Estrogen Replacement Therapy

Introduction
Hormone Replacement Therapy
Age is an Iimportant Factor
Who can benefit from hormone replacement therapy?
If you're already taking hormone replacement therapy, should you keep taking it?
Who should avoid hormone replacement therapy?
Alternatives to hormone replacement therapy

Estrogen Replacement Therapy is also called hormone replacement therapy. Hormone therapy (HT) is treatment with prescription hormonal medications to restore a woman's declining hormone levels. Doctors used to advise women who were taking HT to relieve symptoms of menopause such as hot flashes, to continue taking the hormones on a long-term basis to help reduce their chances of developing osteoporosis and heart disease. But with the results of recent studies that indicate a possible increased risk of heart attack, stroke and breast cancer from HT, doctors now recommend that women take HT primarily for the relief of menopausal symptoms and to take the lowest dose of the hormones for the shortest time possible.

However, HRT also has risks. It can increase your risk of breast cancer, heart disease and stroke. Certain types of HRT have a higher risk, and each woman's own risks can vary depending upon her health history and lifestyle. You and your health care provider need to discuss the risks and benefits for you. If you do decide to take HRT, it should be the lowest dose that helps and for the shortest time needed. Taking hormones should be re-evaluated every six months.

Concerns about hormone replacement therapy stem from the results of both the combined estrogen-progestin and the estrogen-alone arms of the Women's Health Initiative (WHI) clinical trial.

Combination estrogen-progestin therapy (Prempro)
For women taking the combination estrogen-progestin used in the study (Prempro), researchers found an increased risk of:

• Heart disease
• Breast cancer
• Stroke
• Blood clots
• Dementia

In addition, researchers found that women taking combination estrogen-progestin experienced an increase in mammography abnormalities. The increased number of false-positives - signs of possible breast cancer that ultimately prove inaccurate - was attributed to the increased breast tissue density that estrogen induces. Women on combination therapy should be aware that they may require more frequent mammograms and additional testing as a result of this therapy.

As for quality-of-life measures, such as sleep, emotional health, general health, physical functioning and sexual satisfaction, the WHI found that for women taking combination hormone replacement therapy - most of whom didn't have troublesome menopausal symptoms - combination HRT didn't provide meaningful improvement in symptoms.

Estrogen-alone therapy (Premarin)
For women taking estrogen alone (Premarin), the WHI found no increased risk of breast cancer or heart disease, as was found with women on combination therapy, but researchers did find a slightly increased risk of stroke.

In addition, researchers found that, as with women on combination therapy, women taking estrogen alone were more likely to have abnormal mammograms than were women not on HRT. The increased number of false-positives - signs of possible breast cancer that ultimately prove inaccurate - was attributed to the increased breast tissue density that estrogen induces. Women on estrogen-alone therapy should be aware that they may require more frequent mammograms and additional testing as a result of this therapy.

Some HRT benefits still valid
Researchers did note important benefits of hormone replacement therapy in the WHI study - including a decreased risk of osteoporosis-related hip fractures and colorectal cancer. These benefits were valid for women whether they were taking combination therapy or estrogen alone.

The WHI's study population consisted of older postmenopausal women. Participants were an average age of 63 at the start of the trial. What's less certain is whether the study findings can be applied to younger women, such as women who typically start estrogen early in menopause.

A more complete analysis of data from the estrogen-alone arm of the WHI suggests there's less of a risk of heart disease if you take estrogen early in your postmenopausal years. The data analysis revealed participants age 50 to 59 who took estrogen experienced fewer heart attacks and deaths from coronary artery disease than study participants who took a placebo.

Many questions regarding younger postmenopausal women and hormone replacement therapy exist. To address some of these issues, a randomized, controlled clinical trial - the Kronos Early Estrogen Prevention Study (KEEPS) - exploring estrogen use and heart disease in younger postmenopausal women is under way, but it won't be completed for several years.

Despite the inherent health risks, hormone replacement therapy still has a role in treating menopausal symptoms. For some women - such as those who experience moderate to severe hot flashes or other menopausal symptoms - the benefits of short-term therapy outweigh the potential risks.

"The absolute risk to an individual woman taking hormone therapy is quite low and may be acceptable to you depending on your symptoms," says Sharonne Hayes, M.D., cardiologist and director of the Women's Heart Clinic at Mayo Clinic, Rochester, Minn. "Talk with your doctor about your personal risks."

Hormone replacement therapy might still be your treatment of choice if you have:

• Hot flashes. Hormone replacement therapy is still the most effective treatment for troublesome menopausal hot flashes and night sweats.
• Vaginal discomfort. Hormone replacement therapy can ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse.
• Osteoporosis. Hormone replacement therapy continues to be an option for osteoporosis prevention, but it's recommended only when other medications for osteoporosis prevention have been considered and determined not to be best for you.

If you're already taking hormone replacement therapy to relieve menopausal symptoms, review its benefits and risks with your doctor.

"Consider the reason you started hormone replacement therapy and whether the reason remains relevant," Dr. Hayes advises. "If you started hormone therapy for hot flashes several years ago, you may no longer have hot flashes and could stop taking the drug."

Your doctor may periodically advise modifications to your regimen. For example, if you're taking a particular dose of estrogen, you may be able to lower the dose. Switching from an estrogen pill to a patch may offer certain benefits. In treating isolated vaginal symptoms, estrogen in a vaginal cream, tablet or ring is usually a better choice than a pill or a skin patch. That's because estrogen applied directly to your vagina remains localized to that area to treat your symptoms and doesn't circulate throughout your body as does estrogen ingested through a pill or absorbed through a patch.

Women on hormone replacement therapy should take the lowest effective dose for the shortest amount of time needed to treat symptoms.

Women with breast cancer or a history of blood clots should not take hormone replacement therapy. Also avoid hormone replacement therapy for preventing memory loss, heart disease, heart attacks or strokes.

Instead, talk to your doctor about other medications you can take or lifestyle changes you can make for long-term protection from these conditions.

You may be able to manage your menopausal symptoms by making healthy lifestyle choices. In fact, your doctor may recommend that you try making changes to your exercise or eating habits before you try medication. After adjustments to your lifestyle, if you're still dealing with bothersome symptoms, you have several options besides hormone replacement therapy to help relieve discomfort.