ConditionHormone Replacement Therapy
If you are confused about whether hormone replacement therapy is right for you, you are not alone. The medical community has flip-flopped on this issue over the last few decades and misinterpretation of data in general media articles creates a feeling of uneasiness for many patients when considering hormone therapy.
Hormone therapy is not one size fits all. The type of therapy and when it is administered matters greatly.
THE IMPORTANT DISTINCTION BETWEEN ESTROGEN THERAPY AND COMBINED THERAPY
COMBINATION THERAPY: HIGHER RISK OF BREAST CANCER, COMPLICATIONS
For relief of menopause symptoms, women who retain their uterus and desire HRT MUST take combination estrogen and progesterone hormone therapy to minimize the risk of uterine cancer. Estrogen-therapy alone can have a negative affect on the uterus. The complication is that combined therapy has been shown to increase breast cancer risk by nearly 300%.
Women’s Health Initiative Study: Estrogen Plus Progesterin Study
This is very important for women who need surgery to remove fibroids to understand. If a patient has fibroids, and fertility is no longer desired or she has reached menopause, retaining the uterus has no benefit, and will require the higher risk hormone therapy for alleviation of menopause symptoms.
ESTROGEN ONLY-THERAPY: LESS OVERALL RISK OF COMPLICATIONS
Women who have had a hysterectomy should take estrogen-only therapy. Once the uterus is removed, low-dose estrogen is the safest form of hormone therapy, and has been proven in multiple studies to alleviate symptoms of menopause, while having low risk of blood clots or stroke, and no effect on heart disease, or breast or colorectal cancers.
For the vast majority of women, hormone replacement therapy, when given correctly, is extremely effective and safe. There are certainly women who should not take hormone replacement therapy at all due to medical reasons. Women should be educated on this matter and decide for themselves if the benefits outweigh the risks.
Women’s Health Initiative Study: Estrogen Alone Study
Menopause: An Overview
Menopause is defined as the permanent cessation of menstrual periods.
Natural menopause occurs when the ovaries no longer produce estrogen and progesterone and stop releasing eggs. It is diagnosed in hindsight, one year after a woman’s last period.
Surgical menopause occurs after both ovaries are removed. The average age of menopause in the United States is 51 years.
Perimenopause is the transitional period when a woman’s hormone production is declining. It begins, on average, four years before the final period. Hormonal fluctuations during this time can cause a variety of symptoms.
THE ROLE OF HORMONES
The ovaries are responsible for the production of the “female” hormones: estrogen and progesterone. Along with the adrenal glands, they also produce testosterone. These hormones are released by the ovary and circulate throughout the entire body. Many organs within the body have receptors for these hormones, such as the breast, uterine lining, vagina, bone, and blood vessels. These hormones are mainly responsible for reproduction, but also have a role in many other functions of the body, such as maintenance of bone and cardiovascular health, and in regulation of body fluid.
As a consequence of the hormonal changes associated with menopause, a woman’s risk for osteoporosis, heart disease, and vaginal dryness increase significantly after menopause.
TREATMENT OF MENOPAUSE
Non-hormonal Treatment for Menopausal Symptoms:
Lifestyle modifications have been shown to be effective for women with mild symptoms. These include:
- Dressing in layers
- Sleeping with a fan nearby
- Using vaginal lubrication
Anti-depressants have been shown to help with hot flashes and mood changes and are good options for women who are unable to take estrogen.
- Brisdell (Paroxetine) was recently approved in 2013 by the FDA as the first non-hormonal treatment for hot flashes associated with menopause. Women on Tamoxifen should not take it, since it may decrease the effectiveness of Tamixifen when used together.
- Venlafaxine (Effexor), Citalopram (Celexa) and Escitalopram (Lexapro) have all been shown to be effective in controlling hot flashes.
- Fluoxetine (Prozac) is also helpful but less than Venlafaxine, Citalopram and Escitalopram.
- Sertraline (Zoloft) is not helpful.
- Phytoestrogens: There is an enormous market for phytoestrogens, which are plant-derived from sources such as soybean and red clover. Although they are readily available, there is no good medical evidence that they actually work beyond a placebo effect.
- Black Cohosh: Clinical studies have not shown black cohosh to be more effective than a placebo.
Gabapentin (Neurontin) is a medication used to treat seizures and nerve pain. It has also been shown to be effective in treating hot flashes when taken once daily at bedtime.
HORMONAL TREATMENT FOR MENOPAUSAL SYMPTOMS
Estrogen therapy (either alone, or combined with progesterone) has been shown in multiple studies to be the most effective treatment available for menopausal symptoms.
Benefits of Hormone Replacement Therapy:
- Reduction in the severity and frequency of hot flashes
- Improvement of moodiness and sleep problems
- Prevention of loss of bone density and osteoporosis
- Prevention of vaginal atrophy, dryness and irritation
- Maintenance of skin collagen (which helps skin elasticity)
Estrogen is not recommended as a first-line medication to prevent chronic diseases such as coronary heart disease, dementia, or osteoporosis, although some women may derive secondary benefits while taking it.
REFERENCES / RESOURCES
- Nedrow A, Miller J, Waler M, et al. Complementary and alternative therapies for the management of menopause related symptoms: a systematic evidence review. Arch Internal Medicine 2006;166:145
- Thacker HL. Assessing risks and benefits of nonhormonal treatments for vasomotor symptoms in perimenopausal and postmenopausal women. J of Women’s Health 211; 20(7):1007-16.
- ACOG Practice Bulletin No 141: management of Menopausal Symptoms. Obstetrics and Gynecology 2014:123(1):202-216
Types of Hormone Therapy
Hormone therapy can be given in two ways:
- Low-dose Vaginal Estrogen Therapy – These products are used to treat vaginal symptoms but do not help with other menopausal symptoms such as hot flashes, mood changes, or bone loss. This can be taken as a vaginal cream, ring, or vaginal tablet.
- Systemic Hormone Therapy – This is what is often referred to as “hormone replacement therapy,” or “HRT”. There are various forms, including oral pills, transdermal patches, or transdermal creams, sprays or gels. It is important to note that there are two types of systemic hormone therapies: Estrogen-Only HRT and Combination Estrogen+Progesterone HRT, and the risk profiles of the two types are not the same.
Types of Hormone Therapy
- Estrogen-only HRT – Safer than combination HRT but should only be taken by women who have had a hysterectomy. Because estrogen causes the lining of the uterus to thicken, if a woman with a uterus takes estrogen-only HRT, the endometrium will thicken without the balancing effects of progesterone. This increases the risk for endometrial cancer.
- Estrogen + Progesterone HRT – Women who have a uterus must have HRT with added progesterone. This is necessary in order to balance the effect of estrogen on the uterine lining and prevent overgrowth and potential cancer within the uterus.
The Evidence: Understanding the Main Studies
There have been a number of very large, well-designed studies that examined the risks of both types of HRT. Much of the confusion regarding HRT stems from misinterpretation of a landmark study called the Women’s Health Initiative (WHI).
The WHI study was a large study of healthy post-menopausal women ranging in age from 55 to 77, with an average age of 61. It included over 160,000 women and was the largest and most comprehensive study done on this subject. It was designed specifically to assess the role of HRT for prevention of coronary heart disease (heart attacks) in women but also looked at other outcomes. There were two arms of this study:
- Women with a uterus were randomly assigned to take either combination HRT or a placebo; and
- Women who had undergone a hysterectomy were randomly assigned to take either estrogen-only HRT or a placebo.
This study was stopped earlier than the researchers had originally planned, because the preliminary evidence actually showed a slight increase in risk of coronary heart disease, breast cancer, stroke, and blood clot events in the women taking combined HRT.
Among women taking estrogen only, there as an increased risk of thromboembolic event, but NOT an increased risk for breast cancer or cardiovascular events.
Following the WHI study published in 2002 and the flurry of publicity that followed, thousands of women and the medical community rapidly abandoned all HRT due to generalized fears of taking HRT. Why the confusion?
When it comes to risks of HRT, Age Matters!
WHY CIGC FOR HORMONE REPLACEMENT THERAPY
Trying to understand the role of hormone replacement therapy during menopause can be confusing. Conflicting information from the healthcare industry and media can result in unnecessary suffering. Whether a woman enters menopause naturally or surgically, at CIGC, our GYN surgical specialists have the experience to provide women with tailored hormone replacement therapy when appropriate, and understand that each woman experiences menopause differently.
Know your options.
Part of the role of the surgeons at CIGC is to thoroughly evaluate each patient’s unique condition, and provide insight to the right approach for therapy. While this may be a form of hormone replacement therapy, it may instead be a series of lifestyle adjustments to cope with your body’s changes.
CIGC surgeons specialize in minimally invasive GYN care. While focused primarily on surgery, additional treatments that support GYN health are critically important to overall patient well-being. Patients who require non-surgical treatments are offered the best medical solutions possible.
CIGC surgeons are laparoscopic surgical specialists who have dedicated their careers to the performance of minimally invasive GYN care. Additionally, our commitment to surgery means that we have worked on a higher volume of cases, more difficult cases, and use advanced techniques and procedures learned in extensive training. We strive to complete even the most complex surgeries with low complication rates.
We know that our customers are picky when choosing their surgeons, and we think doing extensive research is important. When you are exploring your hormone replacement therapy options, get to know our surgical specialists and see why they are the best in the industry.
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