Even after you've decided to take estrogen replacement therapy (ERT), the decision-making isn't over. There are many types of estrogen therapy in many different forms -- pills, patches, suppositories, and more. The best type of hormone replacement therapy (HRT) depends on your health, your symptoms, personal preference, and what you need to get out of treatment. For example, if you still have your uterus, then estrogen will be given in combination with the hormone progestin.
Here's an overview of types of ERT.
Estrogen Treatment: Pills
- What are they? Oral medication is the most common form of ERT. Examples are conjugated Estrogens (Premarin), estradiol (Estrace), and Estratab. Follow your doctor's instructions for dosing. Most estrogen pills are taken once a day without food. Some have more complicated dosing schedules.
- Pros. Like other types of estrogen therapy, estrogen pills can reduce or resolve troublesome symptoms of menopause. They can also lower the risk of osteoporosis. While there are newer ways of getting ERT, oral estrogen medicines are the best-studied type of estrogen therapy.
- Cons. The risks of this type of estrogen therapy have been well-publicized. On its own, estrogen causes a slight increase in the risk of strokes, blood clots, and other problems. When combined with the hormone progestin, the risks of breast cancer and heart attack may rise as well. Oral estrogen -- like any estrogen therapy -- can also cause side effects. These include painful and swollen breasts, vaginal discharge, headache, and nausea.
Because oral estrogen can be hard on the liver, people with liver damage should not take it. Instead, they should choose a different way of getting estrogen.
Estrogen is also sometimes not well absorbed, especially if you take certain medicines or have stomach problems. It may also increase your cholesterol, because it is metabolized in the liver.
Estrogen Treatment: Skin Patches
- What are they? Skin patches are another type of ERT. Examples are Alora, Climara, Estraderm, and Vivelle-Dot. Combination estrogen and progestin patches -- like Climara Pro and Combipatch -- are also available. Menostar has a lower dose of estrogen than other patches, and it's only used for reducing the risk of osteoporosis. It doesn't help with other menopause symptoms.
Usually, you would wear the patch on your lower stomach, beneath the waistline. You would then change the patch once or twice a week, according to the instructions.
- Pros. In addition to offering the same benefits as oral therapy, this type of estrogen treatment has several additional advantages. For one, the patch is convenient. You can stick it on and not worry about having to take a pill each day.
While estrogen pills can be dangerous for people with liver problems, patches are OK, because the estrogen bypasses the liver and goes directly into the blood. A 2007 study also showed that the patch does not pose a risk of blood clots in postmenopausal women like oral estrogen does, though more studies are needed before making definitive conclusions on whether patches are safer than pills. Right now, all estrogens carry the same black-box warning with respect to clot formation.
- Cons. While some experts believe that estrogen patches may be safer than oral estrogen in other ways, it's too early to know. So, for now, assume that estrogen patches pose most of the same risks -- a very small increase in the risk of serious problems, like cancer and stroke. They also have many similar -- although perhaps milder -- side effects. These include painful and swollen breasts, vaginal discharge, headache, and nausea. The patch itself might irritate the skin where you apply it.
Estrogen patches should not be exposed to high heat or direct sunlight. Heat can make some patches release the estrogen too quickly, giving you too high a dose at first and then too low a dose later. So don't use tanning beds or saunas while you're wearing an estrogen patch.
Estrogen Treatment: Topical Creams, Gels, and Sprays
- What are they? Estrogen gels (like Estroge and Divigel), creams (like Estrasorb), and sprays (like Evamist) offer another way of getting estrogen into your system. As with patches, this type of estrogen treatment is absorbed through the skin directly into the bloodstream. The specifics on how to apply these creams vary, although they're usually used once a day. Estrogel is applied on one arm, from the wrist to the shoulder. Estrasorb is applied to the legs. Evamist is applied to the arm.
- Pros. Because estrogen creams are absorbed through the skin and go directly into the bloodstream, they're safer than oral estrogen for people who have liver and cholesterol problems.
- Cons. Estrogen gels, creams, and sprays have not been well-studied. While they could be safer than oral estrogen, experts aren't sure. So assume that they pose the same slight risk of serious conditions, like cancer and stroke.
One potential problem with using this type of estrogen treatment is that the gel, cream or spray can rub or wash off before it's been fully absorbed. Make sure you let the topical dry before you put on clothes. Always apply it after you bathe or shower.
Because the estrogen is absorbed right through the skin, don't let other people in your family touch these creams or gels. If they do, they could get dosed with estrogen themselves. For the same reason, make sure your hands are clean and dry after applying the medication.
Estrogen Treatment: Vaginal Suppositories, Rings, and Creams
- What are they? These types of estrogen treatments can be applied directly to the vaginal area. In general, these treatments are for women who are troubled specifically by vaginal dryness, itchiness, and burning or pain during intercourse. Examples are vaginal tablets (Imvexxy, Vagifem), creams (Estrace or Estradiol), and insertable rings (Estring or Femring).
The exact dosing schedule varies, depending on the product. But in general, vaginal rings need to be replaced every three months. Vaginal tablets are often used daily for a couple of weeks; after that, you only need to use them twice a week. Creams might be used daily, several times a week, or according to a different schedule.
- Pros. Studies have shown that when it comes to treating the vaginal symptoms of menopause -- like dryness -- these treatments are more effective than other forms of estrogen therapy. Like patches, some of these treatments might be more convenient than taking a pill each day.
Some vaginal suppositories and rings are low dose, and only affect the immediate area. The advantage is that they can relieve vaginal symptoms without exposing the entire body to high doses of estrogen. Theoretically, this could reduce the more serious risks of estrogen therapy -- and be a safe way for women who cannot take systemic therapy to get relief.
- Cons. Suppositories and rings with low doses of estrogen only help with vaginal symptoms of surgical menopause. They won't help with other symptoms like hot flashes. And while higher-dose suppositories, rings, and creams could help with these symptoms, they may expose you to the same risks as other types of estrogen therapy -- including a higher risk of stroke and cancer. Most doctors do not recommend long-term vaginal estrogen therapy to women who still have their uterus, because it may increase the risk of endometrial cancer.
Choosing the Best Type of Estrogen Therapy
When deciding what type of estrogen therapy to get, work closely with your doctor. While oral estrogen has been around for a long time and is well studied, some modes of taking hormone therapy are not. They may have lower risks or different risks that we don't know about yet. Your doctor should be up to date on the latest research.
Right now, the full risks of hormone therapy are unclear. So if you do decide to get ERT, experts generally recommend that you get it at the lowest dose for the shortest time possible. Talk to your doctor about how long you should expect to take ERT and how you can limit your risks.