Hormone Replacement Therapy

The North American Menopause Society recommends considering the following when deciding whether a woman should use ERT/HRT or other treatments:

• Menopause-related symptoms
• Cardiovascular risk (heart disease)
• Osteoporosis risk (bone wasting)
• Breast cancer risk
• The woman's lifestyle
• The woman's view of each treatment option
• The woman's general health status

If you elect to replace hormones and do not have a uterus, you only need to replace estrogen (ERT). If you do have a uterus, progesterone must be added to prevent excess buildup of the uterine lining and an increased risk of uterine cancer (HRT). Estrogen with progestogen has proved to be as effective as estrogen alone in treating menopause symptoms and reducing risk of heart disease and osteoporosis. HRT can be taken as a combination pill or patch. Both hormones can be taken every day (continuous combined schedule), or estrogen can be taken alone most days with progestogen added for part of the month (cyclic schedule). Vaginal spotting and bleeding may occur during the first six months of HRT, especially on the cyclic schedule. You may elect to use micronized natural progesterone to avoid possible side effects from synthetic progestin such as lowering HDL, fluid retention, headache, breast tenderness, and alterations in mood. However, do not rely on over-the-counter progesterone creams to oppose estrogen replacement, as not enough progesterone is absorbed through the skin to protect the uterus against cancer. If you have a history of breast cancer, blood clotting disorders, or liver disease, you may not be a good candidate for HRT. Be sure to discuss with your health care provider the pros and cons in relation to your risk factors.

ERT/HRT will relieve hot flashes, night sweats, sleep disturbances, vaginal thinning and dryness, skin thinning and loss of elasticity, and urinary symptoms that are not caused by neurological or mechanical impairment. It can be taken orally or applied as a skin patch. An estrogen cream, ring, or tablet can be applied vaginally to relieve vaginal symptoms alone. Women tend to experience the fewest side effects with the estrogen tablet and are less likely to discontinue using it than the cream form.

Women who take ERT/HRT have a 35-50 percent reduced risk of getting cardiovascular disease compared to women who do not use it. Estrogen reduces this risk by raising HDL (good cholesterol), lowering LDL (bad cholesterol), reducing the growth of fatty deposits in blood vessels, and dilating blood vessels. Testosterone should not be added if you are at high risk of heart disease or have low HDL levels (good cholesterol) because it reduces HDL.

Menopause speeds up bone loss (osteoporosis), especially during the first decade after menstruation stops. Having osteoporosis, in turn, increases the likelihood of having fractures of the spinal vertebrae, hip, forearm, pelvis, and ribs. All postmenopausal women should have their bone mineral density (BMD) tested to detect osteoporosis. Calcium, 1200-1500 mg daily, will help slow down bone loss. Younger women should have BMD testing if they have a fracture from any cause. Even if you delay starting HRT until age 65, your protection against fractures will increase more than 60 percent compared to women who have never used HRT. Taking testosterone along with estrogen can promote new bone formation as well as preventing future bone loss. Other drugs such as risedronate, alendronate, etidronate, calcitonin, or raloxifene may be taken instead for osteoporosis. However, these drugs will not help any other symptoms associated with menopause. You may also reduce your risk of osteoporosis by ingesting natural phytogestrogens, which are plant-derived, estrogen-like agents, or ipriflavone, a synthetic derivative. Phytoestrogens are plentiful in flaxseed, red wine, and soy products such as tofu.

HRT may offer additional benefits to women with disabilities such as multiple sclerosis and spinal cord injury. Estrogen substantially increases skin thickness and collagen content, which can prevent, or improve healing of, pressure sores. It may also improve urinary function by reducing the risk of infection, bladder spasm, and incontinence. Replacing estrogen may slow disease progress in MS and rheumatoid arthritis.

When taken for long periods of time, more than 15 years, estrogen may increase the risk of breast cancer. Most health care providers recommend that women who have had breast cancer should not use ERT. Others believe that short-term use of HRT is safe for women who have a history of breast cancer. ERT does not increase the risk of breast cancer when this risk is entirely genetic. For most women, the risk of getting breast cancer is much smaller than their risk for heart disease and osteoporosis.

Other prescription drugs may be taken to relieve hot flashes, such as clonidine, progestogen, and megestrol acetate. Certain medications used to treat depression, such as Effexor, may be prescribed in low doses to alleviate hot flashes, even if you are not depressed.

If you and your health care provider decide that HRT is not a good choice for you, there are other remedies that may help reduce hot flashes and other menopausal symptoms. Of course, beginning with a healthy lifestyle is always the best insurance against severe symptoms. Following are some remedies that have the best evidence for effectiveness.

Vitamin E, at 400-1200 IU a day, can help reduce hot flashes, vaginal dryness, and the risk of fatal heart attacks. However, if you are taking anticoagulant drugs or aspirin, check with your health care provider first, as vitamin E can increase bleeding.

Calcium. Taking your calcium supplement at bedtime with milk may help you sleep, as it has a calming effect.

Soy Products, such as tofu or soy isoflavone extract, and flaxseed contain high levels of natural plant estrogens. Though this estrogen effect is weaker than that obtained from ERT, eating 60-100 mg daily of these products may reduce the number of hot flashes, lower cholesterol, lower blood pressure, and reduce the risk of breast cancer. It may take two to six weeks to note any benefits. Though proven to be highly effective for hot flashes, they provide very little benefit to your bones.

Black Cohosh is an herb that is used to treat hot flashes, especially in Germany, where it has been extensively studied.

Korean Ginseng is an herb that helps relieve fatigue and may prevent vaginal thinning.

Acupuncture was proven to relieve hot flashes for at least three months after each treatment.

Note that products labeled as natural are not necessarily safer or better than other products. "Natural" is a marketing term, and even some plants are poisonous. For example, do not confuse black cohosh with blue cohosh; blue cohosh is toxic. Since herbs may be as chemically potent as prescription drugs and interact with other drugs that you take, be sure to notify a health care provider about which ones you wish to use to determine their safety for you.