Is Hormone Therapy Right For You?

If you have friends who are beyond menopause, there’s a chance you have friends who are taking hormone replacement therapy. You may have heard mixed messages about hormone therapy, and so have we.

It is a fairly controversial topic in the world of health and wellness. Let’s broach this difficult topic so that you can have the knowledge to make informed decisions about your health beyond menopause.

Menopause and hormones

What is hormone replacement therapy, anyway? Often shortened to HRT, hormone replacement therapy is a medication containing female sex hormones. There is also bioidentical hormone therapy for thyroid hormone replacement therapy available, but our discussion will focus on female sex hormones. During menopause, your body stops making estrogen. HRT replaces that.

Hormone replacement therapy is most often used in the treatment of menopause symptoms. These include hot flashes and vaginal discomfort. Menopausal hormone therapy can also prevent bone loss and thus reduce your risk factors for fracture. 

If all the above is true, then why not have all postmenopausal women on HRT? Well, there are also risks involved.

The risks aren’t the same for everyone, and your level of risk will depend upon the type of hormone replacement therapy, the dose, how long you take it for, and your health status. Your doctor will tailor your HRT to your specific case. They should also evaluate every now and then to make sure the benefits outweigh the risks.

What are the basic types of hormone therapy?

Hormone replacement therapy usually focuses on replacing lost estrogen. There are two main types of hormone replacement therapy: systemic hormone therapy and low-dose vaginal products.

Systemic hormone therapy

Systemic hormone therapy has a higher dose of estrogen. Various tissues throughout the body absorb the estrogen. This type of hormone therapy can treat various symptoms of menopause. 

Systemic estrogen therapy comes in the following forms:

  • Pill
  • Ring
  • Gel
  • Patch
  • Cream
  • Spray

hormone replacement therapy patch

Low dose vaginal products

Low-dose vaginal products minimize how much estrogen your body absorbs. This is why doctors use them to treat the urinary and vaginal symptoms of menopause. Low-dose vaginal products come in cream, ring, or tablet format.

If you have not had a hysterectomy, then your doctor will likely advise you to take progesterone or progestin along with estrogen therapy. This is because when you take estrogen alone, it can stimulate the growth of the uterine lining. This can increase your endometrial cancer risk. 

Progesterone helps balance estrogen hormone levels and reduces this risk of hormonal imbalance and cancer. If you have had your uterus removed, then progestin therapy may not be necessary.

What are the risks of hormone therapy?

Your risks will depend upon several factors. These include your age, health history, and the type of hormone therapy you are receiving (such as conjugated equine estrogen or synthetic hormones).

Age

You may be at greater risk if you begin hormone therapy at age 60 or older. This is also true if you start hormone therapy more than ten years from the onset of menopause.

If you begin hormone therapy before age 60 or within ten years of menopause, the benefits may outweigh your risk.

Health history

There are several factors in your health history that determine your risks of hormone therapy. These include your personal history and risks of the following:

  • Stroke
  • Blood clots (such as venous thromboembolism or VTE risk)
  • Coronary heart disease and cardiovascular disease
  • Cancer
  • Liver disease
  • Osteoporosis

Type of hormone therapy

Your risks with hormone therapy will depend upon whether you are taking estrogen alone or with progestin (a synthetic progestogen). For example, medroxyprogesterone is often used in combined hormone replacement therapy with estrogens. They will also depend on the dose, type, and duration of use of the estrogen.

Hormone therapy may increase the risk of the following conditions:

  • Heart disease
  • Stroke
  • Blood clots
  • Pulmonary embolism
  • Lung cancer
  • Breast cancer: Combined hormone replacement therapy is a cause. Estrogen-only hormone replacement therapy may also increase breast cancer risk.
  • Ovarian cancer: Both combined and estrogen-only hormone replacement therapy increase the risk of ovarian cancer, but the risk is low.
  • Uterine cancer: Estrogen-only hormone replacement therapy increases the risk of uterine cancer.

Who can benefit from hormone therapy?

The benefits of hormone therapy may outweigh the risks for you if you are healthy and fall into the following categories.

Experience hot flashes

Systemic estrogen therapy is the most effective treatment for hot flashes (vasomotor symptoms) and night sweats in menopausal women.

hot flashes

Have other menopausal symptoms

Estrogen can help with vaginal symptoms of menopause as well, including the following:

  • Dryness
  • Itching
  • Burning
  • Discomfort during intercourse
  • Vaginal atrophy

Want to prevent bone loss

Systemic estrogen therapy helps protect against osteoporosis (thinning of the bones). Doctors often recommend taking bisphosphonate medication for the treatment of osteoporosis. However, estrogen therapy may be useful if you are not tolerating these medications well or they aren’t effective enough.

Have early menopause

If you experienced menopause early, then your body has been exposed to relatively less estrogen. Early menopause can occur in the following situations:

  • Surgical removal of the ovaries before age 45
  • Premature or early menopause where you stop having periods before age 45
  • Primary ovarian insufficiency (loss of normal ovarian function before age 40)

Estrogen therapy can decrease your risk of the following health conditions: 

  • Osteoporosis
  • Heart disease
  • Stroke
  • Dementia
  • Mood changes
  • Colorectal cancer

If you take hormone therapy, how can you reduce risk?

Your doctor can assist you in finding the method of hormone replacement therapy that has the most benefits and convenience for you, with low risks and cost. Keep in mind that if you have not had a hysterectomy, you will need progestin along with systemic estrogen therapy.

Find the right type of hormone therapy

Estrogen comes in the following forms:

  • Pill
  • Patch
  • Gel
  • Cream
  • Vaginal ring
  • Suppository

If you only have vaginal symptoms, then vaginal estrogen in a low-dose cream, tablet, or ring may be the best option for you.

Minimize how much medication you take

Take the lowest dose possible to treat your symptoms. Remember that if you are under the age of 45, you will require enough estrogen to protect the long-term health effects of estrogen deficiency.

You may need to take medication for longer if you have menopausal symptoms that significantly impair your quality of life.

Get checked regularly

You’ll want to make sure you are under the supervision of your doctor throughout your hormone replacement therapy. Check up with your doctor regularly. This way, they will ensure that the benefits continue to outweigh the risks. They will also provide important screening exams, such as mammograms and pelvic exams.

regular hormone replacement therapy checkups

Make healthy lifestyle choices

You can help to reduce your risks of hormone replacement therapy by doing the following:

  • Physical activity
  • Eat a healthy diet
  • Maintain a healthy weight
  • Don’t smoke
  • Manage your stress levels
  • Limit your alcohol intake
  • Manage your blood pressure levels
  • Manage your cholesterol levels

What can you do if you can’t take hormone therapy?

You may be able to manage menopausal hot flashes with healthy lifestyle approaches, including the following:

  • Keeping cool
  • Limiting alcohol intake
  • Limiting caffeine intake
  • Practicing paced, relaxed breathing
  • Using other relaxation techniques
  • Losing weight

Psychological interventions such as mindfulness and cognitive behavioral therapy can be helpful as well. They can help to reduce hot flashes in the short and medium-term. They can also reduce menopausal symptoms in the long term. Clinical hypnosis can significantly reduce hot flashes. There are also several non-hormonal prescription medications that can help to relieve hot flashes. 

For vaginal symptoms such as dryness or painful intercourse, a vaginal lubricant or moisturizer can be helpful. The medication ospemifene may also be helpful with painful intercourse. 

Physical therapy may be helpful for genitourinary syndrome of menopause, which involves changes to the following:

  • Labia
  • Introitus
  • Clitoris
  • Vagina
  • Urethra
  • Bladder

gut microbes

Did you know that one of the main regulators of circulating estrogens is the gut microbiome? The gut does this through the secretion of an enzyme called beta-glucuronidase. This process is impaired through dysbiosis of the gut. This means lower microbial diversity. The decrease in conjugation means fewer circulating estrogens. If you want to balance your hormones naturally, it’s important to ensure you have a diverse microbiome through the diet or supplementation with a probiotic

Please note that although you may be at high risk of breast cancer, you may still have hormone replacement therapy as an option. Even though women with a high risk of breast cancer are usually told not to take hormone replacement therapy, it might be possible. This is true if you have proper counseling and follow up with your doctor.

Conclusion

I don’t know about you, but I have certainly heard my fair share of menopausal horror stories. But it doesn’t have to be that way! With advancements in medicine, we now have estrogen therapy as a potential option. 

Our goal here is to inform you so you can confidently make decisions surrounding your hormonal health. If you believe you could benefit from balancing your hormones, speak to your health care provider about hormonal and non-hormonal therapy options.

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References

  1. American College of Obstetricians and Gynecologists. Practice Bulletin No, 141: Management of menopausal symptoms. Obstet Gynecol. 2014;123(1):202-216. 10.1097/01.AOG.0000441353.20693.78
  2. Baker, J, Al-Nakkash, L & Herbst-Kralovetz, M. Estrogen-gut microbiome axis: Physiological and clinical implications. Maturitas. 2017;103:45-53. 10.1016/j.maturitas.2017.06.025
  3. North American Menopause Society. Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of the North American Menopause Society. Menopause. 2015;22(11):1155-72. 10.1097/GME.0000000000000546
  4. North American Menopause Society. The 2017 hormone therapy position statement of the North American Menopause Society. Menopause. 2017;24(7):728-753. 10.1097/GME.0000000000000921
  5. Shifren, J. Genitourinary syndrome of menopause. Clin Obstet Gynecol. 2018;61(3):508-516. 10.1097/GRF.0000000000000380
  6. Van Driel, C, Stuursma, A, Schroevers, M, Mourits, M & de Bock, G. Mindfulness, cognitive behavioural and behaviour-based therapy for natural and treatment-induced menopausal symptoms: a systematic review and meta-analysis. BJOG. 2019;126(3):330-339. 10.1111/1471-0528.15153

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