Postmenopausal Hormone Therapy
What is Hormone Therapy?
Postmenopausal hormone therapy is the term used to describe the two hormones, estrogen and progesterone, that are given to relieve bothersome symptoms of menopause. Estrogen is the hormone that relieves the symptoms. Women with a uterus must also take progesterone to prevent uterine cancer. This is because estrogen alone can cause the lining of the uterus to overgrow (potentially leading to uterine cancer).
Women who have had a hysterectomy do not have a uterus and cannot develop uterine cancer. These women are treated with estrogen alone.
What are the types of estrogen?
Estrogen is available in many different forms. For hot flashes, it can be taken as an oral pill, a transdermal gel, a transdermal patch (worn on the skin), or a "ring" or tablet or cream that is inserted into the vagina. There are three human estrogens. Estriol is present only during pregnancy. Estrone is not recommended for hormone replacement. Estradiol is the typical ‘bioidentical’ hormone.
A common form of estrogen prescribed in the U.S. is Premarin, which is comprised of 11 equiline estrogens – this drug is manufactured from horses.
What are the types of progesterone?
The best option is likely to be intrauterine progestogen: an intrauterine system called Mirena that releases levonorgestrel into the uterus throughout the day for 5 years.
Natural progesterone (Prometrium) is the best oral option. A common oral progestogen prescribed in the U.S. is medroxyprogesterone acetate (Provera); this is a synthetic drug.
Risks and Benefits of Hormone Therapy
The Women's Health Initiative (WHI) was a large study designed to find out if hormone therapy would reduce the risk of heart attacks (coronary heart disease [CHD]) after menopause. The study found that taking combined oral estrogen-progestin (in the form of Premarin-Provera) over a period of years actually increases the risk of heart attacks, breast cancer, blood clots, and strokes in older postmenopausal women.
The results of the WHI estrogen-only study were different. Women who took estrogen alone had a small increase in the risk of stroke and blood clots, but there was no increased risk of heart attacks or breast cancer.
Heart attacks and combined E+P HRT
The risk of having a heart attack related to use of estrogen and progestogen hormone therapy appears to depend on your age. There is no increased risk of heart attacks related to hormone therapy in women who: 1) became menopausal less than 10 years before starting hormones or 2) were 50 to 59 years when they took hormone therapy . Women who become menopausal more than 10 years ago or over age 60 years were at increased risk of having a heart attack related to hormone therapy.
Breast cancer and combined E+P HRT
There is a small increased risk of breast cancer in women who took combined estrogen-progestin therapy, but not in women who took estrogen alone.
Osteoporotic fracture and combined E+P HRT
The risk of breaking a bone at the hip or spine because of osteoporosis is lower in women who take estrogen-progestogen or estrogen alone. However, hormone therapy is not recommended to prevent or treat osteoporosis because there are bone medicines (such as bisphosphonates) that have fewer serious risks.
Dementia and combined E+P HRT
In women who took combined estrogen-progestin or estrogen alone, there was no significant improvement in memory or thinking, but there was an increase in the risk of developing dementia. But some experts think that estrogen treatment might be helpful for preventing dementia if you take it in the early years after menopause (although this is not proven); paradoxically, taking it many years after menopause seems to be harmful.
Many perimenopausal and postmenopausal women have sleep problems. Sometimes this is because they have hot flashes at night that interfere with sleep (night sweats). But women can have trouble sleeping even if they don’t have hot flashes. This can be due to disorders like restless leg syndrome and sleep apnea. Estrogen treatment is very effective for improving sleep in women with night sweats.
Who should consider taking hormone therapy?
The most common reason for taking hormone therapy is to treat bothersome menopausal symptoms, such as hot flashes. Most experts agree that hormone therapy is safe for healthy women who have menopausal symptoms. If you decide to take hormones, you should take them for the shortest period of time possible. Short-term use of hormones (less than five years) does not seem to increase the risk of breast cancer.
Most experts recommend that you eventually decrease and stop taking hormone therapy. If you are taking pills, one way to do this is to skip one pill per week. If you are using a patch, your doctor or nurse can give you a lower-dose patch.
If menopausal symptoms return as you lower your dose of hormones, you can try hormone therapy alternatives.
Who should avoid hormones?
Hormone therapy is not recommended for women with the following concerns: