So this is menopause. You are having hot flashes and trouble sleeping. That leaves you tired all day. You wonder about osteoporosis. Your doctor has suggested that hormones might help. But you have heard stories on the news that make you wonder if they are right for you. You don't know what to do. How do you decide?
Millions of women take hormones around the time of menopause, called menopausal hormone therapy. Some women should not. It may or may not be the right choice for you.
What Is Menopausal Hormone Therapy?
Menopause is the time around the age of 51 when your body makes much less of the female hormones estrogen and progesterone and you stop having periods. This can cause troublesome symptoms for some women. As early as your forties, you may start having signs like irregular periods or hot flashes (sudden warmth, often followed by sweating).
Doctors sometimes prescribe estrogen to ease these symptoms. This can also protect against the loss of bone after menopause. But there are risks. Estrogen used alone can cause cancer of the lining of the uterus (endometrial cancer). According to the National Cancer Institute, about 5 cases of endometrial cancer may develop in every 10,000 women using this hormone for 10 years. This is about 4 more cases than we would expect in a group of 10,000 women who don't use estrogen. More importantly estrogen used alone can cause a thickening of the lining of the uterus and irregular bleeding. But, if you have had a total hysterectomy (surgery to remove the uterus and cervix), you can use estrogen alone (estrogen therapy or ET). Several types of estrogen are available. They come in many forms. You can use a pill or tablet, a skin patch, vaginal cream, vaginal ring insert, implant, or shot.
If you still have your uterus and want to take hormones, doctors will prescribe estrogen along with progesterone or one of several progestins, synthetic forms of progesterone. The progestin protects against endometrial cancer. Using estrogen and progesterone or a progestin is called estrogen plus progestin therapy or EPT. Progesterone or progestin is often taken as a pill, sometimes in the same pill as the estrogen. It is also available as a patch, an IUD (intrauterine device), a vaginal gel, suppository, or shot.
The form your doctor suggests may depend on your symptoms. For example, estrogen creams and tablets are used for vaginal dryness. The vaginal ring insert treats vaginal dryness and may help urinary tract symptoms. Pills or patches provide relief from annoying symptoms such as hot flashes, night sweats, sleep problems, and vaginal dryness. They will also prevent bone loss and help delay osteoporosis while you are using them and could improve your cholesterol levels. Some experts think they may help your memory if begun at menopause. But improving cholesterol or helping memory should not be the main reason you take menopausal hormone therapy.
Schedules for Taking EPT
If your doctor suggests estrogen plus progestin and you agree, talk to him or her about the schedule that is best for you. The pill form of EPT is taken following one of these two plans:
- Estrogen every day
- Progesterone or progestin added for 10 to 14 days out of every 4 weeks
- Often causes monthly bleeding like a light menstrual period
Combined Continuous Plan:
- Estrogen and progestin taken every day of the month without a break
- May stop monthly bleeding after about 6 or more months of treatment
- Problem spotting may continue longer
- Also available as a patch
What Are The Risks of These Hormones?
Both estrogen and progestin can have side effects. You could feel bloating, breast tenderness, cramping, irritability, depression, and sometimes have spotting or a return of monthly periods for a few months or years. By changing the type or amount of these hormones, the way they are taken, or the timing of the doses, your doctor may be able to control these side effects. Or, over time they may go away on their own.
But there could be more serious risks. These include heart disease, blood clots, stroke, and breast cancer in all postmenopausal women, and possibly dementia in women over 65. Many women now live 25, 30, or more years after menopause. Could taking hormone therapy for many of those years be helpful to women? Would it be safe? Women and their doctors need to think about the benefits and risks of using menopausal hormone therapy for just a few years or for longer.
Doctors have known for a while how to reduce the risk of endometrial cancer from using estrogen. But, what about other risks? Studies are now being done to learn more about the risks of using hormones after menopause. An important study of menopausal hormone therapy is included in the Women's Health Initiative (WHI), funded by the National Institutes of Health (NIH). In 2002 these scientists found that for every 10,000 women taking a pill containing a specific hormone combination of conjugated equine estrogens and a progestin called medroxyprogesterone acetate, each year there would be:
- 8 more cases of breast cancer than in women not using these hormones,
- 7 more cases of heart disease,
- 8 more cases of stroke, and
- 8 more cases of blood clots in the lungs.
But there would also be health benefits:
- 5 fewer cases of hip fracture, and
- 6 fewer cases of colorectal cancer.
The WHI hormone study has a substudy called the WHI Memory Study (WHIMS) to look at whether using hormones after age 65 can prevent or delay dementia in older women. In 2003 investigators from WHIMS announced that older women using estrogen plus progestin in their study were at twice the risk for developing dementia. Each year in 10,000 women over age 65 using estrogen plus progestin they found:
- 23 more cases of dementia than in older women not using these hormones.
The risks found in these two studies may be small for each individual woman, but they need to be taken into account when thinking about menopausal hormone therapy. Other estrogens and progestins that are different from the ones used in these studies are available. They have not been tested for as long or in as many women as the ones used in the WHI studies. Experts think that using these could cause similar effects, but they do not know for sure.
Benefits and Risks of Menopausal Hormone Therapy
Here is what scientists can say so far about the advantages and disadvantages of menopausal hormone therapy. ET is estrogen only therapy, and EPT is therapy using estrogen with a progestin.
- EPT and ET reduce the risk of osteoporosis.
- EPT and ET relieve hot flashes and night sweats.
- EPT and ET relieve vaginal dryness.
- EPT and ET improve cholesterol levels.
- EPT and ET reduce the risk of cancer of the colon
- ET, without the use of a progestin, increases the risk of cancer of the uterus.
- EPT and ET modestly increase risk of breast cancer while they are being used; long-term use may pose the greatest risk.
- EPT increases cardiovascular problems such as heart attack and stroke and is not recommended in women who have these diseases.
- EPT and ET may increase the risk for blood clots.
- EPT and ET can have unpleasant side effects, such as bloating and breast tenderness.
- EPT and ET in pill form can raise level of triglycerides (a type of fat in the blood).
Under study(as of May 2003)
- EPT and ET to improve mood and psychological well-being.
- ET to prevent the loss of mental abilities with age.
- EPT to lower risk of developing diabetes.
- EPT to lower risk of ovarian cancer.
Should I Use Menopausal Hormone Therapy?
Right now, experts do not have all the answers to their questions about menopausal hormone therapy. Are other forms of estrogen or progestin safer than the ones used in the WHI studies? How long can a woman safely use menopausal hormone therapy? Is one form of such hormone therapy (pill, patch, or cream, for example) better than another? Which schedule is best? These are just some of the questions that remain.
For now we know that each woman is different, and the answer for each one may also be different. That means this question is best thought about after talking with your doctor (general practitioner, internist, or gynecologist). He or she can help you apply what is known about menopausal hormone therapy to your medical history. For example, you probably should not use these supplements if you have liver disease, high levels of triglycerides (a type of fat in the blood), or a history of blood clots in your veins. However, some experts think that using a patch, rather than a pill, will not make your triglyceride level go higher or increase your chance of gall bladder problems. Women with a family history of breast cancer should check with their doctor about that risk.
The first step is to decide how much you are bothered by menopause symptoms such as hot flashes or vaginal dryness. For many women hot flashes or night sweats will likely go away over time, but vaginal dryness may not. You will also need to think about your medical history, your risk of osteoporosis, heart disease, breast cancer, gall bladder disease, and blood clots, and your family history of these illnesses.
Then talk to your doctor about how best to treat or prevent your symptoms or the diseases for which you are at risk. Ask about your other choices. These too may have risks and benefits. Along with your doctor you can decide whether the benefits of using estrogen plus progestin or estrogen alone are greater than the risks for you.
If you are already using menopausal hormone therapy and decide to stop, ask your health care provider how to do that. Some doctors suggest tapering off.
And remember any decision about using estrogen plus progestin or estrogen alone is not final. You can start or end the treatment anytime. But, if you stop it, the protection these therapies give you will stop as well. Your decision about menopausal hormone therapy should be reviewed each year with your doctor at your annual checkup. At that time you can ask if there are any new study results.
Research on using hormones during and after menopause is continuing. Almost every study gives women and their doctors another part of the answer to the question: Is menopausal hormone therapy right for me?
For more information contact:
National Heart, Lung, and Blood Institute
NHLBI Information Center
Bethesda, MD 20824-0105
National Cancer Institute
NCI Public Inquiries Office
6116 Executive Blvd. MSC8322
Bethesda, MD 20892-8322
American College of Obstetricians and Gynecologists (ACOG)
409 12th Street, SW
Washington, DC 20090-6920
North American Menopause Society
PO Box 94527
Cleveland, OH 44101
The National Institute on Aging offers free information on menopause and osteoporosis.
National Institute on Aging
U.S. Department of Health and Human Services
National Institutes of Health
This document sourced from the National Institute on Aging.