McKesson Clinical Reference Systems: Women's Health Advisor 2002.2

What is hormone replacement therapy?

Hormone replacement therapy (HRT) is a treatment that can ease the symptoms many women have during menopause. Regular doses of hormones are taken to replace the natural hormones that decrease at menopause. The 2 main female hormones are estrogen and progesterone.

Menopause is the time when menstruation stops permanently. It is often a gradual process. Menstrual periods become irregular and then end completely. After menopause, your ovaries no longer produce eggs. Your body also 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 change. Some women have problems caused by the decrease in hormones, particularly by the lack of estrogen. These problems may be helped by treatment that replaces some of the lost hormones.

If your uterus has been removed, you may take estrogen alone. If you still have your uterus, taking estrogen alone increases your risk of cancer of the uterus. Your provider will recommend taking progesterone with estrogen to reduce this risk.

The hormones can be taken as tablets. They are also available in creams, skin patches, vaginal suppositories, vaginal rings, injections, and pellets placed under the skin.

When is it used?

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

There are two kinds of menopause:

• Physiologic menopause is menopause that occurs naturally for most women between ages 45 and 55; the average age is 50 to 52.
• Artificial menopause refers to when your menstrual periods stop because the ovaries have been removed by surgery.

You may have both physical and psychological symptoms during menopause. Symptoms may occur for a few weeks, a few months, or sometimes over several years. Your symptoms may come and go, or they may occur regularly. Health care providers might recommend hormone replacement therapy to relieve the following symptoms:

• hot flashes
• trouble sleeping
• joint and muscle pain
• dizziness
• heart palpitations
• depression
• memory problems
• fatigue
• headaches
• irritability
• nervousness
• vaginal dryness, which can cause discomfort or pain during sexual intercourse
• less desire for sex.

Hormone therapy may be prescribed if you are at risk for osteoporosis. It also may help prevent colon cancer and tooth loss.

Sometimes HRT is recommended for women who go through menopause early (before the age of 40). Symptoms caused by a sudden lack of hormones may be severe after an early menopause resulting from removal of the ovaries or the uterus and the ovaries.

The long-term effects of HRT are not yet fully known. You should talk with your health care provider about the potential benefits and risks of therapy to help you decide about whether to begin or continue HRT.

What are the benefits of HRT?

• Relief of menopausal symptoms, such as hot flashes and vaginal dryness
• Prevention and treatment of osteoporosis

  Osteoporosis is a skeletal disorder that reduces the density of bone. This makes it easier for your bones to break. Bone loss begins around age 35. You start losing bone more rapidly at menopause. Estrogen therapy can slow down bone loss if it is begun soon after menopause. Calcium supplements with vitamin D can also help to reduce bone loss, especially when taken with estrogen.

What are the risks of HRT?

The risks of hormone replacement therapy include:

• Uterine cancer

  Exposure of the uterus to estrogen without progesterone increases the risk of cancer of the uterus. To lessen this risk, health care providers prescribe estrogen combined with progesterone if you have not had your uterus removed.

• Breast cancer

  A recent large study of women taking a form of estrogen combined with progesterone (Prempro) showed an increase in the risk of 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. If you have a family history of breast cancer, it is especially important to discuss this with your provider.

• Cardiovascular disease, strokes, and blood clots in the legs and lungs

  The same study, cited above, of women taking a combination of estrogen and progesterone showed an increased risk of heart attack, strokes, and blood clots.

The risks of all forms of HRT are continuing to be studied. The risks described above for breast cancer and cardiovascular disease may be different for HRT that involves lower doses of estrogen and progesterone, estrogen only, or progesterone only.

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 like those of premenstrual tension, such as headaches and mood swings, when estrogen is taken with progesterone
• abnormal blood clotting.

If your therapy includes both estrogen and progesterone, you will usually have some vaginal bleeding when you stop hormone therapy or if there are days in the cycle when you are not taking hormones. Not a menstrual period, the bleeding typically lasts 2 or 3 days. Usually you will not have any cramps or bloating with the bleeding. If you take both estrogen and progesterone in low doses every day, the hormones will not cause vaginal bleeding except perhaps some spotting of blood for the first 2 to 3 months.

Who should not take HRT?

HRT is not recommended for women who have any of these conditions or diseases:

• recent history of a heart attack
• uncontrolled high blood pressure
• history of stroke
• recent blood clots or a history of blood clots
• cancer of the breast or uterus
• unexplained vaginal bleeding
• liver disease
• a history of porphyria (a metabolic disorder that causes severe abdominal pain).

You should not take HRT if you are or suspect you may be pregnant.

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

• uterine fibroids (These benign tumors may 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. Smoking may increase your risk of heart attack or stroke while you are taking hormones. The risk increases with age and the number of cigarettes smoked a day.

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.
• Get a mammogram before you begin HRT to check for breast cancer. Then make sure you continue to have a mammogram every year.

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. Taking estrogen alone when you still have your uterus is not recommended.
• Do not change your hormone dose without checking with your health care provider.
• Eat a healthy diet, exercise regularly according to your provider's recommendations.
• Have a mammogram every year. Examine your breasts monthly.
• Have a complete physical exam every year. Your blood should be tested regularly for cholesterol levels and liver function.

This content is reviewed periodically and is subject to change as new health information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.