Hormone Replacement Therapy

Also called: ERT, Estrogen replacement therapy, HRT, Menopausal hormone therapy 

 Renata Trister DO

Menopause is a normal life event that usually occurs between ages 40 and 55. It is defined as 12 months without a menstrual period. Surgical removal of the uterus and ovaries, chemotherapy or other medical interventions and/or trauma can lead to early menopause (younger than 40).

Each woman will experience menopause in her own unique way. Some women may not experience any symptoms at all. For many women, however, the most common symptoms are hot flashes, night sweats, and vaginal dryness. The most effective treatment for these symptoms is hormone replacement therapy (HRT), although other treatments are also available.

HRT commonly refers to two different options:

     If you have a uterus, you may be prescribed combination estrogen plus progestin therapy (EPT). The progestin is added to protect your uterus from cancer that can occur when estrogen is used alone. If you are prescribed a low‐dose vaginal estrogen for treatment of vaginal dryness, you probably will not be prescribed a progestin.

     If you do not have a uterus, you will need only one hormone, estrogen (ET). There are many HRT options available by prescription from your doctor:

     A pill taken by mouth  a patch, cream, gel, or spray that can be applied to your skin  a cream, suppository, tablet, or ring that can be used within the vagina.

Many doses are available to meet your needs. Each of these options has different pros and cons that you can discuss with your healthcare provider.

Bioidentical hormones, which are similar to the hormones naturally made by the ovaries, are available in well‐tested, government‐approved products that can be prescribed by your doctor. Bioidentical hormones are a good option for many women.

In 2002, a large study called the Women’s Health Initiative (WHI) reported an increased risk of breast cancer, heart disease, stroke, and blood clots with the use of HRT. In the ten years since the reporting of those results, we have learned that the type of HRT (Estrogen versus estrogen-progestin therapy), how it is taken, and the timing of starting this treatment (early versus late after menopause) produce different benefits and side effects. The risk of side effects (such as heart attack, stroke, blood clot, or breast cancer) with HRT in healthy women ages 50 to 59 is low. In contrast, using HRT for a long time or starting HRT when you are a number of years beyond menopause is associated with a higher risk of these side effects.

Evaluating the benefits and risks of HRT for you personally is an important discussion for you to have with your physician. Treatment options should be tailored to your needs and your concerns.

HRT remains the most effective treatment available for menopausal symptoms, including hot flashes and night sweats that can interrupt sleep and impair quality of life. Many women can use these therapies safely.

Having a history of blood clots, heart disease, stroke, or breast cancer, make HRT risky, and is only used in special situations.

     The length of time is different for EPT (estrogen-progestin) and ET(estrogen only). For EPT, the time is limited by the increased risk of breast cancer that is seen with more than 3 to 5 years of use. For ET, no sign of an increased risk of breast cancer was seen during an average of 7 years of treatment, a finding that allows more choice in how long you choose to use ET.

     Healthy women under age 60, do not increase risk of heart disease with HRT. The risks of stroke and blood clots in the lungs do increase, averaging to 1 in every 1000 women per year.

     ET delivered through the skin (by patch, cream, gel, or spray) and low‐dose oral estrogen may have lower risks of blood clots and stroke than standard doses of oral estrogen, but all the evidence is not yet available. Research will continue to bring valuable information to help women with their decision about HRT.