Hormone Replacement Therapy

Overview :

HRT medications come in several different forms, including tablets, stick-on patches, injections, and creams that are worn inside the vagina. The form prescribed depends on the purpose of the hormone replacement therapy. Women who want relief from vaginal dryness, for example, would be given a cream or vaginal ring. Women using HRT to relieve hot flashes or to prevent osteoporosis and heart disease often prefer oral medications or patches. All HRT medications used in the United States are available only with a doctor's prescription.

HRT treatment regimens

One of the complications of HRT is the number of treatment options, including combinations of types of estrogen; dosage levels; forms of administration; and whether or not progestins are used with the estrogen to offset the risk of uterine cancer. This variety, however, means that a woman who wants to use HRT while minimizing side effects can try different forms of medication or dosage schedules when she consults her doctor. It is vital, however, for women to follow their doctor's directions exactly and not change dosages themselves.

At present, women who are taking a combination of estrogens and progestins are placed on one of three dosage schedules:

• Estrogen pills taken daily from the first through the 25th day of each month, with a progestin pill taken daily during the last 10-14 days of the cycle. Both drugs are then stopped for the next five to six days to allow the uterus to shed its lining.
• Estrogen pills taken on a daily basis with low-dose progestin pills, also on a daily basis. Both medications are taken continuously with no days off.
• Estrogen pills and low-dose progestins taken on a daily basis for five days each week, with both medications stopped on the last two days of each week.

TIMING AND LENGTH OF TREATMENT. One of the disagreements about HRT concerns the best time to begin using it. Some doctors think that women should begin using HRT while they are still in perimenopause. Others think that there is no harm in a woman's waiting to decide. Either way, the question of timing means that a woman should keep track of changes in her periods and other signs of perimenopause so that her doctor can evaluate her readiness for HRT.

The other question of timing concerns length of treatment. Some women use HRT only as long as they need it to relieve the symptoms of menopause. Others regard it as a lifetime commitment because of concerns about osteoporosis. One study found that the average length of time that women stay on HRT is 23 months. Information from the WHI released in 2002 and 2003 would indicate that long-term HRT use produced too many risks for the expected benefits.

UNWANTED SIDE EFFECTS. In addition to the identified health risks mentioned above, much of the disagreement about unwanted side effects from HRT concerns the role of progestins in the estrogen/progestin combinations that are commonly prescribed. Many women who find that estrogen relieves hot flashes and other symptoms of menopause have the opposite experience with progestin. Progestin frequently causes moodiness, depression, sore breasts, weight gain, and severe headaches.

Other treatment approaches

Women who are uncertain about HRT, or who should not take estrogens, should know about other treatment options, such as natural progesterone. Progestins, which are synthetic hormones, were developed because natural progesterone cannot be absorbed in the body when taken in pill form. A new technique called micronization has made it possible for women to take natural progesterone by mouth. Many women prefer this form of hormone because it lacks the side effects of the synthetic progestins even though it is somewhat more expensive. The most common form of natural progesterone is called Prometrium. which is available by prescription only. Another form of natural progesterone consists of the hormone suspended in vitamin E oil. It is absorbed through the skin and is available without a prescription.

Alternative therapies also are available. Many mainstream as well as alternative practitioners recommend changes in diet and nutrition as helpful during menopause. Women who limit their intake of fats and salts, increase their use of fresh fruits and vegetables, quit smoking, and drink only in moderation often find that these dietary changes help them feel better. Naturopaths typically recommend vitamin and mineral supplements for general well-being as well as for relief from hot flashes and leg cramps. In addition, herbal teas and tonics are helpful to some women in treating water retention, insomnia, constipation, or moodiness.

Women who find menopause emotionally stressful because of negative social attitudes toward older women are often helped by meditation, biofeedback, therapeutic massage, and other relaxation techniques. Yoga and tai chi provide physical exercise as well as stress reduction. Exercise is an important safeguard against osteoporosis.