What is hormone replacement therapy?

Hormone replacement therapy (HRT) refers to taking regular doses of hormones, usually the lowest effective doses, to replace the natural hormones that decrease at menopause. The two major female hormones are estrogen and progesterone.

Menopause is the time when menstruation stops. It is often a gradual process in which menstrual periods become irregular and eventually end completely. After you have passed through menopause, your ovaries no longer produce eggs and your body produces less of the female hormones.

Menopause is part of a natural aging process and not a disease. For many women menopause is an easy transition. However, some women have a variety of difficulties that are related to the decrease in hormones, particularly a lack of estrogen. If you are one of these women, you may benefit from treatment that replaces some of the hormones lost at menopause.

If your uterus has been removed, you may take estrogen alone. However, if you still have your uterus, progesterone is added to the estrogen doses because taking estrogen alone may increase the risk of cancer of the uterus. The addition of progesterone reduces this risk.

The hormones can be taken as tablets. They are also available in the forms of creams, skin patches, vaginal suppositories, and injections.

When is it used?

Hormone replacement therapy can be used before, during, and after menopause.

Menopause means having no menstrual periods for at least 6 months to 1 year. There are two kinds of menopause:

• Physiologic menopause refers to menopause that occurs naturally for most women between ages 45 and 60; the average age is 50 to 52.

• Artificial menopause refers to when a woman's menstrual periods stop because the ovaries have been removed by surgery.

Hormone replacement therapy is often recommended to relieve these symptoms associated with menopause:

• severe hot flashes

• sleeplessness

• vaginal dryness, resulting in discomfort or pain during sexual intercourse.

In addition, hormone therapy may be prescribed if you are at risk for osteoporosis or coronary heart disease.

Many health care providers recommend HRT for women who go through menopause prematurely; that is, for women who stop menstruating before the age of 40, either naturally or artificially. Symptoms caused by a sudden lack of hormones may be severe after an early, artificial menopause resulting from removal of the ovaries or the uterus and the ovaries.

The long-term effects of HRT are not yet fully known. Different studies have produced conflicting results. You should talk with your health care provider about the potential benefits and risks of therapy so you can make an informed decision about whether to begin or continue HRT.

What are the benefits of HRT?

• Prevention and treatment of osteoporosis

  Osteoporosis is a skeletal disorder that reduces the density of bone, thus making you prone to fractures. Bone loss begins around age 35 and accelerates rapidly at menopause. You are at greatest risk of osteoporosis- related fractures if you are Caucasian and thin, if you smoke, or if your mother had osteoporosis.

  Estrogen replacement therapy is the best prevention and treatment of osteoporosis. Low-dose estrogen therapy can slow down bone loss if the medication is begun soon after menopause. Calcium supplements can also help to reduce bone loss.

• Reduction of the risk of coronary heart disease

  The risk of heart disease dramatically increases for women who have gone through menopause. Evidence shows that estrogen reduces the risk of coronary heart disease. If you have high blood pressure, diabetes, high blood- cholesterol levels, or a family history of heart disease before age 55, hormone therapy may reduce your risk of heart disease.

• Relief of menopausal symptoms

  Hormone replacement therapy is also prescribed to relieve these symptoms of menopause:

  • hot flushes or flashes, which may last for several months to a few years and are accompanied by profuse sweating

  • sleep disturbances

  • atrophic vaginitis, an irritation of the vagina, caused by loss of estrogen (less estrogen in the body causes the tissues of the vagina to shrink and become thin and drier).

What are the risks of HRT?

The risks of hormone replacement therapy include:

• Uterine cancer

  Prolonged exposure of the uterus to estrogen without progesterone may increase the risk of cancer of the uterus. To lessen this risk, health care providers may prescribe lower doses of estrogen combined with progesterone for a woman who has not had her uterus removed.

• Breast cancer

  Studies are being done to determine if taking HRT increases the risk of getting breast cancer. Talk to your health care provider about this possible risk. Many providers recommend that women be checked thoroughly for any tumors and have a mammogram before beginning HRT. They also advise women taking HRT to have yearly mammograms and physical exams and to examine their own breasts monthly. If you have a family history of breast cancer, discuss this with your provider.

What are the side effects of HRT?

The side effects of HRT may include:

• uterine bleeding and vaginal discharge

• bloating, fluid retention, and weight gain

• breast tenderness and enlargement

• nausea

• symptoms resembling those of premenstrual tension, such as headaches and mood swings

• increased risk of gallstones if the medication is taken orally.

If your therapy includes both estrogen and progesterone, you will usually have some vaginal bleeding when you stop hormone therapy or during the days in the cycle when you are not taking hormones. Not a menstrual period, the bleeding typically lasts 2 or 3 days and is not usually accompanied by cramps or bloating.

Who should not take HRT?

If you have any of the following conditions or diseases, you should not take HRT until the reason for the condition is diagnosed:

• unexplained vaginal bleeding

• liver disease

• history of blood clots or strokes (thromboembolic disease); however, estrogen may decrease heart disease

• breast cancer.

If you have any of the following diseases or conditions, you may want to discuss with your health care provider the effect of HRT on these conditions:

• uterine fibroids (These benign tumors grow in response to estrogen. They begin to shrink at menopause unless a woman takes estrogen. Taking progesterone with estrogen does not prevent the growth of uterine fibroids.)

• endometriosis

• fibrocystic breast disease

• migraine headaches

• gallbladder disease.

Also, if you smoke, you may want to avoid HRT.

What can I do to take care of myself?

If you are considering HRT:

• Talk to your health care provider about the risks and benefits of HRT, especially about how it might help your heart and cholesterol levels.

• Get a mammogram before you begin HRT to check for breast cancer.

If you are already taking HRT:

• Ask your health care provider about any special precautions or side effects to consider while you are taking the hormones.

• If you are taking estrogen combined with progesterone, tell your health care provider if bleeding occurs at any time other than the days when you do not take the hormones.

• If you are taking estrogen without progesterone and your uterus has not been removed, ask your health care provider how often you should be checked for uterine cancer.

• Do not change your hormone dose without checking with your health care provider.

• Eat a healthy diet, exercise regularly, and check your cholesterol levels periodically.

• If you have a history of hypertension, check your blood pressure regularly.