some Commonly Used Postmenopausal Hormones?

Below are the names of some, but not all, postmenopausal hormones.

Who Shouldn't Take Hormone Therapy?

HT is not usually recommended for women who have:

• Active or past breast cancer
• Recurrent or active endometrial cancer
• Abnormal vaginal bleeding that has not been evaluated
• Recurrent or active blood clots
• History of stroke
• Liver disease
• Known or suspected pregnancy
• Cigarette smokers should be encouraged to stop smoking before taking HT.

What are the Side Effects of Hormone Therapy?

Like almost all medications, hormone therapy has side effects. The most common side effects are:

• Monthly bleeding (If progestin given cyclical)
• Irregular spotting
• Breast tenderness

Less common side effects of hormone therapy include:

• Fluid retention
• Headaches (including migraine)
• Skin discoloration (brown or black spots)
• Increased breast density making mammogram interpretation more difficult
• Skin irritation under estrogen patch

How can I Reduce These Side Effects?

Adjusting either the dosage or the form of the medication you are taking can often reduce side effects of HT. However, you should never make changes in your medication or stop taking it without first consulting your doctor.

How can I Know if HT is Right for me?

The balance of risks versus benefits of hormone therapy can be very different for each woman, depending on the following:

• age
• family history
• personal medical history

It is important to allow enough time at an office visit to discuss the risks and benefits of hormone therapy. This is a question that should usually be addressed at a separate office visit to allow plenty of time for detailed discussion with your doctor.

How Long Should I Take HT?

Since research on HT is ongoing, women should reevaluate their treatment plans each year. Discontinue HT (under your health care provider's guidance) if you develop a medical condition that would make it less safe for you.

Based on the WHI Study Results, Should I Stop Taking HT?

It's important that you do not make any abrupt changes to your HT without consulting your doctor. He or she can discuss with you the benefits and risks of HT based on your individual circumstances.

1. First, the therapy should not be continued or started to prevent heart disease. Women should consult their doctor about other methods of prevention, such as lifestyle changes, and cholesterol- and blood pressure-lowering drugs.
2. Second, for osteoporosis prevention, women should consult their doctor and weigh the benefits against their personal risks. Alternate treatments also are available to prevent osteoporosis and fractures.
3. Finally, women taking HT for relief of menopausal symptoms may reap more benefits than risks. Women should talk with their doctor about their personal risks and benefits.

References:

• Cleveland Clinic Guide to Menopause: Holly L. Thacker, MD and Barbara Kaplan, MD
• Effect of Hormone Replacement Therapy on Cardiovascular Events in Recently Postmenopausal Women: Randomized Trial. BMJ Oct 2013
• Position statement: The 2012 hormone therapy position statement of the North American Menopause Society. www.menopause.org Accessed 5/30/13
• American Association of Clinical Endocrinologists Medical Guidelines for the Clinical Practice for the Diagnosis and Treatment of Menopause. Accessed 6/23/13 https://www.aace.com/files/menopause.pdf
• Committee on Gynecological Practice. Postmenopausal estrogen therapy: Route of administration and risk of venous thromboembolism. Obstet Gynecol 2013 Apr; 121:887.
• Estrogen alone and joint symptoms in the Women's Health Initiative randomized trial. Menopause 2013 Mar 18