MEDICATIONS: HORMONE THERAPY

What Is Hormone Therapy?

Hormone therapy (HT) is a means of replacing the sex hormones estrogen and often progesterone that a woman's body stops making in sufficient quantities when she reaches natural menopause (or after surgical removal of the ovaries). HT is usually begun at menopause to relieve menopausal symptoms such as hot flashes and night sweats.

Doctors used to recommend that women take HT for the rest of their lives to achieve long-term health benefits such as a reduced risk of osteoporosis, bone fractures, colon cancer, and possibly heart disease and Alzheimer's disease. But in 2002, a large study called the Women's Health Initiative, sponsored by the National Institutes of Health, was stopped early because of evidence of an increased risk of heart disease, stroke and breast cancer in women taking a specific estrogen-progestin combination drug regimen.

HT is available by prescription in pills, patches and creams. A woman and her doctor choose the appropriate delivery method based on the woman's health risks, her preferences, and the risks and benefits to her personally.

Weighing the Risks and Benefits of HT

In making the decision to take HT, each woman needs to discuss the risks and benefits with her doctor in the context of her health history and health risks. Women who should not take estrogen are those who have breast cancer or a history of breast cancer, abnormal vaginal bleeding, very high triglyceride (a potentially harmful type of fat in the blood) levels, a history of blood-clotting disorders, active liver disease, or gallstones or gallbladder disease. If you have or had any of these conditions, talk to your doctor. You may be able to use estrogen patches rather than pills.

Benefits

For women who experience debilitating short-term symptoms of menopause that interfere with their quality of life — such as hot flashes, night sweats, sleep disturbances, mood swings, and vaginal dryness, itching and burning — HT is the most effective treatment. Estrogen also reduces thinning of the vaginal walls and pain with intercourse and, in many cases, improves mood, sleep and short-term memory. Low doses of HT can relieve these symptoms. Many newer lower-dose estrogen products are available.

HT protects against osteoporosis by slowing the rate of bone loss and improving bone density throughout the body, including in the hips and spine. Postmenopausal women who take HT have a decreased risk of fractures. However, because of the potential slightly increased risk of heart disease, stroke and breast cancer from HT, unless a woman also has severe menopausal symptoms such as hot flashes, doctors no longer recommend HT solely for preventing or treating osteoporosis. If you have osteoporosis or its precursor condition osteopenia, your doctor can recommend another bone-building medication (see below).

Disadvantages and Health Risks

Taking estrogen alone, the former HT regimen sometimes called estrogen replacement therapy (or ERT), was found to increase the risk of uterine cancer (in women who had not had a hysterectomy). For this reason, progestin (a synthetic form of the female hormone progesterone, which counterbalances estrogen in the body) is now combined with estrogen in HT for women who have a uterus. Women who have had a hysterectomy (and therefore no longer have a uterus) are not at risk for uterine cancer and can take estrogen alone.

Side effects of HT can include vaginal bleeding, breast tenderness, nausea and bloating. In some cases, these side effects can be eliminated by reducing the dose or trying a different drug combination. Various formulas are available that provide different types of estrogens and progestins or a different estrogen-progestin ratio.

The Women's Health Initiative found a link between taking HT longer than five years and a slightly increased risk of breast cancer. For this reason, most doctors recommend that women who have had breast cancer should not take estrogen. Women who have a family history or other risk factors for breast cancer should talk to their doctor if they are considering taking HT. Whether or not you are taking HT, you need to continue doing month breast self-examinations and, after age 40, have regular mammograms as often as your doctor recommends.

The 2002 Women's Health Initiative study found that HT slightly increased some women's risk of heart disease. The precise effect that estrogen has on cholesterol levels and heart disease risk is not clear, but normal levels of estrogen in the body before menopause seem to protect women from heart disease; before menopause, women are much less likely than men to die of heart disease. After menopause, by age 65, women's death rates from heart disease equal those of men. Doctors no longer recommend that women take HT solely to reduce their risk of heart disease.

Choosing the Right Method for You

If you and your doctor determine that HT might be beneficial for you, the next step is to choose the delivery method. You can choose from different pill combinations and doses, patches, and creams.

Estrogen Pills
Estrogen-only pills are usually taken every day. Estrogen-only pills are prescribed only for women who have had a hysterectomy. Women who have not had a hysterectomy should take a combination of an estrogen and a progestin (either in separate pills or in one tablet) to avoid the increased risk of uterine cancer from taking estrogen alone.

Estrogen/Progestin Pill Regimens
There are two methods for taking estrogen and progestin: the continuous method and the cyclic method.

In the continuous method, you take a pill that contains both estrogen and progestin or separate estrogen and progestin pills every day. Like other HT regimens, the continuous method can cause irregular bleeding (especially during the first three months), but the bleeding usually stops after a few months.

In the cyclic method, you take estrogen and progestin in separate pills, as prescribed, or a combination formula that packages the proper dose in a pill-pack. You take estrogen either every day or for 25 days of the month and progestin for 10 to 14 days each month. The cyclic method can cause monthly bleeding that can last up to a year or longer.

Hormone Patches
To use the estrogen patch or the estrogen-progestin patch, a woman applies the patch to the skin of her abdomen or buttock for three and a half or seven days, and then applies a new one. A patch is worn every day and can be left on all the time, including while bathing and swimming. The hormones are delivered through the skin into the bloodstream. Progestin can be taken in pill form with the estrogen patch. Both patches may cause monthly bleeding. Estrogen patches relieve menopausal symptoms and protect against bone loss

Estrogen Cream
Estrogen cream is inserted into the vagina or around the vulva to ease vaginal dryness and urinary problems. Women who are not bothered by hot flashes may choose this method to decrease vaginal or urinary symptoms such as painful intercourse or urinary frequency. However, if a woman still has a uterus and she uses the vaginal cream more often than once a month, she needs to take progestin for at least 10 days every other month to counteract the increased risk of uterine cancer from the estrogen. Talk to your doctor about whether you need to take progestin while you are using the vaginal estrogen cream.

Raloxifene
Raloxifene is an estrogen-like drug that is part of a class of drugs called selective estrogen receptor modulators (SERMs). Raloxifene can be prescribed to prevent or treat osteoporosis. The drug does not seem to increase the risk of uterine cancer as estrogen does, and it may actually protect against some invasive forms of breast cancer. Raloxifene does not cause monthly bleeding, but it also does not relieve hot flashes or other menopausal symptoms.

HT can usually be customized to provide maximum benefits with minimum side effects. If you have irregular bleeding or other side effects while taking HT, talk with your doctor about switching regimens or lowering the dose. Such adjustments can often decrease or eliminate the symptoms. Women who start HT usually have a three-month checkup, followed by six-month or annual checkups that include pelvic and breast examinations. These checkups may also include blood tests to measure cholesterol levels, especially if you have risk factors for heart disease. In addition, remember that after menopause you should have a mammogram every year.

Questions to Ask Your Doctor

Your doctor is familiar with your health history and can help you make decisions about HT. Here are some questions you might want to ask your doctor:

· If I decide to take HT, when should I begin?

· Which form of HT is most appropriate for me?

· What side effects are possible from the form of HT I'm taking?

· What tests or procedures might I have during my regular checkups?

· How long should I wait for any side effects to stop before considering a change in dosage or regimen?

· For how long should I take HT?

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