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Hormone Replacement Therapy (HRT)
Hormone Replacement Therapy (HRT) provides women with the female hormones that decrease as they age. Oestrogen is a female hormone that brings about changes in other organs in the body. Progesterone is a female hormone that prepares the uterus for a pregnancy each month. During the transition to menopause ("perimenopause") these hormone levels start to fluctuate, causing some uncomfortable symptoms. When the ovaries stop producing oestrogen and progesterone, menstrual periods cease and the woman has experienced menopause.
Benefits of Hormone Replacement Therapy
Hormone Replacement Therapy has been used to relieve the short-term symptoms of menopause, such as hot flashes, sweats, and disturbed sleep. It is also believed to be useful in preventing or alleviating an increased rate of bone loss that leads to osteoporosis. Preliminary evidence shows that HRT may be helpful in preventing Alzheimer's disease, colon cancer, and macular degeneration (age-related vision loss).
Risks of Hormone Replacement Therapy (HRT)
Risks are discussed as short term and long term side effects
Short-term side effects: Some women report side effects from taking Hormone Replacement Therapy, including unusual vaginal discharge and bleeding, headaches, nausea, fluid retention and swollen breasts. Some women think HRT will make them gain weight while taking HRT, but research now shows this is not true. Some women do gain weight during menopause, but it is because their metabolism slows down as they age, and they many not be increasing their amount or level of physical activity. Short-term benefits or side effects should become apparent within weeks or months after treatment begins.
Long-term risks (These will not be readily apparent for each individual woman):
Cancer: There is concern that HRT can increase the risk of some cancers. When oestrogen is taken alone, it raises the risk of endometrial cancer (lining of the uterus). Adding progestin with oestrogen (HRT) can dramatically reduce this risk. Progestin is added to prevent the overgrowth (or hyperplasia) of cells in the lining of the uterus, so women who still have an intact uterus are generally given this combined therapy.
Breast Density: Taking both oestrogen and progestin also can affect a woman's breast density. Increased breast density from HRT makes it more difficult for a radiologist to read some mammograms, leading to the need for follow-up mammograms or breast biopsies. Increased density also is a concern because other studies have shown that women age 45 and older whose mammograms show at least 75 percent dense tissue are at increased risk for breast cancer. However, it is not known if increased breast density due to HRT carries the same risk for breast cancer as having naturally dense breasts. Heart Disease: In the past, taking HRT (oestrogen plus progestin) was thought to help protect women against heart disease. But recent findings from the Women's Health Initiative (WHI) study showed that taking HRT poses more risks than benefits. The study found that HRT could increase a woman's risk for heart disease, stroke, and pulmonary embolism (blood clot in the lung), as well as breast cancer.
If you are taking HRT, watch for signs of trouble, such as abnormal bleeding, breast lumps, shortness of breath, dizziness, severe headaches, pain in your calves or chest, and report them to your health care provider right away. Also, talk with your health care provider about how often you should have an exam.
Does the duration of taking HRT affect breast cancer risk?
There is considerable uncertainty about the relationship between a woman's risk of developing breast cancer and the length of time that she receives HRT. Some women take HRT for only a few years, until the worst of their menopausal symptoms have passed, while others have taken it for a decade or more. Some researchers believe that there is little or no increased risk of breast cancer associated with short-term use of either HRT with oestrogen alone or oestrogen combined with progestin, while long-term use is linked to an increased risk.
Why is menopausal Hormone Replacement Therapy used in spite of the cancer risk?
The known benefits of HRT can improve the quality of life for many women, by reducing uncomfortable hot flashes, night sweats, and vaginal dryness. There also is evidence that HRT helps prevent and treats osteoporosis, and preliminary evidence that it can help prevent other problems associated with age, including Alzheimer's disease, colon cancer and deterioration of eyesight. The addition of progestin to the treatment has dramatically reduced the risk of endometrial cancer. Family history of breast cancer, early age of the first menstrual period (menarche), late age of child bearing, high fat diet, obesity, increased breast density on mammograms, and certain benign breast lesions increase the underlying risk of developing a breast cancer. These factors need to be considered when deciding to take HRT. If you are currently taking HRT and have concerns, talk with your health care provider as soon as possible.
Are there other drug therapies known to treat conditions related to menopause?
A class of drugs called SSRIs (such as Prozac and Zoloft) is very effective in treating menopause-related symptoms of depression or mood changes. Vitamin E and Clonidine, a drug typically used for high blood pressure, can alleviate hot flashes. To prevent osteoporosis, bisphosphonates, alendronate, raloxifene and calcitonin are used in women who are at high risk for bone loss. Lastly, a class of cholesterol-lowering drugs called HMG-CoA-reductase inhibitors (statins) are proven to be effective for reducing risk of heart disease and are being explored to prevent osteoporosis. No alternatives to oestrogen exist for prevention of Alzheimer's disease, colon cancer, and macular degeneration - diseases for which preliminary evidence suggests HRT is beneficial.
Herbal remedies for Menopause
There are many "herbal" products for sale that claim to help menopausal symptoms. These products are not regulated through the same government system as drugs, so there is little research to back up their claims. In addition, most have to be taken routinely, are not covered by insurance, and can become costly over time. Any herbal remedies for menopause should be thoroughly discussed with your health care provider. You should tell your provider if you are taking any other medications, since some of the herbal products can have harmful interactions with other drugs.
Who should not use HRT?
HRT is often not recommended for women who have any of the following conditions:
- Vaginal bleeding of an unknown cause
- Suspected breast cancer or history of breast cancer
- History of endometrial cancer or cancer of the uterus
- Chronic disease of the liver
- History of heart disease
- History of venous thrombosis (blood clots in the veins or legs, or in the lung). This includes women who have had thrombosis or blood clots during pregnancy or when taking birth control pills. Although the risk of blood clots in women is very low, HRT increases the risk.
How can I sort through the benefits and risks to make a good decision about whether or not to use postmenopausal Hormone Replacement Therapy?
Here are several points to help you summarize the findings of the Women's Health Initiative (WHI) study: First, it's important to know that, because the study involved healthy women, only a small number of them had either a negative or positive effect from oestrogen plus progestin therapy. The percentages describe what would happen to a whole population-not to an individual woman. For example, the increased risk of breast cancer for the women in the WHI study who were taking the oestrogen plus progestin therapy was less than a tenth of 1 percent each year. But if you apply that increased risk to a large group of women and over several years, then the number of women affected becomes an important public health concern. About 6 million American women take oestrogen plus progestin therapy. That would translate into nearly 6,000 more cases of breast cancer every year- and, if all of the women took the therapy for 5 years, that might result in 30,000 more cases of breast cancer.
Second, bear in mind that percentages aren't fate. Whether expressing risks or benefits, they do not mean you will develop a disease. Many factors affect that likelihood, including your lifestyle and other environmental factors, heredity, and your personal medical history. Finally, realize that most treatments carry risks and benefits. No one can make a treatment choice for you. Talk with your doctor or other health care provider and decide what's best for your health and quality of life. Begin by finding out your personal risk profile for heart disease, stroke, breast cancer, osteoporosis, colorectal cancer, and other conditions. Discuss quality of life issues and alternatives to postmenopausal Hormone Replacement Therapy with your health care provider. Then, weigh every factor carefully and choose the best option for your health and quality of life. And keep talking with your health care provider-your health status can change and so can your choice.
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