Hormone therapy

• Alternative Names

  HRT; Estrogen replacement therapy; ERT; Hormone replacement therapy

• Information

  Hormone therapy used to be widely regarded as a very safe treatment for menopause. However, several major studies have shown that hormone therapy creates risks for certain medical conditions and problems, including heart disease, stroke, and cancer.

  However, hormone therapy may help relieve some of the bothersome symptoms of menopause, such as hot flashes, vaginal dryness and pain with intercourse, and long-term complications of estrogen loss, such as osteoporosis.

  You and your doctor should decide whether hormone therapy is right for you. The key is to weigh the risks associated with taking hormone therapy against your risk of heart disease or osteoporosis without taking hormone therapy. Every woman is different. Your doctor should be aware of your entire medical history when considering prescribing hormone therapy.

  At this time, short-term use (up to 5 years) of hormone therapy at the lowest possible dose to treat the symptoms of menopause still appears to be safe for many women.

  BENEFITS OF HORMONE THERAPY

  Perhaps the largest benefit women receive from hormone therapy is relief from:

  • Hot flashes
  • Night sweats
  • Sleep difficulties
  • Vaginal dryness
  • Anxiety

  Usually, hot flashes and night sweats are less severe after a couple of years, especially if hormone therapy is slowly reduced.

  A woman's body produces less estrogen during and after menopause, which may affect her bone strength. Hormone therapy may also prevent the development of osteoporosis. For information on treating bone loss, see: Osteoporosis.

  Studies have not been able to definitely show that hormone therapy helps with urinary incontinence, Alzheimer's disease or dementia, or colon cancer.

  RISKS OF HORMONE THERAPY

  BLOOD CLOTS

  Doctors have long known that taking estrogen increases a person's risk for blood clots. Generally, this risk is higher if you use birth control pills, which contain high doses of estrogen. Your risk is even higher if you smoke and take estrogen. The risk is not as high when estrogen skin patches (transdermal estrogen) are used.

  CANCER

  Breast cancer: Woman who take estrogen therapy for a long period of time have a small increase in risk for breast cancer. Most guidelines currently consider hormone therapy safe for breast cancer risk when taken for up to 5 years.

  Endometrial/uterine cancer: The risk for endometrial cancer is more than five times higher in women who take estrogen therapy alone, compared with those who do not. However, taking progesterone with estrogen seems to protect against this cancer. Endometrial cancer does not develop in women who do not have a uterus.

  CARDIOVASCULAR DISEASE

  Heart disease: Estrogen may increase the risk of heart disease in older women. However, it may still be somewhat protective in preventing heart disease when given under certain circumstances. Estrogen is probably the safest for women under 60 years of age.

  Deep venous thrombosis (DVT or blood clot in a vein) and pulmonary embolus (PE or blood clot in the lungs) are more common in women who take oral estrogen.

  Stroke: Women who take estrogen have an increased risk for stroke.

  GALLBLADDER DISEASE

  Several studies have shown that women who take estrogen/progestin therapy have an increased risk for developing gallstones.

  SIDE EFFECTS OF HORMONE THERAPY

  As with all medicines, side effects are possible. Some women taking hormone therapy may have water retention, bloating, nausea, breast soreness, mood swings, and headaches. Changing the dose or form of hormone therapy may help reduce these side effects.

  Some women have irregular bleeding when they start taking hormone therapy. Changing the dose often eliminates this side effect. Close follow-up with your doctor is important when you have any unusual bleeding.

  FORMS OF HORMONE THERAPY

  Hormone therapy is available in various forms. It may be necessary to try more than one form before finding the one that works best for you.

  Estrogen comes in the following forms:

  • Nasal spray
  • Pills or tablets, taken by mouth
  • Skin gel
  • Skin patches, which are applied to the thigh or belly area
  • Vaginal creams or vaginal tablets, to help with dryness and pain with sexual intercourse
  • Vaginal ring

  Most women who take estrogen and who have not had their uterus removed also need to take progesterone. Taking these medicines together helps reduce the risk of endometrial (uterine) cancer.

  Progesterone or progestin comes in the following forms:

  • Pill
  • Skin patch
  • Vaginal cream

  When estrogen and progesterone are prescribed together, your doctor will recommended one of the following schedules:

  • Cyclic hormone therapy is often recommended when a woman is starting menopause. With this therapy, estrogen is taken in pill or patch form for 25 days, with progestin added somewhere between days 10 - 14. The estrogen and progestin are used together for the remainder of the 25 days. Then, no hormones are taken for 3 - 5 days. There may be monthly bleeding with cyclic therapy.
  • Continuous, combined therapy involves taking estrogen and progestin together every day. Irregular bleeding may occur when starting or switching to this therapy. Most women stop bleeding within 1 year.

  Additional medications may be recommended for some women with severe symptoms from menopause, or women who are at very high risk for osteoporosis or heart disease. One of these supplemental drugs might be testosterone, a hormone that is more plentiful in males, to improve sex drive. Nonhormonal medications are sometimes used either in addition to, or instead of, hormone therapy.

  HEALTHY LIFESTYLE

  In addition to hormone therapy, a woman can take other steps to adjust to the changes in life during menopause. Eating healthy foods and getting regular exercise will also help decrease bone loss and maintain healthy heart muscle.

  CALLING YOUR HEALTH CARE PROVIDER

  It is important to have regular checkups with your health care provider when taking hormone therapy. If you have vaginal bleeding during hormone therapy or other unusual symptoms, call your health care provider.

• References

  Estrogen and progestogen use in postmenopausal women: July 2008 position statement of The North American Menopause Society. Menopause. July/August 2008;15(4)584-602.

  Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007 Mar 20;115(11):1481-501.

  Nelson HD. Menopause. Lancet. 2008 Mar 1;371(9614):760-70.

  North American Menopause Society. Estrogen and progestogen use in peri- and postmenopausal women: March 2007 position statement of The North American Menopause Society. Menopause. 2007;14:168-182.

  National Osteoporosis Foundation. Clinician's Guide to Prevention and Treatment of Osteoporosis. Feb. 2008. Accessed Feb. 22, 2008.

  Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007 Apr 4;297(13):1465-77.

  U.S. Preventive Services Task Force. Hormone therapy for the prevention of chronic conditions in postmenopausal women: recommendations from the U.S. Preventive Services Task Force. Ann Intern Med. 2005;142:855-860.

  Ritenbaugh C, Stanford JL, Wu L, et al. Conjugated Equine Estrogens and Colorectal Cancer Incidence and Survival: The Women’s Health Initiative Randomized Clinical Trial. Cancer Epidemiol Biomarkers Prev. 2008;17(10):2609-2618.

  Rosen HN, Drezner MK. Postmenopausal hormone therapy in the prevention and treatment of osteoporosis. Accessed September 2, 2009.

  Martin KA, Barbieri RL. Preparations for postmenopausal hormone therapy. Accessed September 2, 2009.

Review Date: 9/2/2009

Reviewed By: Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Redmond, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.