The decision to start hormone replacement should be considered carefully. The decision should be influenced by your individual risk factors for the following including:
It is in your best interest to learn as much as possible about hormone replacement in order to decide whether it is appropriate for you.
Many studies have confirmed the overwhelming advantages of hormone replacement therapy in prolonging life and improving the quality of life. Most women, however, are more concerned about the increased incidence of breast cancer associated with hormone replacement. Hormone therapy needs to be evaluated in perspective with the known benefits as well as the risks with regard to each individual patient.
The leading cause of death in postmenopausal women is from cardiovascular disease. Last year 32% of all deaths in postmenopausal women resulted from a heart attack. Only 4% of all deaths were from breast cancer. An additional 4% of women died from complications related to osteoporosis. Other causes of death were from other cancers, strokes, and respiratory complications related to smoking and non-smoking conditions.
The major benefit of hormone replacement is to protect against heart disease. The PEPI trial from Harvard University is an ongoing study which has followed 50,000 nurses for more than 30 years. So far this study has shown that women who take estrogen have 50 percent fewer heart attacks than those who do not. The Women's Health Initiative, however, has recently reported a slight increase in heart attacks during the first year of use in women with existing coronary artery disease. Women who have a history of a heart attack should discuss the risks and benefits of estrogen replacement with their cardiologist. Estrogen can aide in protecting against heart disease by multiple different mechanisms. One is by raising the "good" cholesterol or the HDL's while decreasing the LDL's or "bad" cholesterol. Estrogen also causes vasodilation (relaxing) of the arteries which prevents plaque formation and hardening of the cardiac (heart) arteries. Women on hormone replacement also have a 50% reduction in the risk of stroke.
Bone loss, which begins at around age 35, accelerates dramatically at menopause. Hormone therapy's effectiveness in preventing bone loss is firmly established. Studies have confirmed that women who have taken estrogen have significantly less bone loss than women who have not. In addition, for women who already demonstrate bone loss, osteoporosis is halted and may even improve when estrogen therapy is started. Calcium (1000 mg / day) and exercise should also be continued.
Hormone therapy can reduce or eliminate hot flashes and night sweats. Mood swings, depression, difficulty sleeping, fatigue and memory loss are also aided by treatment with estrogen. These symptoms occur in 75 percent of women entering menopause and should improve with estrogen therapy.
Vaginal dryness, decreased muscle tone and painful intercourse can be reduced with hormone replacement. Recurrent bladder infections that occur from abrasions to a dry vagina can also be prevented with estrogen. Skin elasticity does not deteriorate as rapidly and younger appearing skin continues.
Recent studies have shown a reduced risk of colon cancer by 50% in women who use hormone therapy. It also appears that Alzheimer's disease may have a 50% decrease in incidence in women who use estrogen. Macular degeneration of the retina leading to blindness is significantly reduced in women who use estrogen and dental decay resulting from periodontal disease is also decreased in women on hormone therapy.
The Lancet in 1997 published an article which demonstrated the increased incidence of breast cancer in women on estrogen therapy. If a woman reaches 70 years of age, she has a 63 / 1000 chance of developing breast cancer. If she has used estrogen for 5 years her chances of developing breast cancer increases to 65 / 1000 and if she uses it for 10 years, her chances of developing breast cancer increased to 69 / 1000. This demonstrates an increased incidence of breast cancer while on estrogen treatment. The breast cancer that develops while on estrogen therapy, however, is often of a different type than breast cancer that occurs without estrogen ingestion. It usually has a much better prognosis and cure rate than spontaneous breast cancer in post- menopausal women who have never taken hormone replacement. Women still live longer if they develop breast cancer while on estrogen therapy than if they never took estrogen at all. This is probably due to the cardiac benefits that outweigh the risk of dying from breast cancer. It may also be due to earlier detection from more encounters with the physician, mammograms and self breast exams.
Unopposed estrogen can increase the risk of uterine cancer from 1 / 1000 to 1 / 100. The risk increases with the amount and duration of estrogen use. For this reason, progesterone has been added to the regimen of hormone replacement if the uterus is still present. Adding progesterone has been shown to be protective as it decreases the risk for endometrial cancer for women on HRT as compared to those women who use no HRT at all. If you take estrogen alone and have not had a hysterectomy, it is important to have a yearly ultrasound and / or endometrial biopsy. Even with combined estrogen and progesterone therapy, any abnormal bleeding should be reported to your physician.
The risk appears to be more than offset by the enormous reduction in deaths due to osteoporosis and cardiovascular disease in women who use estrogen therapy. Continued monthly self breast exams and yearly mammograms are important in early detection of breast cancer.
Side effects of hormone replacement are different than risks of hormone replacement. Vaginal bleeding is the most common reason for stopping hormone therapy. While bleeding stops after one year for the majority of women, it may continue for many. Altering the way progesterone is given or the type of progesterone is one way to reduce or eliminate bleeding. Many different options are available. Breast tenderness is another unpleasant side effect. Altering the route of estrogen use may decrease this side effect. Some women also complain of headaches, fluid retention, vaginal discharge, depression, or nausea. Studies have confirmed that hormones do not cause weight gain and may help decrease weight gain due to menopause. Changes in the dose, method of administration and schedule of the hormones may decrease these side effects.
After deciding to start hormone therapy, your doctor and you have many options. Estrogen can be ingested orally, or through the skin - transdermally, vaginally or by injection. Most women start with the oral preparations. Estrogen is usually prescribed daily. Oral estrogens are better at preventing heart disease because they are processed by the liver which increases the levels of HDL in the blood stream. Injections and the patch feed hormones directly into the bloodstream and bypass the livers metabolism. The patch is more useful in women with significant breast tenderness or hot flashes which are difficult to control. Creams that are applied to the skin also bypass the liver but cannot be monitored effectively to determine the correct dosage. Vaginal creams or the vaginal ring, Estring, are usually prescribed to reduce vaginal dryness locally and do not have the same systemic effects as the estrogen pill or the patch.
It is best to start on the lowest dose estrogen that will prevent cardiovascular disease and osteoporosis. This dosage is about 1 / 6th the dose of an oral contraceptive pill. If menopausal symptoms continue, the amount of estrogen is increased until the symptoms resolve.
Progesterone is added to estrogen to prevent uterine cancer. Multiple regimens can be recommended. Progesterone can be prescribed in a continuous daily method or a cyclic method. The continuous method may reduce the amount of bleeding that occurs with hormones after an initial 6 - 8 months of irregular bleeding. Cyclic therapy is another way of taking progesterone which usually results in a predictable withdrawal period. Progesterone in this manner can be prescribed for the first 5, 10, 12 or 14 days of the month depending on the type of progesterone used. Withdrawal bleeding occurs in about 80 percent of women. Topical progesterone creams are available but have not been proven as effective as oral progesterone. If symptoms from progesterone use cannot be tolerated, some women take "unopposed" estrogen. If this is necessary, an annual ultrasound with or with-out an endometrial biopsy is recommended to insure that uterine cancer is not developing.
In addition to taking hormone therapy to improve the
quality of life after menopause, many other options should be considered. It
is important to maintain optimal body weight in the BMI (body mass index)
level of 22-23.4. This can be calculated as:
BMI = (weight (lb) x 703) / (height (inches) x height (inches))
It is recommended that diet should be "natural" foods with at least 5 fruits and vegetables per day. Exercise of both aerobic type and weight bearing type should be accomplished at least 3-4 times per week. Adequate sleep and at least eight glasses of water should be consumed each day. Coffee and alcohol should be limited. Stress and cigarettes should be avoided. Vitamin E (200-400 IU), Vitamin C, Vitamin D and one aspirin / day should be considered. Calcium of at least 1000 mg per day should be consumed. Yearly mammograms, monthly self breast exams, and yearly exams with your doctor are extremely important.
Every woman entering menopause should have a discussion about hormone replacement therapy, both the risks and benefits, with her physician. All of the above issues should be considered to determine if hormone replacement is appropriate for you and which method to use in the treatment of menopause.