Chapter List

• Introduction to Age Erasers for Women
• Stop the Clock
• Age Spots
• Allergies
• Anger
• Arrhythmias
• Arthritis
• Back Pain
• Binge Eating
• Bladder Problems
• Burnout
• Bursitis and Tendinitis
• Cellulite
• Depression
• Dieting
• Double Chin
• Drinking Problems
• Drug Dependency
• Eating Disorders
• Endometriosis
• Fatigue
• Fibroids
• Foot Problems
• Hair Loss
• Heart Attack
• Heart Disease
• Hemochromatosis
• High Blood Pressure
• Hysterectomy
• Infertility
• Midlife Crisis
• The Pill
• Respiratory Diseases
• Sex Problems and Stds
• Smoking
• Snoring and Sleep Apnea
• Stress
• Stroke
• Television
• Thyroid Disorders
• Type A Personality
• Unwanted Hair
• Varicose Veins
• Vision Changes
• Worry
• Wrinkles
• Adventure
• Aerobics
• Affirmations
• Alcoholic Beverages
• Altruism
• Antioxidants
• Aspirin
• Breakfast
• Breast Care
• Calcium
• Career Change
• Change and Adaptability
• Confidence and Self-Esteem
• Cosmetic Dentistry
• Cosmetic Surgery
• Creativity
• Fiber
• Fluids
• Forgiveness
• Friendships
• Goals
• Honesty
• Hormone Replacement Therapy
• Humor
• Immunity
• Learning
• Leisure Time
• Low-Fat Foods
• A Litany of Low-Fat Foods
• Makeup
• Marriage
• Massage
• Medical Checkups
• Optimism
• Relaxation
• Religion and Spirituality
• Resistance Training
• Sex
• Skin Care
• Sleep
• Stretching
• Vegetarianism
• Vitamins and Minerals
• Yoga
• Credits
• Gray Hair Rethinking Your True Colors
• Biological Clock
• Body Image
• Caffeine
• Cancer
• Cholesterol
• Dental Problems
• Diabetes
• Digestive Problems
• Hearing Loss
• Injuries and Accidents
• Memory
• Menopausal Changes
• Metabolism Changes
• Migraines
• Osteoporosis
• Overweight
• Premenstrual Syndrome
• Reaction Time
• Skin Cancer
• Ulcers

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Hormone Replacement Therapy

Hormone
Replacement Therapy

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A Midlife Option

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You've made a lot of health decisions in your lifetime: what type of contraception to use, how and when to exercise, which doctor to go to.

Now with menopause ahead, you face another. And this time, it feels like a real biggie. You keep mulling over the question: "Should I take hormone replacement therapy?"

Millions of women baby boomers are asking themselves the same thing. It's estimated that more women than ever--from 40 to 50 million--will be entering menopause during the next two decades.

We've all heard about the possible difficulties of menopause: hot flashes and night sweats, vaginal dryness and skin changes and increased risk for heart disease and osteoporosis once menopause has passed. We've also heard about hormone replacement therapy as a means to combat these aging effects.

In fact, whether to take hormone replacement therapy is often one of the first questions women have about menopause, says Joan Borton, a licensed mental health counselor in private practice in Rockport, Massachusetts, and author of Drawing from the Women's Well: Reflections on the Life Passage of Menopause. "It's still a very difficult decision to make. I see a lot of women being very thoughtful and trying to get as much information as possible," she says.

The choice is difficult, because there are both benefits and risks to taking hormone replacement therapy, or HRT. Women often find themselves trying to weigh the pros--HRT can relieve hot flashes and vaginal dryness, protect against heart disease and osteoporosis and maintain youthful skin and hair--against the cons--women worry that it may increase their risk for breast cancer, uterine cancer and gallstones. HRT also causes women to start having their periods again, which some view as an inconvenience. Most experts agree that the decision is an individual one and depends largely on a woman's health history and her own experience with menopause.

Understanding Estrogen

HRT is a formulation of hormones designed to replenish a woman's natural hormone levels. In the years preceding menopause, called perimenopause, a woman's natural estrogen levels steadily decline. Then after she stops ovulating and has her last period (when menopause actually begins), her estrogen levels plunge even further. The average age for menopause is 51, but it can occur earlier; about 1 percent of women experience menopause before age 40.

Estrogen plays a vital role in maintaining tissues and organs throughout a woman's body, including her skin, vaginal tissue, breasts and bones. So when estrogen levels dip low during menopause, there can be vaginal dryness, skin wrinkling and deterioration in bone mass and strength. Estrogen also affects a number of bodily functions, such as metabolism and body temperature regulation. So when estrogen levels decline, a woman's cholesterol can rise, placing her at increased risk for heart disease. Her body's internal thermometer can also be thrown off kilter--thus the hot flashes and night sweats.

Years ago, the hormone formulations designed for menopausal women contained just estrogen and were called estrogen replacement therapy, or ERT. But those formulations contained levels of estrogen that proved to be too high; the pills were found to contribute to the formation of blood clots. And giving estrogen alone proved dangerous: Studies showed it promoted uterine cancer.

So researchers redesigned the formulas, lowering the estrogen content and adding a synthetic form of the hormone progesterone called progestin. In addition to regulating estrogen, progesterone prompts the shedding of the uterine lining. The combination of estrogen and progestin is what is known as HRT. The lower doses of estrogen are high enough to replace what's missing and to provide protection for the heart but low enough so as not to promote clots. And the progestin offers protection against uterine cancer because it triggers the uterine lining to slough off, thereby preventing the dangerous buildup that can progress to cancer if unchecked. So today, if a menopausal woman decides she wants to take hormones and she still has her uterus, the recommendation of most doctors is low-dose estrogen plus progestin.

But some women have difficulty tolerating progestin, experts say. It can cause unbearable PMS-like symptoms. These women can receive low-dose estrogen alone, but if they do, they must undergo regular biopsies of the uterus to monitor for cancer. If a woman no longer has her uterus, she's eligible to receive low-dose estrogen alone, but some doctors recommend estrogen and progestin in these cases.

HRT involving both estrogen and progestin can be taken in several different ways. The progestin component of the therapy is available only in a pill, which women can take either in higher doses for 10 to 12 days at the end of their menstrual cycles or in lower doses every day of the month.

Estrogen, however, is available in a number of different forms, including creams, patches and pills, and is taken either every day of the month or for the first three weeks of the menstrual cycle.

Estrogen creams are inserted into the vagina with applicators and have their greatest impact on vaginal tissue; this form of estrogen is most effective for vaginal dryness and urinary tract problems. Estrogen patches are the size of a small bandage and are worn on the abdomen; estrogen is released from the patch in timed sequences and passes directly into the bloodstream. This form is appropriate for women who have medical conditions that prohibit them from taking estrogen orally, such as gallbladder disease or high blood pressure.

Because the estrogen from both creams and patches goes directly into the bloodstream, it does not pass through the digestive tract and the liver, where it would normally have its greatest effect on reducing cholesterol. Cream and patch forms of estrogen are therefore thought to be less effective in protecting against heart disease.

The pill form of estrogen is taken by mouth and is thought to be the best method for fighting heart disease. The most common estrogen pill, called Premarin, is made from natural sources--estrogen from mares--while other pills are made from synthetic sources.

Immediate Concerns

Hot flashes and vaginal dryness are the two main symptoms that send a woman to her doctor about menopause and HRT, says Brian Walsh, M.D., director of the Menopause Clinic at Brigham and Women's Hospital in Boston.

Hot flashes are estimated to affect 75 to 85 percent of menopausal women. Eighty percent of women who get hot flashes experience them for more than a year, and 25 to 50 percent complain of them for more than five years. Hot flashes can vary from a mild to moderately warm sensation that lasts between 1 and 5 minutes to an extremely hot feeling that lasts up to 12 minutes and involves profuse sweating and flushing.

Hot flashes may occur during the day or at night, when they're known as night sweats. Women may wake up hot and sweating, says Dr. Walsh. They are often so drenched that they must change their nightclothes, further interrupting their sleep and leaving them exhausted and irritable during the day. HRT is highly effective against hot flashes, experts say.

Vaginal dryness also responds to HRT, experts say. The tissue of the vagina has estrogen receptors in it. When estrogen declines with menopause, the lining of the vagina and uterus thins, and vaginal dryness results.

A woman's skin may also have estrogen receptors, so when menopause arrives, skin can begin to wrinkle. HRT is effective in maintaining smooth, youthful-looking skin, experts say.

Heart Helper

A big concern for women who go through menopause is heart disease, since risk of it increases from one in nine women before age 65 to one in three women after 65, according to the American Heart Association.

The reason a woman's risk goes up is that estrogen helps keep levels of HDL (high-density lipoprotein) cholesterol, the good kind, high and levels of LDL (low-density lipoprotein) cholesterol, the bad kind, low. It also helps prevent blood vessel walls from attracting cholesterol. When a woman's natural levels of estrogen decline with menopause, these protections against heart disease are removed.

Will taking HRT restore the protection? Some studies indicate that it may.

The problem with existing studies is that they are based mostly on the older formulations of ERT--those containing just estrogen. The majority of these studies indicate that taking estrogen without progestin will decrease a woman's heart disease risk by 50 percent compared with what her risk would be if she didn't take it, says Cynthia A. Stuenkel, M.D., associate clinical professor in the Department of Medicine and Reproductive Medicine at the University of California, San Diego.

But what about HRT, which uses both estrogen and progestin? Well, less research has been done on those formulations. And there's some question among researchers about whether progestin reduces the protective effect of estrogen.

A study published in the New England Journal of Medicine, however, looked at the effects of both HRT and ERT on heart disease. The report analyzed data from the Atherosclerosis Risk in Communities Study, a large study of 15,800 people from four areas of the country. Based on their findings, researchers reported that the levels of good cholesterol were similar for users of estrogen alone and users of estrogen plus progestin. And both groups had higher levels of good cholesterol than women who did not use estrogen. The researchers also estimated that women who took estrogen alone decreased their risk of heart disease by 42 percent compared with nonusers and that women who used estrogen with progestin would have even greater benefit, although just how much more wasn't specified.

Bone Bonanza

Another concern for menopausal women is osteoporosis, a disease in which the density and strength of bone, particularly in the hips and wrists, declines. Experts say that four in every ten women develop the disease. The consequences can be devastating--an estimated 1.5 million Americans suffer osteoporosis-related fractures each year. After menopause, between 25 percent and 44 percent of women experience hip fractures due to osteoporosis. And by the time they are 90 years of age, women are twice as likely as men to fracture their hips.

Research suggests that using HRT will decrease a woman's risk of suffering osteoporosis-related fractures by 50 percent. And for women who already have osteoporosis, HRT is still thought to be effective and may increase their bone mineral density, a measurement of bone strength, by 5 percent.

How long does a woman need to take HRT in order to protect her bones? In Boston, the Framingham Osteoporosis Study analyzed the bone mineral densities of 670 white women from the Framingham Heart Study. (The Framingham Heart Study began in 1948 and followed study participants through their lives to evaluate risk factors for heart disease.) The Framingham Osteoporosis Study concluded that women needed to take hormone therapy for more than seven years for their bone mineral densities to increase. Women who took it for only three to four years had bone mineral densities similar to women who had never taken it. So according to this study, women may need to stay on HRT for at least seven years for their bone mineral densities to increase significantly.

Researchers also found that when women took HRT for seven to ten years or more and then stopped, the protective effect of HRT against declining bone density lasted only until age 75. After that, any effect of prolonged therapy appeared to be slight. This is important, given that a woman's risk for osteoporosis is greatest in her eighties and nineties.

The findings of this study have prompted discussion in the medical community about how long women need to take HRT to maintain bone density into the last decades of life. Some physicians are tossing around the idea of keeping women on HRT indefinitely--that is, they would start on it after menopause and stay on it through their eighties and nineties. Other doctors are considering the possibility of waiting longer after menopause to start HRT.

Risks of HRT

There are other health issues and risks for women who take hormones. First, there's the risk of uterine cancer, which affects about 1 in 1,000 women per year, says Dr. Walsh. Taking estrogen alone increases a woman's risk for endometrial cancer about fourfold, says Dr. Walsh. That's why doctors today don't recommend estrogen alone for a woman who still has her uterus. But women who take estrogen and progestin may actually have a lower risk than if they didn't take hormones at all, says Dr. Walsh. Their risk is possibly 30 to 40 percent lower, he says.

Taking HRT places a woman at risk for gallstones, particularly in the first year, says Dr. Walsh. In addition, there are women for whom HRT or ERT is not appropriate. Neither is recommended for women who have known or suspected cancer of the uterus or breast, who have had problems with blood clots called pulmonary embolus or who have active liver disease, says Dr. Walsh.

The Breast Cancer Question

A major concern for most women considering HRT is whether it will increase their risk for breast cancer. The breast contains estrogen receptors, and the administration of estrogen in animals promotes cancer. So there's some reason to suspect that taking HRT or ERT could promote breast cancer in women.

The relationship between HRT and breast cancer is controversial; various studies on the issue have come to different, often contradictory conclusions. But one study by researchers at the Centers for Disease Control and Prevention in Atlanta compiled the results of a number of different studies and came to the following conclusions: Current users may be at increased risk, but it appears that the risk is relative to how long a woman takes ERT. There does not appear to be an association between ERT use and breast cancer in women who have taken it for less than 5 years, but women who have used it for over 15 years may have about a 30 percent increased risk. Women who used ERT in the past but are not currently taking it do not appear to be at increased risk for breast cancer.

What You Can Do

So how does a woman decide? It's not easy. But here's what you can do.

Find the right doctor. Doctors may vary in their approaches to HRT, so it's important to find one you're comfortable with and who respects your feelings and opinions, says Borton. Don't be afraid to shop around for a doctor, and ask your friends about theirs.

Know your family history. In deciding about HRT, it's important to know your family history, says Dr. Walsh. Find out if anyone in your family has a history of heart disease, osteoporosis, breast cancer or endometrial cancer. Tell this to your doctor.

Weigh your risks. Deciding on HRT is often a matter of balancing your risk for one disease against your risk for another. One solution is to try "to decide as a woman what you are at risk for and what your risk profile is and to make an intelligent decision about what diseases you ought to be preventing that you are likely to get," says David Felson, M.D., of the Boston University Arthritis Center.

Keep menstrual records. When women go on HRT, they often get their periods again, particularly if they are taking progestin with estrogen. Hormone preparations can affect your flow. So record your bleeding pattern, says Dr. Walsh. Take a calendar, mark the days when you bleed and show it to your doctor, so she can determine whether the timing and amount of flow are appropriate, he says.

Expect time for adjustment. It may take four to six weeks for the hormones to kick in and for you to feel an effect, says Dr. Walsh. And once you're on them, it may take several months to get your therapy adjusted so that your periods become regular.

Do those breast exams. All the questions about the connection between HRT and breast cancer aren't definitively answered. So cover your bases and perform monthly breast self-examinations; they'll enable you to detect breast cancer early if you develop it. One of the most important things a woman can do is perform monthly breast self-examinations, says Dr. Walsh. "Most breast cancers are found by the woman herself, which is why it makes sense for her to examine her breasts once a month," he says. "That's 11 more times than her doctor has a chance to find a breast lump."

Get your mammogram. A mammogram is another way to detect breast cancer. Most doctors recommend that women have their first mammograms between the ages of 35 and 40. It's important for women on HRT to get mammograms on a regular basis, says Dr. Walsh. "People argue about how often and starting at what age, but by age 50, women should definitely be having mammograms at least every year," he says. Mammograms "allow the breast cancer to be detected when it's small and it's potentially curable," says Dr. Walsh.

Have a cancer check. Another type of follow-up test that women can have is called an endometrial biopsy. This checks the lining of the uterus, or endometrium, for cancer. Some doctors do a baseline biopsy at the start of HRT and then do a biopsy as an annual screening, although not all doctors do this with women who are receiving both estrogen and progestin. The test is more important when a woman is taking just estrogen, because the protective effect of progestin is absent. Ask your doctor about her approach.

Look for support. Other women going through menopause can be a tremendous source of support, says Borton. Talk to other women your age--either women you already know or those you meet in a support group--about their thinking, decisions and experiences surrounding HRT, she says. Hearing other women's experiences can often help. Call your local hospital for support groups in your area. Or start one of your own.