How will I know when I need hormone replacement therapy?
Hormone replacement therapy — medications containing female hormones to replace the ones the body no longer makes after menopause — used to be a standard treatment for women with hot flashes and other menopause symptoms. Hormone therapy (as it's now called) was also thought to have the long-term benefits of preventing heart disease and possibly dementia.
Use of hormone therapy changed abruptly when a large clinical trial found that the treatment actually posed more health risks than benefits for one type of hormone therapy, particularly when given to older postmenopausal women. As the concern about health hazards attributed to hormone therapy grew, doctors became less likely to prescribe it.
Hormone therapy is no longer recommended for disease prevention, such as heart disease or memory loss. However, further review of clinical trials and new evidence show that hormone therapy may be a good choice for certain women, depending on their risk factors.
What are the benefits of hormone therapy?
The benefits of hormone therapy depend, in part, on whether you take systemic hormone therapy or low-dose vaginal preparations of estrogen.
- Systemic hormone therapy. Systemic estrogen — which comes in pill, skin patch, gel, cream or spray form — remains the most effective treatment for relief of troublesome menopausal hot flashes and night sweats. Estrogen can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse. Although the Food and Drug Administration (FDA) still approves estrogen for the prevention of the bone-thinning disease called osteoporosis, doctors usually recommend medications called bisphosphonates to treat osteoporosis.
- Low-dose vaginal products. Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms and some urinary symptoms, while minimizing absorption into the body. Low-dose vaginal preparations do not help with hot flashes, night sweats or protection against osteoporosis.
Long-term systemic hormone therapy for the prevention of postmenopausal conditions is no longer routinely recommended. But some data suggest that estrogen can decrease the risk of heart disease when taken early in postmenopausal years:
- In a recent Danish study, after 10 years of treatment, women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure or heart attack, without any apparent increase in risk of cancer or stroke.
- A randomized, controlled clinical trial — the Kronos Early Estrogen Prevention Study (KEEPS) — exploring estrogen use and heart disease in younger postmenopausal women was recently completed, with results expected soon.
For women who experience menopause naturally, estrogen is typically prescribed along with progesterone or progestin (progesterone-like medication). This is because estrogen alone, when not balanced by progesterone, can stimulate growth of the lining of the uterus, increasing the risk of uterine cancer. Women who have had their uterus removed (hysterectomy) don't need to take progestin.
What are the risks of hormone therapy?
In the largest clinical trial to date, a combination estrogen-progestin pill (Prempro) increased the risk of certain serious conditions, including:
- Heart disease
- Blood clots
- Breast cancer
A related clinical trial evaluating estrogen alone (Premarin) in women who previously had a hysterectomy found no increased risk of breast cancer or heart disease. The risks of stroke and blood clots were similar to the combination therapy.
Hormone therapy, particularly estrogen combined with a progestin, can make your breasts look more dense on mammograms, making breast cancer more difficult to detect. Also, especially when taken for more than a few years, hormone therapy increases the risk of breast cancer, a finding confirmed in multiple studies of different hormone therapy combinations, not just limited to a combination estrogen-progestin pill (Prempro).
The risks of hormone therapy may vary depending on whether estrogen is given alone or with a progestin, and depending on your current age and age at menopause, the dose and type of estrogen, and other health risks such as your risks of heart and blood vessel (cardiovascular) disease, cancer risks and family medical history.
All of these risks should be considered in deciding whether hormone therapy might be an option for you.
Who should consider hormone therapy?
Despite the health risks, systemic estrogen is still the most effective treatment for menopausal symptoms. The benefits of hormone therapy may outweigh the risks if you're healthy and:
- Experience moderate to severe hot flashes or other menopausal symptoms
- Have lost bone mass and either can't tolerate or aren't benefitting from other treatments
- Stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian insufficiency)
Women who experience an early menopause, particularly those who had their ovaries removed and don't take estrogen therapy until at least age 45, have a higher risk of:
- Coronary heart disease (CHD)
- Earlier death
- Parkinsonism (Parkinson's-like symptoms)
- Anxiety or depression
- Sexual function concerns
Early menopause typically lowers the risk of most types of breast cancer and ovarian cancer. For women who reach menopause prematurely, protective benefits of hormone therapy usually outweigh the risks.
Your age, type of menopause and time since menopause play a significant role in the risks associated with hormone therapy. Talk with your doctor about your personal risks.
Who should avoid hormone therapy?
Women with current or past history of breast cancer, ovarian cancer, endometrial cancer, blood clots to the legs or lungs, stroke or liver disease should usually not take hormone therapy. Women taking hormone therapy should not smoke.
Women who aren't bothered by menopause symptoms and started menopause after age 45 do not need hormone therapy to stay healthy. Instead, talk to your doctor about strategies to reduce the risk of conditions such as osteoporosis and heart disease, which might include lifestyle changes and medications other than hormone therapy for long-term protection.
If you take hormone therapy, how can you reduce risk?
Talk to your doctor about these strategies:
- Find the best product and delivery method for you. You can take estrogen in the form of a pill, patch, gel, vaginal cream, or slow-releasing suppository or ring that you place in your vagina. If you experience only vaginal symptoms related to menopause, estrogen in a low-dose vaginal cream, tablet or ring is usually a better choice than an oral pill or a skin patch.
- Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat symptoms, unless you're younger than age 45, in which case you need enough estrogen to provide protection against long-term health effects of estrogen deficiency. If you have lasting menopausal symptoms that significantly impair your quality of life, your doctor may recommend longer-term treatment.
- Seek regular follow-up care. See your health care provider regularly to ensure that the benefits of hormone therapy continue to outweigh the risks, and for screenings such as mammograms and pelvic exams.
- Make healthy lifestyle choices. Include physical activity and exercise in your daily routine, eat a healthy diet, maintain a healthy weight, don't smoke, limit alcohol, manage stress, and manage chronic health conditions such as high cholesterol or high blood pressure.
If you haven't had a hysterectomy and are using systemic estrogen therapy, you'll also need a progestin. Your doctor can help you find the delivery method that offers the most benefits and convenience with the least risks and cost.
What can you do if you can't take hormone therapy?
You may be able to manage your menopausal symptoms by healthy lifestyle approaches, such as keeping cool, limiting caffeinated beverages and alcohol, and by practicing paced relaxed breathing or other relaxation techniques. There are also alternative medicine approaches, such as tai chi, yoga and acupuncture. Work with your doctor to find a healthy, effective approach that works for you.
The bottom line: Hormone therapy isn't all good or all bad
To determine if hormone therapy is a good treatment option for you, talk to your doctor about your individual symptoms and health risks. Be sure to keep the conversation going throughout your menopausal years. As researchers learn more about hormone therapy and other menopausal treatments, recommendations may change. If you continue to have bothersome menopausal symptoms, review treatment options with your doctor on a regular basis.