Most women experience menopausal symptoms between 45 to 55 years of age. Hormone replacement therapy (HRT) is treatment of menopausal symptoms by use of hormones, most commonly estrogen or estrogen-progesterone combinations.
While many women experience improvement of symptoms, most notably hot flashes, there is still some reservation abouttaking hormones due to associated risks. Once a relatively common practice, concern for potential harm of hormone replacement has caused a decrease in HRT from 22 percent in 1999 to 4.7 percent in 2010 in women over 40 years old.
The current consensus is that the benefits outweigh the risks for potential harm in women within 10 years of menopause or under age 60 years. However, a recent study published in the Journal of the American Medical Association found estrogen-progesterone had an increased risk for invasive breast cancer, dementia, stroke, gallbladder disease, urinary incontinence and blood clot. Benefits were found to be a decrease in colon cancer, diabetes and fractures.
Prior to prescribing hormone replacement, providers are recommended to calculate risk of heart disease and breast cancer. Women who have a history of breast cancer, heart disease, previous stroke or blood clot, active liver disease or unexplained vaginal bleeding, or who are at a high risk for uterine cancer, should not take hormone replacement.
Estrogen is available as a patch, pill, gel, lotion, vaginal cream or vaginal ring. It is recommended women with a uterus should receive a combination of estrogen and progesterone to prevent uterine cancer. There is slight increase risk for blood clots and heart disease in estrogen-prosterone combination, however, stroke risk is decreased with use of the patch rather than oral administration. The patch has also shown to be as effective as oral estrogen in preserving bone density.
Vaginal cream, rather than oral replacement, is recommended for vaginal dryness and/or painful intercourse associated with menopause. Vaginal cream is not associated with an increased risk of heart disease. Whether starting with a patch, pill, cream, or vaginal ring, recommendations are to start with lowest effective dose and increase as needed.
Most estrogen replacement is derived from plants (soy and yams) or from pregnant horse urine. Both types are equally effective and patients may prefer one or the other. Another form of estrogen is the slightly new and controversial compounded “bioidentical hormone,” a hormone which is a replacement meant to mimic natural hormone levels. This replacement often requires multiple patient hormone tests and is not FDA approved. Consensus is to avoid this form of hormone replacement as studies have not been performed to assess safety or efficacy.
Discontinuation of treatment is another controversial subject with HRT. Despite improvement in symptoms, most women stop taking hormone replacement on their own one to two years after starting. While it is not generally recommended to continue HRT past 60 years old or for more than five years, continuing may be appropriate if symptoms are well controlled and patient does not have high level of risk.
In summary, hormone replacement therapy may be a safe option for women within 10 years of menopause or younger than age 60 who do not have contraindications. Consider low doses of hormone and transdermal patches or vaginal creams as these options may have fewer risks. If interested in treatment for menopausal symptoms, starting hormone replacement therapy should be a discussion of risks and benefits with you and your primary care provider.
Dr. Caroline Reusser is a family medicine physician with WesleyCare Family Medicine Residency.