Hormone Replacement Therapy for Menopause

If you’re looking for relief from menopause symptoms, knowing the pros and cons of hormone replacement therapy (HRT) can help you decide whether it’s right for you.

What Is Hormone Replacement Therapy?

During menopause, your estrogen levels fall. Some women get uncomfortable symptoms like hot flashes and vaginal dryness. HRT (also known as hormone therapy, menopausal hormone therapy, and estrogen replacement therapy) is the most effective treatment for menopause symptoms. .

Estrogen Therapy

Estrogen Therapy: If a woman is having symptoms of menopause after a hysterectomy (surgery to remove the uterus) or a hysterectomy with bilateral salpingoophorectomy (surgery to remove the uterus, fallopian tubes, and ovaries), doctors may suggest a low dose of estrogen. Estrogen comes in different forms. The daily pill and patch are the most popular, but the hormone also is available in a vaginal ring, gel, or spray.

• Estrogen pill. Pills are the most common treatment for menopausal symptoms. Among the many forms of pills available are conjugated estrogens (Cenestin, Estrace, Estratab, Femtrace, Ogen, and Premarin) or estrogens-bazedoxifene (Duavee). Follow your doctor's instructions for dosing. Most estrogen pills are taken once a day without food. Some have more complicated dosing schedules.
• Estrogen patch. The patch is worn on the skin of your abdomen. Depending on the dose, some patches are replaced every few days, while others can be worn for a week. Examples are Alora, Climara, Estraderm, and Vivelle-Dot. Combination estrogen and progestin patches -- like Climara Pro and Combipatch -- are also available. Menostar has a lower dose of estrogen than other patches, and it's only used for reducing the risk of osteoporosis. It doesn't help with other menopause symptoms.
• Topical Estrogen. Creams, gels and sprays offer other ways of getting estrogen into your system. Examples include gels (like EstroGel and Divigel), creams (like Estrasorb), and sprays (like Evamist). As with patches, this type of estrogen treatment is absorbed through the skin directly into the bloodstream. The specifics on how to apply these creams vary, although they're usually used once a day. EstroGel is applied on one arm, from the wrist to the shoulder. Estrasorb is applied to the legs. Evamist is applied to the arm.
• Vaginal estrogen. Vaginal estrogen comes in a cream, vaginal ring, or vaginal estrogen tablets. In general, these treatments are for women who are troubled specifically by vaginal dryness, itchiness, and burning or pain during intercourse. Examples are vaginal tablets (Vagifem), creams (Estrace or Premarin), and insertable rings (Estring or Femring). Dosing schedules vary, depending on the product. Most vaginal rings need to be replaced every three months. Vaginal tablets are often used daily for a couple of weeks; after that, you only need to use them twice a week. Creams might be used daily, several times a week, or according to a different schedule.

Estrogen/Progesterone/Progestin Hormone Therapy

This is often called combination therapy, since it combines doses of estrogen and progestin, the synthetic form of progesterone. It’s meant for women who still have their uterus. Taking estrogen with progesterone lowers your risk for cancer of the endometrium, the lining of the uterus, compared with taking estrogen alone.

While generally used as a form of birth control, progesterone can help treat many menopausal symptoms such as hot flashes.

• Oral progestins. Taken in pill form, progestin medications include medroxyprogesterone acetate (Provera) and the synthetic progestin pills (norethindrone, norgestrel). Many experts now treat the majority of their menopausal patients with natural progesterone rather than synthetic progestins. Research suggests that natural progesterone may not have a negative effect on lipids and is a good choice for women with high cholesterol levels. In addition, natural progesterone might have other advantages when compared with medroxyprogesterone acetate.
• Intrauterine progestin. Low-dose intrauterine devices (IUD) with levonorgestrel are sold under the brand names Liletta, Kyleena, Mirena, and Skyla. These are approved for pregnancy prevention and bleeding control in the United States, and they’re sometimes used “off-label” along with estrogen. If you have one of these IUDs when you enter perimenopause, your doctor may suggest that you keep it in until perimenopause is complete to help with uneven periods.

What Are the Benefits of Hormone Replacement Therapy?

HRT may:

• Relieve hot flashes and night sweats
• Help you sleep better
• Ease vaginal dryness and itching
• Make sex less painful

• Help prevent fractures caused by osteoporosis (thinning bones)
• Make some women less likely to have heart disease
• Lower your chances of dementia

What Are the Risks of Hormone Replacement Therapy?

Research has shown that the benefits can be greater than the risks for many women. But HRT may still raise your chances of:

• Endometrial cancer, if you take estrogen without progestin and you still have your uterus
• Blood clots
• Stroke
• Breast cancer

You may be less likely to have problems if you:

• Start HRT within 10 years of menopause or before age 60
• Take the lowest dose that works for you for the shortest possible time
• Take progesterone or progestin if you still have your uterus
• Ask about other forms of HRT besides pills, like patches, gels, mists, vaginal creams, vaginal suppositories, or vaginal rings
• Get regular mammograms and pelvic exams

Who Shouldn’t Take Hormone Replacement Therapy?

If you have these conditions, you may want to avoid HRT:

• Blood clots
• Cancer (such as breast, uterine, or ovarian)
• Heart, liver, or gallbladder disease
• Heart attack
• Known or suspected pregnancy
• Stroke
• Unexplained vaginal bleeding

Do you smoke? Your doctor may encourage you to stop before prescribing HRT.

What Are the Side Effects of Hormone Replacement Therapy?

HRT comes with side effects. Call your doctor if you have any of these:

• Bloating
• Breast swelling or tenderness
• Headaches
• Mood changes
• Nausea
• Vaginal bleeding

How Do I Know If Hormone Replacement Therapy Is Right for Me?

Your doctor can help you weigh the pros and cons and suggest choices based on the severity of your symptoms and your medical history.

Here are some questions to ask:

• Based on my medical history, is there any reason I shouldn’t use HRT?
• Do you think it could help my symptoms, especially hot flashes, sleep issues, and vaginal dryness?
• Are there other treatments I should consider? (Vaginal moisturizers may help vaginal dryness, for example.)
• Do you think I’ll have side effects from HRT? (Be sure to tell your doctor if you had any issues with taking birth control pills.)
• Does my family medical history make me a good or bad candidate for HRT? (If your mom had osteoporosis, HRT will help lower your chances of it. But if your mom had breast cancer, you’ll want to talk about that with your doctor.)
• What type of HRT might be best for me?

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