Menopause is when a woman stops having her menstrual periods and the ovaries stop releasing eggs. This happens because a woman’s body stops or reduces the production of certain hormones, such as estrogen and progesterone. A woman is considered to be in menopause after she hasn’t had her period for 12 months. In the U.S., the average age of menopause is 51.
— Hot flashes. About 75% of menopausal women will experience hot flashes, taking place for an average of seven to nine years.
— Brain fog.
— Decreased interest in sex.
— Heart disease.
— Mood disturbances.
— Night sweats.
— Osteoporosis, or a thinning of the bones.
— Sensitive bladder, such as the need to urinate more frequently.
— Sleep disturbances.
— Vaginal dryness that leads to discomfort or painful sex.
These symptoms occur frequently in women who have naturally reached menopause or those who have had their ovaries surgically removed, says Dr. Jonathan Black of the Center for Gynecologic Oncology, with various locations in the Ft. Lauderdale and Miami area. Sometimes, the use of chemotherapy or radiation to treat cancer can lead to early menopause.
Coping with these symptoms can be challenging, leading some women to ask their primary care doctor or OB/GYN how they can find relief. One option is hormone replacement therapy, which involves the prescribed use of hormones. Hormone therapy helps to treat the bothersome symptoms associated with menopause.
Often called hormone replacement therapy or HRT, many health providers now use the term hormone therapy or HT instead — although the term can also refer to other medical treatments, such as using hormones to slow or stop certain types of breast cancer.
For menopause treatment, HRT and HT refer to the same thing. “We are not trying to replace what the ovaries used to produce. Rather, we are aiming to provide just enough to manage symptoms,” says Dr. Stephanie S. Faubion, the Penny and Bill George Director of the Mayo Clinic Center for Women’s Health in Jacksonville, Florida, and medical director of the North American Menopause Society.
[READ: Tips for Better Vaginal Health.]
Understanding Hormone Therapy
Estrogen and progesterone are the hormones used most often to treat menopausal symptoms. Both types of hormones can help with many of the symptoms associated with menopause, such as hot flashes, vaginal dryness and sleep difficulties. They also can prevent bone loss. Estrogen also helps protect the heart, although women are not usually given estrogen nowadays solely for heart health.
Estrogen and progesterone are often given together to decrease the risk for cancer of the endometrium, which is the uterus lining. That risk can be higher when estrogen is given alone.
Sometimes, testosterone cream is used during hormone replacement therapy if the symptoms include reduced sex drive and vaginal dryness. Although testosterone is traditionally associated with males, women produce testosterone as well.
Hormone therapy comes in many different forms:
— Vaginal suppositories.
— Vaginal rings.
It’s best to talk to your health provider about the best hormone therapy approach for you, says Dr. Mache Seibel, a women’s wellness and menopause expert at Beth Israel Deaconess Medical Center/Harvard Medical School in Boston and author of “The Estrogen Fix.” Women who have used birth control for many years may feel comfortable taking a pill, while others prefer a cream, he explains.
The use of an estrogen cream usually works more effectively for vaginal dryness and pain compared with oral estrogen, Black notes. That’s because they can be applied directly to the affected area.
Each product may have a different dosing frequency. You may need to take a pill daily or change a patch once or twice a week, Faubion says. Vaginal rings are generally reinserted every 90 days.
Progesterone hormone therapy is typically taken orally, either once daily or as a higher dose for about two weeks out of the month. There are also progesterone creams.
There are different forms of estrogen or progesterone in hormone therapy, including bioidentical hormones. These are hormones that are chemically the same or almost the same as those made by the ovaries but are plant-derived. Bioidentical hormones also are called compounded hormone therapy and are typically made by a compounding pharmacy and customized for each patient. Bioidentical hormones are not approved by the U.S. Food and Drug Administration.
The more traditional form of hormone therapy includes conjugated equine estrogens and synthetic forms of progestins, Faubion says. Conjugated equine estrogen contains a blend of different estrogen hormones. They’re derived from the urine of pregnant horses. Synthetic progestins are made to act similarly to naturally occurring progesterone. Each doctor may have a preference for bioidentical or traditional hormone therapy and should consider your overall health risks and benefits before any hormones are used.
The Controversy Over Hormone Replacement Therapy
Doctors have differing opinions about hormone replacement therapy. Controversy over hormone replacement therapy began in 2002, after the Women’s Health Initiative study results published in JAMA found a higher risk of blood clots, breast cancer, heart disease and stroke associated with hormone replacement therapy. Women in the study used both estrogen and synthetic progestin. However, that study has since been criticized for grouping together healthy women in their 50s with women in their 60s and 70s who often smoked or had pre-existing health conditions, such as heart disease and high blood pressure, Seibel says. The risks were higher in older women.
Based on what health providers know now, women are most likely to get health benefits from hormone therapy — and have a lower risk for cancer or heart disease associated with the therapy — if they begin hormone therapy within 10 years of the last menstrual period, Faubion says.
Research since the Women’s Health Initiative study has found that risk from HRT is often linked to a woman’s age (being 60 or older or more than 10 years after your last period is considered higher risk), a history of blood clots or heart disease, and what types of hormones and dosing are used.
Still, the Women’s Health Initiative study left its mark, and some medical providers are still hesitant to prescribe hormones to menopausal women. The FDA recommends that women use the smallest dose possible for the shortest amount of time needed if they choose to use HRT. The FDA doesn’t specify what a short amount of time would be.
The American Cancer Society recommends that health providers consider a woman’s risk for certain types of cancer, the risk for conditions such as heart disease and stroke, and what other medicines could be used for menopause or osteoporosis.
There are some women who should avoid HT, such as those who have:
— A history of blood clots or stroke.
— A history of hormone-dependent cancer such as breast or uterine cancer. However, these women still may be able to use a vaginal ring, Seibel says.
— Deep vein thrombosis.
— A history of heart disease. If you have heart disease, you’re at a higher risk for blood clots. Hormone replacement therapy also may put you at a higher risk for blood clots.
— Significant liver disease.
— Undiagnosed uterine bleeding.
Talk to your doctor about your risk factors that may preclude the use of hormone therapy. Women who are considering hormone therapy should get multiple opinions to help weigh the pros and cons of it, Black advises.
When to Start Hormone Therapy
A woman starting hormone therapy is usually going through menopause or is postmenopausal. You shouldn’t use hormone therapy only because you have reached menopause. It also shouldn’t be used solely for any protective effects that estrogen may give. Hormone therapy is typically recommended if you have symptoms that bother you regularly, such as hot flashes.
Women who have bothersome symptoms but who are in perimenopause may be given low-dose hormonal contraception to help with any troublesome symptoms, Faubion says. That’s because women in this age group can still get pregnant, so the contraception both aids in preventing pregnancy and controlling hormonal-related symptoms.
It’s usually better for menopausal and post-menopausal women interested in hormone therapy to start it sooner rather than later, Seibel says. When women wait too long to try it — say, in their mid-60s or later — they may already have developed heart disease and be at higher risk for strokes or blot clots if they use hormone therapy. The estrogen vaginal ring is a potential option for women in their 60s or older who want some symptom relief.
Ninety percent of women who try HT will find relief from it, Seibel says. This could happen in just a few days after starting treatment or within about three months. “I give them the lowest dose that I think will work and have them come back in two to three months,” he says. You may need to see your doctor more than once and have bloodwork or imaging tests done to help find the right dosing for you, Black says.
The average woman will use hormone therapy for about five years. A re-evaluation of hormone therapy every five years is reasonable to review how a woman’s health has changed over that time, Seibel says. Once a woman reaches her early or mid-60s, Seibel will re-evaluate hormone therapy use once a year. Some women choose to use hormone therapy long term due to symptoms that continue well past menopause, such as hot flashes. Seven percent of women continue to have hot flashes in their 70s, he says.
Side Effects of Hormone Replacement Therapy
Some side effects associated with hormone replacement therapy include:
— Vaginal bleeding. This is the most common reason that women will stop using hormone therapy, Seibel says. It usually means that you need a different dose. Talk to your doctor if have this symptom but want to continue using hormone therapy.
— Breast tenderness.
— Indigestion or abdominal pain.
Doctors can change the dosing as needed or offer nonhormonal alternatives if the side effects from HRT are too severe, Black says. This could include certain medications, cognitive behavioral therapy and certain herbs.
Seibel likes to remind patients about the importance of talking to health providers about their menopausal symptoms. He has met many women who have problems like a sensitive bladder or vaginal dryness for years but don’t bring it up to their health providers. They avoid the topics out of embarrassment or wrongly believing that there are no treatments to help.
“Women shouldn’t feel they have to suffer in silence. They should ask for help and expect to get some,” Seibel says.
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