What is HRT?

HRT refers to the use of prescription drugs to "replace" the hormones that the ovaries quit making at the time of menopause. These hormones are estrogen and progesterone. Estrogen is made synthetically from plants and other sources or obtained from the urine of pregnant horses.
 

Two main types of progesterone are available. The most commonly used forms are made synthetically and called "progestins."   A form of progesterone that is nearly identical to the hormone made by the ovaries is also available and called "natural progesterone" or "micronized progesterone."
 

Women who still have a uterus usually take both estrogen and progestin. If taken without progestin, estrogen makes the lining of the uterus (the endometrium) grow and can cause endometrial, or uterine, cancer. Women who take estrogen without progestin must have a yearly endometrial biopsy, in which tissue from the lining of the uterus is evaluated for cancer.
 

Women who do not have a uterus can take estrogen alone. This is often referred to simply as estrogen replacement therapy, or ERT. Estrogen is most often taken orally, as pills, or absorbed from skin patches placed on the abdomen.

Why take HRT?
 

HRT (or ERT) is commonly prescribed to relieve menopausal symptoms. HRT may also be used to treat osteoporosis or to reduce a woman's chances of getting osteoporosis, and there is a possibility that HRT may reduce the risk of coronary heart disease. 

On the other hand, HRT may increase a woman's chance of getting breast cancer.

What are the effects of HRT on menopausal symptoms?
 

HRT is extremely successful at relieving menopausal symptoms, such as hot flashes,

night sweats, and sleep disturbances. When taken only to relieve menopausal symptoms, HRT is used for a relatively short period of time typically from several months to several years.

What are the long-term health effects of HRT? 
 

In addition to relievingthe symptoms of menopause, HRT reduces bone loss and helps prevent thinning of the walls of the vagina. Remember, though, if you are taking HRT for prevention of osteoporosis, it helps the most if you take it for many years. Once you stop taking HRT, you start losing bone again. However, if you begin (or resume) using HRT later in life, it protects against further bone loss. The effect of HRT on heart disease is uncertain, and HRT may also increase your risk of breast cancer.

What are the side effects of HRT? 
 

The most common side effects of HRT, and the percentage of women in the United States who experience them, are listed below. If you experience any of these, discuss them with your healthcare provider.

In addition to relieving the symptoms of menopause, HRT reduces  bone loss and helps prevent thinning of the walls of the vagina.

Common Side Effects of HRT
 

Percentage of Women Who Develop This Side Effect:

Monthly bleeding (from cyclical estrogen and progestin)
 

Most women
 

Irregular spotting (from daily estrogen and progestin) (Women who are having heavy periods and irregular bleeding or bleeding between periods should see a healthcare provider.)
 

30%-50% (stops permanently for most women within a year)
 

Breast tenderness or enlargement
 

12% on unopposed estrogen
 

33% on estrogen & progestin
 

Fluid retention
 

1%-10%
 

Headaches, including migraine
 

1%-10%
 

Dizziness
 

Less than 1%
 

Skin discoloration
 

Less than 1%
 

Nausea
 

Unknown
 

Changing either the type of HRT you are taking or the dose may reduce side effects and improve HRT's acceptability to you.
 

Women sometimes worry that HRT will make them gain weight. We now know that this is not true. Some women gain weight after menopause. This is most likely because the metabolism gradually slows down with increasing age. Some women find that they retain water or feel bloated while taking HRT. This is different from true weight gain.
 

Is HRT safe? In general, HRT is a safe and effective way of managing menopausal symptoms and preventing osteoporosis. However, some women should not take HRT, or if they decide to take it, they should be monitored closely by their healthcare providers. 
 

HRT is generally not recommended for women who have any of the following conditions:
 

Vaginal bleeding of unknown cause ( this should be evaluated before HRT is initiated) .
 

Suspected breast cancer or a history of breast cancer.
 

History of endometrial cancer or cancer of the uterus.
 

History of-or active-venous thrombosis (blood clots in the veins of the legs or in the lung) . This includes women who have had thrombosis or blood clots during pregnancy or when taking birth control pills.  Although the risk of blood clots in women is very low, HRT increases the risk of blood clots in the legs and lungs.

Chronic disease of the liver.
 

In some women, HRT can cause gall bladder disease or gallstones that may require surgery. Women with uterine fibroids ( benign or noncancerous tumors of the uterus) should know that HRT may make fibroids grow larger (ordinarily the withdrawal of estrogen after menopause causes them to shrink) . However, most women with fibroids can take HRT safely.

Are there different ways to take HRT? 
 

There are many different ways to take HRT. Estrogen is typically taken by pill or skin patch, and progestin is almost always taken by pill. The estrogen from either pills or patches is absorbed into the blood stream, and in general the effects are similar. However, most studies have been done on women taking estrogen pills, so scientists are not certain that estrogen from the patch affects disease risks in the same ways as estrogen taken by pill. While the pill is taken just once a day, the patch releases estrogen at a steady rate throughout the day and night.
 

     I started doing research a year or two ago, reading every book I
 

     could get my hands on, magazine articles, talking to other women 
 

     because I knew I was going to have to make this decision at some
 

     point. And I've learned a lot, and you know, it's still not an
 

     easy subject. I am concerned about taking drugs for the rest of my
 

     life. After all the research, I think the conclusion I've come to
 

     is that I want to try natural methods first.
 

There are also differences in the mix of hormones and in the scheduling of the medication. When discussing HRT with your healthcare provider if you decide to take HRT you can talk about which of these schedules is best for you. These differences are described briefly here.
 

Unopposed estrogen: Women who have had a hysterectomy typically will take estrogen alone with no progestin.
 

Cyclical estrogen and progestin: With cyclic HRT a woman usually takes estrogen every day, adding progestin for 12 to 14 days a month, and then takes no hormone for 5 to 6 days per month. This regimen is often selected for women who are still having periods when they begin HRT. Most women have a light period or "withdrawal bleeding" during the time when they take no hormones each month.
 

Daily estrogen and progestin: With this regimen, often called continuous combined HRT,   a woman takes both estrogen and progestin every day. This regimen is usually selected by women who have had no period for at least 6 to 12 months. The major disadvantage is that 30% to 50% of women will have episodes of irregular bleeding or spotting.  After 6 to 8 months, however, bleeding stops permanently for 75% to 80% of women.
 

Your dose and schedule may need to be adjusted. Let your healthcare provider know if you decide to take HRT and are uncomfortable with the regimen or are having unacceptable side effects. You may be able to try different combinations of drugs and/or schedules in order to minimize side effects.
 

HRT is not a one-time decision. Women may want to consider the pros and cons of HRT in several stages: first, at the time of menopause, as a short-term therapy for relief of menopausal symptoms; later, as the symptoms fade, as a longer-term regimen for prevention of osteoporosis.
 

As new information about HRT becomes available, we are learning more about the effects of starting HRT some years after menopause. At the same time, new alternatives for preventing osteoporosis are being developed, so it's important to stay informed. Changes in your
 

personal health may also lead you to re-evaluate your decision. For prevention of osteoporosis, women reap the greatest benefits if they
 

start HRT around the time of menopause and take it indefinitely. But whenever a woman starts taking HRT, she will reduce her risk for further
 

bone loss.

Are there other ways - besides taking HRT - to relieve menopausal symptoms?
 

Hot flashes:
 

Hot flashes are sometimes brought on by specific things, such as a hot environment; eating or drinking hot or spicy foods, alcohol, and caffeine; and stress. Some women find they can decrease hot flashes by avoiding these "triggers."  You may want to dress in layers. If you are having hot flashes at work, you may want to bring a small fan to your workplace and keep ice water at your desk. Some women
 

find that a program of regular exercise brings relief of hot flashes and other menopausal symptoms.
 

Vaginal dryness:
 

Some women find that vaginal lubricants relieve vaginal dryness. Estrogen cream may also help relieve vaginal dryness and
 

painful intercourse. Although estrogen creams are absorbed into the blood in smaller amounts than similar doses of estrogen pills, remember
 

that you are still taking estrogen. If you use estrogen creams regularly and you still have a uterus, the creams could affect the uterine lining
 

in the same way that estrogen pills do. Your doctor may recommend that if you use vaginal estrogen, you take progestin pills for at least 10
 

days per month. If you have spotting or bleeding while using estrogen creams, you should have this evaluated by your healthcare provider.
 

     I look forward to a long life. I want to be useful in my sixties
 

     and my seventies and my eighties and nineties. I think that is why
 

     I feel that being healthy is very very important now because I
 

     want to be useful in those ages.
 

Difficulty sleeping: 
 

There are many "home remedies" to promote a good night's sleep. Regular exercise - such as walking 30 minutes a day can help promote a good night's sleep. However, you should avoid vigorous exercise too close to the time you plan to go to bed. Some women sleep better after drinking something warm, such as herb tea or a glass of warm milk (milk has the added advantage of calcium) . Other tips: Keep your room a comfortable temperature; avoid caffeine, alcohol, or large meals close to bedtime; avoid working right before bedtime; define the amount of sleep you need and then go to bed and get up at the same time every day to get the right amount of sleep; don't nap in the daytime if you are having trouble sleeping at night.
 

An important message about uterine cancer and HRT: It has been proven that in women who still have a uterus, taking estrogen without progestin dramatically increases the risk of endometrial cancer (cancer of the uterus). Women with a uterus should take estrogen with progestin unless they are followed closely (at least once a year) by a healthcare provider and have a yearly endometrial biopsy.
 

Unresolved issues and misconceptions about HRT:
 

How early to start HRT: Some women believe they cannot begin taking HRT until their periods have completely stopped. This is not the case. Women may have menopausal symptoms for several years before they stop menstruating. In this case a healthcare provider may suggest some kind of hormonal regimen to help manage symptoms and regularize menstrualperiods.
 

HRT’s effects on Alzheimer's disease, memory, and colon cancer: 
 

You may have heard that HRT prevents Alzheimers disease, improves memory, and decreases the risks of colon cancer. Although there have been encouraging results from some studies, very little is known, and at this
 

point we do not have scientific evidence that HRT is beneficial for these conditions.
 

Herbal remedies and plant estrogens for menopause:
 

You may wonder if herbal remedies for menopause are safer than HRT. You may also want to know if certain estrogen - like chemicals in plants ( called phytoestrogens) can help with menopausal symptoms. Many over-the-counter herbal remedies are available to help women through menopause (for example, black cohosh or Remifemin(r)*) . Unfortunately, at this time there is little more than anecdotal evidence that these remedies are effective. The observation that women in Japan and China, where traditional diets are higher in soy, are less likely to suffer from menopausal symptoms suggests that phytoestrogens found in soy products might be beneficial. So far, some studies show that soy estrogens decrease hot flashes, but many studies have found no difference with soy. Some over-the-counter herbal remedies contain progestins or estrogens. We know very little about their effects on the body. If you choose to use alternative botanical remedies, we recommend that you see a health professional who is familiar with them and can monitor their effects.
 

Natural versus artificial hormones: 
 

The estrogens and progestins in currently used pills come from a variety of sources. Some, for example the estrogens in Premarin(r)*, come from the urine of pregnant horses (mares). Others are mostly synthetic. Still others, "natural" estrogens and progestins, are made from plant sources. For example, the estrogen in Cenestin(r) is synthesized from Mexican yam and soybeans. Some women believe that "natural" estrogen and progestin may be safer than artificial (synthetic) hormones. However, natural and synthetic sources of estrogen and progestin are believed to be equally safe and effective. Some women react differently to different sources of estrogens and progestins. If this is an issue for you, discuss it with your healthcare provider.
 

* Use of trade names is for identification only and does not imply
 

  endorsement by the U. S. Department of Health and Human Services.
 

     I've found doctors that I can work with. And they know that I'm        
 

     going to do what I think is best. You know, I'll listen to them  
 

     and what they have to say, and then I'll decide what I'm going to
 

     do.