What is menopause?
After several years of
fluctuating hormone levels and irregular menstruation in your 40s or 50s, your
progesterone levels begin to decline. After 6 months
to 1 year of decline, your estrogen level drops past a certain point, and your
menstrual cycle ends. Menopause is the point in time when you've had no
menstrual periods for 1 year.
During the first year or so after
menopause (postmenopause), estrogen levels continue to decline, which can cause
perimenopausal symptoms like hot flashes and insomnia
or make them worse. After your hormone levels reach a stable low point, these
symptoms are likely to subside. This typically takes 1 to 2 years. But some
women continue with symptoms for years, perhaps because their estrogen levels
are lower than average.
Low estrogen is part of the healthy,
natural state of the postmenopausal phase of life-it is tailored to the way
your body is meant to function after your childbearing years. Low estrogen is
good for you in the sense that it lowers your hormone-related cancer risk. But
because estrogen also plays an important role in skin and bone health, low
estrogen creates some health concerns for the postmenopausal woman.
- Following years of gradual decline in bone
density and strength, low estrogen after menopause speeds up bone loss, which
increases your risk of osteoporosis.
- Low estrogen leads to low
collagen, a building block of skin and connective
tissue. As a result, the vaginal lining and the lower urinary tract also thin
and weaken. This condition, called genitourinary atrophy, can make sexual
relations difficult and can increase the risk of vaginal and urinary tract
What other treatments are available for perimenopausal symptoms?
Although the perimenopausal transition itself is a
natural body change that doesn't require treatment, severe symptoms can disrupt
a woman's life and sense of well-being. The first and best approach to reducing
your perimenopausal symptoms (and long-term health risks related to aging) is
to lead a healthy lifestyle-avoid excess caffeine, alcohol, and stress; eat
well; and exercise regularly.
If you need additional relief, you
have several non-HRT treatment options to choose from. Slow, rhythmic
breathing exercises may help you manage hot flashes
and emotional symptoms. Vaginal lubricants (such as Astroglide or K-Y Jelly)
are useful for vaginal dryness, and
vaginal estrogen (cream, ring, or tablet) can help
with vaginal dryness and irritation. Certain types of
blood pressure medication (clonidine) may reduce hot flashes.
Black cohosh may help with hot flashes and other hormone-related
Before menopause, you can also consider
low-dose estrogen-progestin birth control pills for
perimenopausal symptoms and pregnancy prevention, as long as you have no risk
factors for heart disease or breast cancer and you do not smoke.
What is hormone replacement therapy?
Estrogen replacement therapy (ERT) refers to the daily use of estrogen to
increase a woman's hormones to premenopausal levels. Women with a uterus who
take estrogen also need the hormone
progestin to prevent the estrogen from affecting the
uterine lining (endometrium), which can lead to
endometrial cancer. The combination of estrogen and
progestin is called
hormone replacement therapy (HRT). Women with a uterus
take HRT. Women who have had a
hysterectomy to remove the uterus take ERT.
The U.S. Food and Drug Administration (FDA) has updated its HRT
recommendations and now only approves estrogen-progestin HRT for:
Short-term treatment of perimenopausal
symptoms. Women who do decide that HRT benefits outweigh their risks are
advised to use the lowest effective dose for as short a time as possible, not
exceeding 3 or 4 years.
Osteoporosis prevention and treatment, in select,
severe cases. Most experts recommend that HRT only be considered for women with
significant risk of osteoporosis that outweighs their risks from taking
HRT.10 Women are now encouraged to consider all
possible osteoporosis treatments and to compare their risks and
benefits.11 For more information, see the topic
The FDA is reviewing its ERT recommendations, based on
March 2004 stroke risk information from the
Women's Health Initiative ERT study.12 Other low-dose ERT research is currently in progress.
What are the benefits of taking estrogen?
taken as ERT or HRT, estrogen:2, 1
- Helps prevent osteoporosis after menopause by
slowing bone loss and promoting some increase in bone density.1
- Reduces hot flashes and sleep problems in most,
but not all, women.1
- Maintains the lining of the vagina, reducing
- Maintains skin collagen levels, which decline as
estrogen levels decline. Collagen is responsible for the stretch in skin and
- Increases the amount of HDL ("good") cholesterol and
decreases the amount of LDL ("bad") cholesterol in the
- Reduces the risk of dental problems, such as tooth loss and
- May reduce the risk of colon cancer.2
What are the risks of hormone replacement therapy?
HRT increases the risks of breast cancer, ovarian cancer, blood clots,
heart disease, stroke, and dementia. Estrogen alone (ERT) is also linked to
increased stroke, ovarian cancer, dementia, and possible breast cancer
risk.13, 5, 14 No particular form or dosage of ERT or HRT has been proved
safer than another.15
Among the women
using HRT in the recent Women's Health Initiative trials, most did not develop
major health problems. But after the first 1 to 4 years of using HRT, a small
yet significant number of women did develop signs of cancer, blood clots, heart
disease, stroke, and dementia.2, 3, 4
- Within the first 2 years, HRT use slightly increased the risk
of blood clots in the lungs (pulmonary embolism) and legs (deep vein thrombosis) in all healthy postmenopausal women regardless of risk
- During the second year, HRT use
began to slightly increase
heart attack and
stroke risk in all healthy postmenopausal women,
regardless of risk factors. Early signs of heart disease first became apparent
during the first year of use.16, 6 Heart disease risk does not increase for women in the first
10 years after menopause.17, 7, 8
- After 1 year, HRT use
increased the number of abnormal
mammograms by approximately 4% each year. Daily
estrogen-progestin increased breast density compared with estrogen alone or
placebo. Although the abnormal mammograms required
additional medical evaluation, they were not linked to an early increase in
breast cancer. Studies are ongoing to learn more about breast density change
- After 4 years of use,
HRT-related breast cancers first became apparent. The number of HRT-related
breast cancers increased with each additional year of HRT use. Women taking HRT
generally had larger, more advanced tumors than women who developed breast
cancer while taking a placebo treatment.2 (But some of
these cancers may respond more favorably to treatment.)18
- After 4 years, HRT use slightly increased the incidence of
Alzheimer’s disease and other
dementias in women ages 65 and older. HRT does not
provide protection from dementia or
cognitive impairment, as was previously
believed.4 (Most of the women in this study started
HRT several years after menopause, when Alzheimer's risk naturally increases.
So, experts do not yet know whether the effect of HRT on Alzheimer's risk is
the same for younger women who use short-term HRT starting at menopause.) An
HRT-related increase in dementia has been observed in women older than
Your risks. It is impossible to
know whether you will develop health problems from HRT. If you have no personal
or family history of breast cancer, ovarian cancer, heart attack, stroke, blood
clots, and dementia, your increased HRT risks are likely to be small. If you
have a personal or family history of breast cancer, ovarian cancer, or
heart disease, your HRT risks are likely to be higher
than average, making the risks outweigh the benefits. If you have had breast
cancer, which can be triggered or made worse by estrogen, taking HRT is not
safe for you.
Low-dose HRT. The typical
HRT dose is 0.625mg of estrogen plus
2.5mg of progestin. In March 2003, the FDA
approved a low-dose version of Prempro, containing
0.3mg of estrogen and
1.5mg of progestin. This low-dose version may
help hot flashes and bone density and is hoped to reduce the risks related to
higher-dose HRT, but it needs more study.
Low-dose estrogen for osteoporosis. Researchers are studying
the effects of low-dose estrogen therapy. A small early study has shown that a
low estrogen dose-0.25mg per day-may keep the
bones as strong as the higher dose.19 But the long-term
risks of taking low-dose estrogen are not yet known.
How and when do I stop taking hormone replacement therapy?
There is no way of knowing in advance whether you will
have perimenopausal symptoms when you stop using HRT (or ERT). While some women
have no symptoms, others are mildly affected, and some have moderate to severe
symptoms. Most women find that their symptoms subside over time.
How to stop HRT. There are currently no
evidence-based guidelines for stopping HRT. Talk to your doctor about how you
should stop HRT. Your doctor may want you to stop HRT right away or try
tapering off. You may taper off by lowering your daily dose, increasing the
time between dosages, or trimming back an estrogen patch over time.
When to stop HRT. Ultimately, it is up to you and
your doctor to decide how long you will take HRT. After weighing the risks,
some women will continue to take HRT for years to come, while others stop as
soon as they learn of the risks. If you have been taking HRT for many years,
talk to your doctor about stopping HRT.
There are currently no
evidence-based guidelines for when to stop
short-term HRT.15 But based on
the risks, HRT use for 4 or more years is considered "long term."
If you develop symptoms when tapering or suddenly stopping HRT, consider
how severe your symptoms are, what other treatment options are available for
symptom relief, and how long you've been taking HRT. You can:
- Slightly increase your HRT dose until
symptoms subside. After another 6 months to 1 year, try to taper off
- Continue with your plan to stop HRT and see whether symptoms
subside over a few months.
- Continue with your plan to stop HRT and try another type of
If you need more information, see the topic
Menopause and Perimenopause.