Estrogen Replacement Therapy

After menopause, your doctor may recommend hormone replacement therapy, in which hormones are given to replace those your body made. The main goals of hormone replacement therapy are relieving symptoms, preventing osteoporosis, and protecting against heart disease, a major cause of death of women aged 55 and older.

Hormone treatment works better to prevent osteoporosis if it is started at menopause (or when the ovaries are removed). The fastest bone loss occurs in the first seven years of menopause,however estrogen started at any time after menopause can be effective. In addition, studies suggest that giving estrogen may decrease the risk of heart disease by 50 percent in postmenopausal women. It may also reduce your risk of colon cancer and Alzheimer's disease.

Most of the symptoms of menopause can be eased by taking estrogen. Estrogen usually will not get rid of the symptoms, but it can make them less frequent and intense. It is used to treat hot flashes. It also relieves itching and burning and reduces vaginal dryness. Estrogen can also relieve some emotional problems that stem from the loss of the natural hormone. It will not, however, solve problems that are a part of the natural aging process.

Along with estrogen, your doctor will often prescribe another hormone called progestin to reduce some risks of taking estrogen. Progestin is similar to the progesterone your body makes before menopause. When progestin is used, you may have vaginal bleeding once a month. This may bother some women. Ask your doctor what to expect, and contact him or her if unexpected bleeding occurs.

Risks from Hormone Use
There are both risks and benefits to hormone use. Estrogen taken alone has been linked to cancer of the endometrium. However, this risk may be decreased by giving progestin with estrogen, as well as by reducing the dose of estrogen given. On the other hand, there is some question about the role of progestin in heart disease. While estrogens help reduce the risk, it is not known whether progestins may block some of the effect of the estrogen. Discuss these issues, as well as questions about dosage and hormone combinations, with your doctor.

Most studies suggest no link between hormone replacement therapy and breast cancer. Some studies, though, indicate that a woman's chances of developing breast cancer increase a small amount if she has been on hormones for more than 10 years by as much as 20 percent. Like other women their age, women taking replacement hormones should have regular breast exams and mammograms.

Side Effects of Hormones

Although many women who take hormones don't notice any side effects, they do occur in some women. Side effects can include any or all of the following problems:

• Vaginal bleeding
• Breast tenderness
• Fluid retention
• Swelling
• Mood changes (eg, depression or irritability)
• Pelvic cramping

It's Not for Everyone
Although most women benefit from taking estrogens, not every woman can take them. If you have had breast cancer, endometrial cancer, or liver disease, estrogen often is not recommended unless your symptoms are so severe that you feel the benefit from taking it is greater than the risk. If you have a blood-clotting disorder, have abnormal vaginal bleeding, or think you might be pregnant, tell your doctor. In addition, the decision is a very personal one to make and should be discussed with your physician. Ask about other ways to treat the symptoms of menopause.

Estrogen
The human body produces hormones to control the functions of certain organs. Estrogen is a hormone that plays a key role in a woman's reproductive function. It affects fertility, the menstrual cycle, and changes that take place during puberty. The lack of estrogen also causes some of the symptoms of menopause, when menstrual periods end.

In addition to being produced by a woman's body, estrogen is also available in both natural and synthetic forms. This type of estrogen is used to ease some of the changes that take place during menopause. Knowing the role that estrogen plays in the female reproductive process helps to explain the way in which it can affect your body.

Why Use Replacement Estrogen?
The decision to begin estrogen replacement therapy depends on a woman's medical history, symptoms, and risk of bone loss. Osteoporosis, or bone loss, is another effect of reduced estrogen levels after menopause. At this time, bone slowly loses calcium and becomes more brittle. As a result, a woman in her older years is more likely to have bone fractures.

She is also more likely to have spinal curvature, which causes a "stooped" or hunched-over posture as the weakened bones in the spine become less able to support the weight of the upper body. Women with an increased risk of getting osteoporosis include fair-skinned women with slender build. Early menopause, low intake of calcium, not enough exercise, drinking alcohol, and smoking cigarettes also add to a woman's risk of osteoporosis.

Emotional changes also can occur during menopause. In some cases, a woman may often feel nervous, short-tempered, tired, or depressed. Such feelings may be linked to changes in her hormone levels or to the physical symptoms these changes produce. Emotional symptoms also may be related to changes in her life style at this time, or sometimes to the loss of sleep due to nighttime hot flushes. Not all women going through menopause need additional estrogen. With estrogen replacement therapy, hot flushes occur less often and are less severe. They may stop altogether. Estrogen can also relieve vaginal dryness and discomfort. Estrogen given at any time after menopause can help reduce bone loss.

How Is Estrogen Used?
The amount of estrogen needed to reduce or prevent the symptoms of menopause varies from person to person. Treatment may last a number of years or longer. If you need to take estrogen to guard against osteoporosis, long-term therapy is needed. When therapy ends, bone loss begins again.

Estrogen can be prescribed in pill form or as cream or ointment for use in the vagina. It can also be applied as a skin patch. If you need to take estrogen, your doctor will explain how you should take it. Progesterone is usually given along with estrogen to offset some of the risks linked to estrogen use.

Risks and Side Effects
Like many medications, estrogen carries with it some degree of risk. Estrogen, when taken alone, may be linked to cancer of the endometrium, and this risk may increase when large doses of estrogen are used for many years. For this reason, the lowest possible doses of estrogen that are still effective are used, and progestin, a form of the hormone progesterone, is added. When given along with estrogen, progestins can protect against endometrial cancer. In fact, women taking both estrogen and a progestin may have a lower risk of endometrial cancer than women not taking any hormones.

About 10% of women receiving estrogen replacement therapy have minor side effects. These can include swollen breasts, nausea, vaginal discharge, headaches, high blood pressure, fluid retention, and weight gain. If you take estrogen and progestin, you may have some vaginal bleeding.

Weighing Benefits Against Risks
The benefits and risks of long term estrogen use should be weighed and discussed by each patient and her doctor. For instance, long term estrogen replacement therapy has some minor risks, but it also has the major benefit of preventing osteoporosis.

Women taking estrogen should follow instructions carefully and must be checked regularly by a doctor. You should tell your doctor about any unexpected vaginal bleeding. Follow-up visits to the doctor for estrogen users will include a blood pressure check and breast and pelvic exams. Your doctor may also decide to take a small sample of the lining of your uterus and examine it under a microscope for any changes.

Not for Everyone
Estrogen replacement therapy is not for everyone. Women who have had cancer of the breast or endometrium should consider other methods of relieving the symptoms of menopause. Women with blood clots or active liver disease also should not use estrogen.

Not all women consider the benefits of estrogen replacement therapy to be worth the risks. Eating a balanced diet with enough calcium, getting enough exercise, and not smoking cigarettes can reduce the rate of bone loss. Most women will need to take a calcium supplement (1000mg to 1800mg per day) to guard against osteoporosis. A vaginal lubricant can be used for vaginal dryness related to menopause. Other medications can be prescribed to relieve the estrogen-related symptoms of menopause. These alternatives can be discussed with your doctor.

If you need to use estrogen or are now using estrogen, you and your doctor should discuss dose levels and hormone combinations. As with all medications, estrogen replacement therapy works better for some people than for others, and it may work better for you during a certain phase of your life than during another phase. By weighing the benefits and risks of estrogen use, you and your doctor together can determine the best treatment for you.

Source: Patient education material from the American College of Obstetrics and Gynecology was used as a source of information to develop the content for this topic.