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Frequently Asked Questions About Hormone Replacement Therapy for Menopause Symptoms

  • Should I stop taking hormone replacement therapy?
  • Answer:

    The answer depends on how long you've been taking hormone replacement therapy, or HRT, and why. Several studies have shown both benefits and risks of HRT. 

    The Women's Health Initiative, a 15-year study conducted by the National Institutes of Health with postmenopausal women -- found that long-term use (five or more years) of hormone replacement therapy combining two hormones, estrogen and progestin, increased women's risk of heart disease, stroke, blood clots, and breast cancer. However, the study found that HRT lowered women's risk of bone fractures and colorectal cancer.

    To analyze the findings in numbers:

    If 10,000 women were taking hormone replacement therapy for a year and 10,000 women were not taking HRT, in the HRT group eight more women would develop invasive breast cancer, seven more would develop heart disease, eight more would have a stroke, and eight more would develop blood clots. There would also be six fewer colorectal cancers and five fewer hip fractures.

    The WHI study was somewhat undermined by another study published in 2006 in the The Journal of Women's Health that showed that the risk of heart disease demonstrated in the WHI was related more to the advanced age of the participants as opposed to the HRT. The study also found that HRT given to younger women, at the onset of menopause, appeared to decrease the risk of heart disease.

    Still another study, published in 2006 in Archives of Internal Medicine, looked at nearly 11,000 women aged 50 to 79 taking only estrogen. Researchers reported no overall difference in heart attack risk among women who took HRT and those who did not. In addition, there appeared to be a lower overall risk of heart disease in the women who began taking the estrogen between the ages of 50 and 59, suggesting a heart-healthy benefit to beginning the therapy at a younger age.

    Finally, a study published in the March 5, 2008, issue of the Journal of the American Medical Association reported on WHI participants three years after they stopped combination HRT. The researchers found that "many of the health effects of hormones such as increased risk of heart disease are diminished, but overall risks, including risks of stroke, blood clots, and cancer, remain high." The study also concluded that the increased risk of breast cancer appears to linger and "other effects of combination hormones, such as decreased risk of colorectal cancer and hip fractures, also stopped when therapy ended."   

    The U.S. Preventive Services Task Force (USPSTF), a panel comprised primarily of physicians, considered the accumulated scientific evidence on HRT and issued recommendations in 2005.  Among them: The use of combination HRT or estrogen-only HRT may slightly lower risk of bone fractures  and colorectal cancer, but has no beneficial effect on heart disease. In fact, the use of either combined estrogen-progestin might lead to a higher risk of breast cancer, blood clots, stroke, cholecystitis and dementia, the task force found.

    The USPSTF also concluded that estrogen-only HRT might raise the risk of blood clots, stroke and dementia.

    The harmful effects of hormone replacement therapy, the task force concluded, outweigh their benefits. 

    How does this information relate to your personal decision about menopause and hormone replacement therapy? Every woman is unique, and no one should start or stop HRT without consulting with her doctor. That said, here are some facts that may help you and your doctor arrive at a decision.

    Menopause: Not all women experience symptoms such as hot flashes, night sweats, or mood swings during menopause. Those who do usually have the symptoms for just a few years. So, don't panic if you need hormone replacement therapy to ease menopause symptoms for a year or two. Most experts today say the benefits of hormone replacement therapy outweigh the risk if hormones are taken for a brief period of time. But if you have been on hormone replacement therapy for several years, or if you started HRT before ever experiencing bothersome symptoms, consider talking with your doctor about tapering off the hormones. You may be surprised. The menopause symptoms you dread may not affect you at all.

    Heart Disease: Women taking standard hormone replacement therapy (Prempro, Premphase, Femhrt, and Activella) to prevent heart disease should talk with their doctors about gradually discontinuing the medication. The latest research clearly indicates that hormone replacement therapy does not prevent heart disease. So why did we ever begin prescribing hormone replacement therapy to prevent heart disease? The practice began because observational studies found that women taking hormone replacement therapy tended to have lower rates of heart disease, stroke, colon cancer, and osteoporosis. It now appears, at least in terms of cardiovascular disease, that these women may simply have been healthier and more likely to see a doctor.

    Osteoporosis: Research shows that hormone replacement therapy does lower a woman's risk of bone fractures. If you are taking hormone replacement therapy to prevent osteoporosis, discuss your family history and treatment options carefully with your doctor. Questions to consider include:

    Is your risk for osteoporosis significantly greater than your risk for heart disease or breast cancer? What other treatments could preserve bone health as well as hormone replacement therapy without the risk? What lifestyle changes (such as diet and weight-bearing exercise) could preserve your bone health? The U.S. Preventive Services Task Force 

    If you choose to stop hormone replacement therapy, taper off the hormones gradually. Some women suffer symptoms of withdrawal if they stop abruptly. For example, Laura Corio, MD, author of The Change Before the Change, recommends her patients taper off by taking the hormones every other day for two weeks, and then stopping completely.

    If you choose to stay on hormone replacement therapy, ask your doctor to re-evaluate you once a year to look at risk vs. benefits. Remember, hormones are strong drugs. Staying on hormones longer than five years is no longer advisable.

  • Is any type of hormone replacement therapy safer?
  • Answer:

    Unfortunately, no one knows for sure. About 20 million American women take some form of estrogen therapy -- in pills, patches, or creams -- but few of these treatments have been carefully studied for long-term risks.

    The standard hormone replacement therapy that increased risks in the Women's Health Initiative study is conjugated equine estrogen (made from mare urine) at 0.625 milligrams a day, combined with a synthetic progestin called medroxyprogesterone acetate at 2.5 milligrams a day. (Women who have their uteruses must take a progesterone with estrogen, because estrogen alone increases the risk of uterine cancer.) This combination is used by about 6 million American women and is sold under many brand names: Prempro, Premphase, Femhrt, Activella, and Ortho-Prefest.

    Here's a summary of what's known -- and not known -- about other options:

    Low-dose hormone replacement therapy: Some doctors believe that lower doses of hormone replacement therapy can offer the benefits without the risks. Studies do indicate that lower doses of estrogen and progestin can relieve hot flashes and vaginal dryness. Theoretically, lower doses may pose less risk to breast tissue and heart health, but studies have not yet been done.

    Estrogen alone: Women who've had their uteruses removed through hysterectomy can take conjugated equine estrogen supplements without progestin. We've known for years that taking estrogen alone can increase the risk of uterine cancer, which is why women who have their uteruses also take progestin. Research published in 2006 showed that taking estrogen alone caused a significant increase in the risk of ischemic stroke. After at least seven years of follow-up, women with prior hysterectomy did not have an increased risk of breast cancer. Also, after the follow-up period, participants taking estrogen alone were found to have a greater risk of blood clots.

    Transdermal Estrogen Patches, Creams, or Vaginal Rings: These forms of estrogen have been shown to be effective against hot flashes and vaginal dryness. Also, they help build bone. They're sold under the brand names Estraderm, Climara, Vivelle, and Alora. Theoretically, estrogen delivered through the skin, thus bypassing the liver and digestive system, could pose less risk to breast tissue and cardiovascular health. However, studies have not yet been done to definitively answer the question.

  • What else can I do to prevent hot flashes and loss of libido due to menopause?
  • Answer:

    There are several alternative remedies you may want to try to reduce menopause symptoms such as hot flashes or night sweats:

    Soy: Soy seems to be an effective, short-term treatment to quell hot flashes and night sweats. It can be difficult to get enough soy from food, so many women use a soy protein powder in fruit shakes. However, soy may be potentially dangerous for women with a history of estrogen-dependent cancer of the breast, uterus, or ovaries.

    Black Cohosh: Growing evidence shows that this ancient Native American remedy is effective in controlling some menopausal symptoms. Black cohosh is an herb that contains plant estrogens.

    One three-month study of 976 postmenopausal women found that those who took 40 mg of black cohosh daily reduced menopause symptoms such as hot flashes, mood swings, night sweats, and insomnia compared with those who didn't take the herb. Those findings were presented in 2002 at the annual meeting of The Endocrine Society. Another study published March 28, 2002, in the Journal of Women's Health and Gender-Based Medicine found that black cohosh extract, marketed as Remifemin, reduced menopause symptoms in 70% of women.

    However, overall reviews of published studies on black cohosh and soy have found that research is limited and inconclusive.

    It should be noted that lack of standardization in the manufacturing of these herbal remedies -- they're not controlled by the FDA like drugs are -- can lead to accidentally taking too much or too little.

    Prescription medications: Two drugs are approved specifically for hot flashes. They are Brisdelle, a paroxetine formula, and Duavee, an estrogens/bazedoxifene formula. Other medications originally used as antidepressants may help relieve hot flashes. These include low doses of fluoxetine (Prozac), paroxetine (Paxil), and venlafaxine (Effexor). Other drugs -- the anti-seizure drug gabapentin and the blood pressure medication clonidine -- also may be effective. 

    Lifestyle changes: Women can also reduce hot flashes by:

    • Dressing in layers, so they can remove clothes as needed
    • Wearing natural fabrics, such as cotton and silk
    • Keeping room temperatures cool or using a fan
    • Sleeping with fewer blankets
    • Drinking cold beverages rather than hot ones
    • Limiting intake of caffeine and alcohol
    • Eating smaller meals
    • Not smoking
    • Using relaxation techniques such as yoga
    • Getting regular exercise

    For vaginal dryness or lost libido, here are a few options that may help:

    Alprostadil: This liquid appears to heighten sexual sensation when applied to the genitals. It is made with prostaglandin E, a naturally occurring substance that has been used for years to treat erectile dysfunction in men. Trials using this medication to treat female sexual dysfunction have not shown consistent effectiveness, however, and more studies are underway.

    KY Jelly, Astroglide, and Replens: These are better over-the-counter lubricants than oil-based petroleum jelly, and can be used safely with condoms. Keep in mind that vaginal dryness happens to all women to some degree as they age. But it affects the sex life of some women more than others. Lubricants help, but so does sex! Indeed, sexual activity, including masturbation and intercourse, maintains a woman's ability to lubricate.

    Vitamin E oil: This common vitamin supplement can also be used directly in the vagina to increase lubrication and soothe the vaginal lining. Women can buy vitamin E oil capsules sold in most drug stores and crack open a capsule to get the oil.

  • What can I do to protect against heart disease or osteoporosis?
  • Answer:

    Now that we know that hormone replacement therapy does not protect against heart disease or stroke, it's time to fall back on some old standby treatments.

    Statins: This powerful class of drugs reduces the amount of cholesterol in the blood -- especially LDL, the so-called "bad" cholesterol. Statins reduce the risk of heart attack and  have also been found to reduce stroke risk by 21%. There is some evidence that statins may reduce osteoporosis, and could be an adjunct treatment for cancer, but more studies are needed.

    Blood Pressure medications: Common blood pressure drugs such as ACE inhibitors and beta-blockers can effectively lower blood pressure, which is a leading cause of heart disease and stroke. By decreasing the heart's workload, these drugs also seem to protect heart health in general. Ideal blood pressure is under 120/80. Risky levels are 140/90 and above. Even if you're in the "high-normal" range, say 130/85, you should talk with your doctor about lifestyle changes or medications, because you're at higher risk of heart attack or stroke, according to Suzanne Oparil, MD, a leading researcher and director of the Vascular Biology and Hypertension Program at the University of Alabama-Birmingham.

    Soy Protein: Studies of soy protein show inconsistent results in reducing blood pressure and LDL cholesterol in postmenopausal women. Although at least one small study found reductions when patients ate natural soy, other studies did not show improvements from soy extracts. Researchers conclude that different proteins found in natural soy appear to interact with phytoestrogens -- plant estrogens -- to increase their cholesterol-lowering activity. More research is needed.

    Lifestyle Changes: Limiting salt in the diet -- and walking at least 30 minutes a day -- can also help lower blood pressure in postmenopausal women by a surprising amount, according to a study published in the August 2001 Journal of the American College of Cardiology. In the study, those who ate only a teaspoon of salt a day and walked lowered their blood pressure by 16 points. To lower sodium in your diet, cook with less salt, use herbs and lemon juice to flavor foods, check packed food labels for sodium, and limit salty snack foods.

    Without doubt, estrogen helps maintain bone health. But there are other alternatives you should consider first:

    Biphosphonates: Alendronate (Fosamax), risedronate (Actonel) and similar bisphosphonate medications are designed to prevent or treat osteoporosis; they slow bone thinning and increase thickness of the bones. This reduces the risk of broken bones.  Zoledronic acid (Reclast) is a biphosphonate that can be given as an intravenous infusion once a year.

    Other injectable osteoporosis treatments: These include denosumab (Prolia), which is injected twice a year, and teriparatide (Forteo), which is taken as a daily injection.

    Evista: A new class of designer estrogens -- called selective estrogen receptor modulators, or SERMs -- are also prescribed to prevent and treat osteoporosis. Evista, also known as raloxifene, was designed to selectively act as an estrogen on bone, but not on breast tissue or the uterus (where estrogen can increase the risk of cancer). Evista has another plus -- it has a favorable effect on cholesterol. Unfortunately, Evista may cause hot flashes and (rarely) blood clots.

    Calcium and Vitamin D Supplements: Older women and men should get about 1,200 mg a day of calcium. Dietary sources of calcium include fat-free milk, yogurt, and cheese. Also, eating more protein could help the body effectively absorb calcium and vitamin D, according to one recent study at Tufts University in Boston. Older people who took 500 mg supplements in addition to dietary calcium -- and ate about 80 grams of protein a day -- had better bone mass than those in the control group. Results of a study detailed in the June 2012 issue of Heart showed that calcium supplements -- but not calcium from food sources -- might increase the risk of heart attacks.

    Exercise: About 30 minutes of weight-bearing exercise a day and strength-training exercise a couple of times a week  -- even for women in their 70s, 80s, 90s, and older -- can build bone. It's one of the most natural remedies, and one that will also help maintain a woman's overall health. Check with your doctor to find out what activity level is right for you.

     

  • If I'm a woman approaching menopause, what should I do?
  • Answer:

    First, you may want to wait to see what menopause symptoms, if any, you experience and how severely they affect your life. Some studies indicate that only 50% of women suffer significant menopause symptoms such as hot flashes, mood swings, or night sweats, and those symptoms usually last just three to four years.

    If menopause symptoms cause you problems, talk with your doctor about lifestyle changes you can consider. Among them: More soy in your diet, regular exercise and relaxation techniques such as yoga, cold beverages, less caffeine and alcohol, and dressing light in natural fabrics.

    If you're still uncomfortable, talk to your doctor about your individual risk from taking hormone replacement therapy for a limited period of time. Remember, each woman's risk is different, based on her personal and family history of cancer and heart disease.

    Some doctors advocate that women take so-called bio-identical hormones such as estradiol and progesterone instead of synthetic hormones such as Premarin, Provera, or Prempro. However, there is still a great deal of controversy surrounding the safety and effectiveness of these types of therapies. 

    Lastly, in light of the latest research, re-evaluate your need for hormone replacement therapy once a year with your doctor. The menopause symptoms that bother you may ease or disappear before your menopause officially ends.

WebMD Medical Reference

Reviewed by Melinda Ratini, DO, MS on June 12, 2012

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