When you enter the early stages of menopause, the question of hormone replacement therapy (HRT) arises. The two female hormones, estrogen and progesterone (often in its synthetic version, the progestins), are certainly the most widely prescribed therapies utilized by physicians for the relief of menopausal symptoms and the prevention of certain hormone-related conditions of aging. Medical research during the past 50 years has created many different types and dosage regimens of hormones. Such therapies vary in terms of absorption, frequency of usage and dosage.
Many women are confused or uninformed about their choices of hormonal therapy. They don't know what to ask at medical visits to determine which hormonal regimens, if any, would suit them best. As a result, the best treatment combination for each individual woman may not be possible. Each woman should explore options and fine tune an individual approach until the best regimen is determined. This book will give you basic information about hormonal replacement therapy that can help you, with your physician, to make an intelligent and informed decision about using HRT. First, the history of hormonal replacement therapy in this country will be discussed; then, the steps to follow before beginning HRT. Detailed information is provided about the different types of estrogen, progesterone and even androgen therapy, as well as the various monthly schedules that can be utilized when taking HRT. Finally, helpful tips are given on how to adjust to HRT as well as on how to comfortably and safely discontinue HRT if you desire to do so.
History of HRT
The use of hormones after menopause is a recent innovation in human history. Relatively few women even survived the rigors of more primitive societies to face the issue of postmenopausal aging. How long a woman lived did not depend on sophisticated hormonal therapies synthesized in a laboratory, but rather, on a combination of good genes, familial longevity, a healthy lifestyle with adequate nutrition, balanced responses to stress and a balance of physical activity and rest. Only since the turn of the century have women begun to outlive their menopause and continue to do so for several decades.
Scientists first isolated estrogen and progesterone in the laboratory in their purified state during the 1920s. In the decades before this advance, physicians prescribed various formulations of the whole gland. Animal ovaries were powdered, pulverized and liquefied and then given by health care providers to women who had gone through surgical menopause or to those who suffered from menstrual cramps. Use of hormones remained limited throughout the 1930s and 1940s. By the 1950s and 1960s, the benefits of estrogen in treating menopausal symptoms were understood and appreciated and its use became widespread. A number of books and articles were written during this era about estrogen's many benefits, both real and fancied. Many women benefited from the relief estrogen brought from unpleasant hot flashes, vaginal dryness, mood swings and other symptoms. Women were told that estrogen would even enhance their attractiveness and youthfulness. However, very little was understood or communicated to women about the risks of using estrogen.
The first adverse reports about estrogen therapy surfaced in 1975. Several research studies published that year linked estrogen use in postmenopausal women with cancer of the lining of the uterus (also called the endometrium). In those studies, women who used estrogen were four to eight times more likely to develop this cancer. Fearful of cancer, postmenopausal women avoided estrogen in dramatic numbers, and physicians were equally hesitant about prescribing it. This decline lasted for several years until further research studies showed that the combined use of estrogen and progestins (synthetic forms of progesterone) offered women excellent protection against the development of cancer of the uterine lining. In the regimens tested, women used estrogen 25 days each month, adding a progestin the last 10 to 14 days of the monthly treatment schedule.
Today, physicians prescribe estrogen and some form of synthetic or natural progesterone to combat early and postmenopausal symptoms. Physicians currently are able to use HRT with much greater wisdom and very little risk. Many research studies done on HRT now enable physicians to prescribe specific types of hormones and dosage regimens for each individual woman's needs. A 1994 Gallup Poll indicated that 40 percent of all menopausal women in the United States use HRT. This low percentage appears to be related to poor compliance, myths or fears about estrogen use, the wish to pass through menopause naturally, and lack of support for finding the right regimen for the individual woman.
Working with Your Physician
Steps to Follow Before Starting HRT
If you are considering beginning HRT therapy, schedule an initial health evaluation to determine if any risk factors exist that the use of hormones could aggravate. In addition to determining the suitability of your using HRT, a good medical evaluation will identify any undiagnosed health issues that can then be adequately treated.
A pre-HRT evaluation may vary in its components depending on your medical status and what specific menopause-related health problems your physician is most concerned about. Tests used in evaluating a woman for HRT may include the following:
1. A complete physical examination, including a pelvic exam and a breast exam.
2. A PAP smear to determine a cancerous or precancerous lesion of the cervix.
3. Blood tests to check liver function, blood sugar, cholesterol, triglyceride, calcium and phosphorus levels, as well as tests of thyroid function.
4. Complete blood count to check for anemia, as well as a urinalysis.
5. Mammography and professional breast examination to check for breast cancer. Mammograms done by experienced radiologists are capable of detecting 90 percent of all breast cancers.
6. Bone density studies (dual x-ray absorptiometry, DEXA) to help determine the level of bone loss. This is an important test for women who may be at higher risk for osteoporosis.
7. A review of your family medical history to gather clues about your risk of cardiovascular disease, osteoporosis, and breast and other cancers.
8. Endometrial biopsy or vaginal ultrasound may be done to check for hyperplasia (overgrowth) of the uterine lining and endometrial cancer. A progesterone challenge test may also be done after menopause to check for endometrial hyperplasia.
If the results of these tests do not contraindicate the use of HRT and you decide to use hormonal therapy, expect frequent follow-up visits with your doctor. He or she will want to monitor the amount of hormones you are taking and their effect on menopausal symptoms, as well as your general health. Most physicians recommend annual visits. At this time, you should discuss any remaining symptoms or possible side effects that have developed since beginning HRT. Blood pressure will be monitored at each visit and a breast and pelvic exam done to check the health of these tissues. Most importantly, it is an excellent time to ask your doctor any questions that you may be concerned about. It is crucial that you tell your doctor any concerns or issues that you may have regarding your therapy. If you are not satisfied with your physician's answers or feel that your physician is standoffish or abrupt, you may wish to seek another opinion or doctor in your community. Unexpressed concerns that are not discussed with your physician may delay the diagnosis and treatment of health problems that can arise during the course of treatment. The best results occur when a true partnership exists between doctor and patient.
Estrogen is taken as a supplement to compensate for the lack of estrogen circulating through your body as your ovaries begin to age. A great deal of research has resulted in three forms of natural and synthetic estrogen that are synthesized in the laboratory (produced in our bodies as estradiol, estrone and estriol). Not only are different types of estrogen available, but they can be administered by different routes which allow for great flexibility. These three major types of estrogen are usually differentiated in clinical practice based on their routes of administration which include oral, transdermal and cream.
Oral Estrogen Tablets
Many women take estrogen by mouth in pill form, known as "oral estrogen" Estrogen tablets are the most commonly used form of ERT. The estrogen tablets available on the market in the United States are composed of different forms of estradiol and estrone. As you may remember, estradiol is the main type of estrogen manufactured by the ovaries, and estrone is the primary type of estrogen that we produce after menopause. Estriol, the weakest and probably safest type of natural estrogen, is difficult to find in the United States, although it is more easily available in Canada and Europe. Estriol can be order by physicians through the Women's International Pharmacy in Madison, Wisconsin.
The most commonly prescribed estrogen tablet is Premarin (Wyeth-Ayers Laboratories), a conjugated equine estrogen derived from a pregnant mare's urine. It has been available since 1941, and much of the medical research has been done using this product. As a result, the benefits and side effects of Premarin are very well understood. Another benefit of Premarin is that it comes in a wider variety of doses than any of the other estrogen products. This allows for much more flexibility in determining the optimal treatment dosage for each woman user. Besides Premarin, currently available are generic, conjugated estrogen and synthetic and semisynthetic estrogen compounds. Other products include Ogen (Abbot), which contains estrone, and Estrace (Meade Johnson), which contains estradiol.
Women should avoid using nonsteroidal synthetic estrogens. One of these drugs, called diethylstilbestrol (DES), was used several decades ago to prevent miscarriage in women with high risk pregnancies. Unfortunately, many female children of these women have subsequently developed vaginal and cervical abnormalities including cancer. Most doctors also avoid estrogen tablets combined with a tranquilizer such as Menrium (Roche). Librium, the medication used to help treat mood problems in this particular formulation, is habit forming and can cause drowsiness. Because estrogen is used on an almost daily basis, the addition of tranquilizers can produce undesirable side effects with long term use.
The use of estrogen in pill form has some drawbacks. In the traditional regimen, women use estrogen 25 days per month with one week off (much like the birth control pill). During this "off" time, some women find that their menopausal symptoms, such as hot flashes, recur. Other women dislike having to track pill intake. These two problems can be remedied by placing the woman on continuous therapy, where she is taking estrogen every day of the month. Obviously, women who dislike having to take a tablet each day would do better switching to another route of administration.
A more serious drawback to the use of oral estrogen is that after ingestion, a large amount of estrogen is concentrated in the digestive tract. When estrogen passes through the intestinal tract, intestinal bacteria transform the estrogen chemically. This can change the type as well as the potency of the estrogen that is reabsorbed back into the body. Once the estrogen is reabsorbed, it enters the blood circulation and is transported to the liver. In the liver, estrogen is again metabolized and converted to the other forms before it finally enters the general circulation. How efficiently this occurs depends on the health of the liver. Many nutritional factors such as fat, sugar, alcohol and B-complex vitamin intake affect liver function, as does pre-existing liver disease. Women with a history of liver or gallbladder disease or hypertension and clotting problems (which are affected by various actions in the liver) may do well to avoid oral estrogen. They might instead use another route that circumvents the digestive tract and instead, disperses estrogen into the general circulation.