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Hormone Replacement Therapy: A Look at the Options

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Hormone replacement therapy (HRT) is sometimes used on a short-term basis for the relief of unpleasant menopausal symptoms, such as hot flashes, vaginal dryness, and irritability. On a long-term basis, some women have used HRT based on the idea that it would reduce the risk of osteoporosis and heart disease . However, results of studies on estrogen replacement therapy (ERT) and estrogen plus progestin suggest that the risks of long-term HRT may outweigh the benefits for many women.

Along with information about the risks of HRT, there are also a number of options. So, if you and your doctor decide that HRT may be right for you in the short- or long-term, how do you decide which therapy would be best?

HRT Options

HRT can include the hormones estrogen alone, or the combination of estrogen and progesterone. If you're considering HRT for the first time, or want to talk to your doctor about changing the regimen you're presently on, here's a rundown of options.

Estrogen Only (ERT)

Therapies containing just estrogen are commonly referred to as estrogen replacement therapy, or ERT. Because of the increased risk of endometrial cancer (lining of the uterus), long-term ERT is usually only offered to women who have had uterus removal through a hysterectomy.

ERT can be administered in a variety of ways. Systemic ERT delivers estrogen so that it circulates throughout the body, whereas local ERT delivers estrogen to a particular area of the body, such as the vagina to treat vaginal dryness or vaginal atrophy.

Systemic ERT can be delivered as oral medicines, skin patches, gels, injections, implanted pellets, and sprays. These medicines may help to reduce hot flashes and vaginal dryness and may reduce your risk of osteoporosis.

Local ERT can be delivered directly into the vagina by a pill, cream, or ring. Because only a small amount of estrogen circulates in the body with local ERT, these products typically only help with local symptoms, such as vaginal dryness. They are usually not helpful in controlling other symptoms of menopause, such as hot flashes, or in preventing osteoporosis.

Potential Side Effects of Systemic ERT
  • Uterine bleeding (if uterus is present)
  • Breast tenderness
  • Nausea or abdominal bloating
  • Fluid retention in extremities
  • Headache (sometimes migraine )
  • Dizziness
  • Increased breast density, which makes mammograms harder to interpret
Potential Risks of Systemic ERT
  • Ovarian cancer
  • Enlargement of benign uterine tumors ( fibroids )
  • Worsening of endometriosis
  • Endometrial cancer (if progesterone isn't taken with ERT)
  • Gallbladder problems, including gallstones (for orally administered ERT)
  • Blood clots
  • Stroke
Estrogen Plus Progesterone (HRT)

Hormone replacement therapy (HRT) is treatment that combines ERT (estrogen only) with a form of the hormone progesterone. This may consist of natural progesterone or a synthetic progesterone, called progestin. Both forms are also called progestogens.

There are several HRT schedules and methods of delivery available, including:

  • Cyclic HRT —This treatment provides estrogen for 25 days each month, adding progesterone on the last 10-14 days out of 25, followed by 3-6 days of no therapy. This way, both hormones are "cycled." Cyclic HRT may cause uterine bleeding (a menstrual period) when the progesterone cycle ends. Hot flashes are also more likely to return on the days when no hormones are taken.
  • Continuous-Cyclic HRT —This treatment provides estrogen every day, with progesterone added 10–14 days of each month. Like cyclic HRT, the main side effect is uterine bleeding (in the form of a period).
  • Continuous-Combined HRT —This treatment provides both estrogen and progesterone every day. The daily dose of progesterone is much lower than the daily dose in cyclic therapy, which may result in a lower total dose over the course of the month. Breakthrough uterine bleeding occurs in some women on this schedule, but usually stops within the first year of therapy.
  • Intermittent-Combined HRT —This treatment provides estrogen every day, with progesterone added intermittently in "on-off" cycles. The cumulative monthly dose of progestogen is about half of that of a continuous-combined pattern. .

Potential Risks of HRT

Potential side effects and risks of HRT are basically the same as those listed for ERT. Long-term HRT may slightly, but significantly, increase the risk of strokes , blood clots, heart attacks, and breast cancer , gallstones, gallbladder disease, and ovarian cancer. Adding progesterone, however, eliminates the increased risk of endometrial cancer caused by estrogen alone. This applies to women who have not had their uterus removed.

Weighing Your Options

If you are currently taking estrogen or combined estrogen and progesterone or were thinking about starting, talk to your doctor before making any final decisions about what to do.

RESOURCES:

American Congress of Obstetricians and Gynecologists
http://www.acog.org/

Menopausal Hormone Therapy Information
http://www.nih.gov/PHTindex.htm/

CANADIAN RESOURCES:

The Canadian Women's Health Network
http://www.cwhn.ca

The Society of Obstetricians and Gynaecologists of Canada
http://www.sogc.org/

References:

Benefits, risks, and side effects of ERT, HRT, and NHRT. Project AWARE website. Available at: http://www.project-aware.org/Managing/Hrt/benefits-risks.shtml#risks. Accessed August 16, 2012.

Breast cancer in women. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated August 14, 2012. Accessed August 16, 2012.

Estrogen-progestin combinations. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated April 11, 2011. Accessed August 16, 2012.

Estrogens, conjugated. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated December 14, 2011. Accessed August 16, 2012.

FAQ: Hormone therapy. American College of Obstetricians and Gynecologists website. Available at: http://www.acog.org/~/media/For%20Patients/faq066.pdf?dmc=1&ts=20120816T1031168395 . Accessed August 16, 2012.

FAQs: Hormone therapy basics. North American Menopause Society website. Available at: http://www.menopause.org/for-women/expert-answers/faqs-hormone-therapy-basics . Accessed August 16, 2012.

Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke . 2010 October 21. Available at: http://stroke.ahajournals.org/cgi/reprint/STR.0b013e3181f7d043v1 . Updated August 10, 2010. Accessed August 16, 2012.

Hormonal replacement therapy. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated December 3, 2010. Accessed August 16, 2012.

Hormone replacement therapy. American Academy of Family Physicians. FamilyDoctor.org website. Available at: http://familydoctor.org/online/famdocen/home/women/reproductive/menopause/738.html . Updated August 2010. Accessed November 15, 2010.

Hormone replacement therapy. WomensGuide.org website. Available at: http://womensguide.org/menopause/hrt.html. Accessed August 16, 2012.

Hormones and menopause. National Institute on Aging website. Available at: http://www.nia.nih.gov/health/publication/hormones-and-menopause . Updated April 25, 2012. Accessed August 16, 2012.

Progestins. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated May 16, 2011. Accessed August 16, 2012.

9/16/2008 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Huang A, Yaffe K, Vittinghoff E, et al. The effect of ultralow-dose transdermal estradiol on sexual function in postmenopausal women. Am J Obstet Gynecol. 2008;198:265.e1-7.

11/19/2008 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Buster JE, Koltun WD, Pascual ML, Day WW, Peterson C. Low-dose estradiol spray to treat vasomotor symptoms: a randomized controlled trial. Obstet Gynecol. 2008;111:1343-1351.



Last reviewed August 2012 by Brian Randall, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

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