Many women I speak to are terrified of hormone replacement therapy (or HRT) as a treatment option for menopausal symptoms. This is reasonable—there are risks associated with HRT, just like any medication. But it is an indisputable fact – HRT is the most effective treatment to alleviate bothersome menopausal symptoms. Although I have lots of opinions about HRT, the above statement is not based on my opinion, but on an extensive review of the literature including long-term randomized clinical trials and observational studies.
Despite these facts, when discussing HRT with patients, I find it as controversial as discussing our current president. In the case of the latter, I avoid all discussions in order to maintain my sunny disposition (but seriously people, please vote!). With HRT, I don’t take that approach. Understanding the basic facts of hormone therapy use and how it might improve menopausal symptoms often can improve quality of life. So, let’s demystify hormone therapy and why it might be a treatment option for you to consider.
What is hormone replacement therapy (HRT)?
Hormone replacement therapy is treatment with estrogen, progesterone—a “SERM” (selective estrogen receptor modulator)—or a combination of these medicines to relieve symptoms of menopause. The medicines work together to supply the body with hormones the ovaries no longer make due to age or surgical removal. There are numerous ways to replace these hormones, including traditional FDA-approved drugs for hormone replacement and compounded bioidentical therapies. I will focus on the FDA approved options in this blog and save the bioidentical discussion for later.
FDA-approved hormone treatment can be broken down into two groups:
- Local Vaginal Therapy: These treatment options contain a lower dose of estrogen that specifically targets the vaginal tissue to treat the vaginal symptoms we associate with menopause (dryness, itching, burning). Using low dose treatment increases moisture, blood flow and sensation in the vagina, which are critical components of sexual function and overall well-being. It does not however seem to directly affect libido or orgasm response (I know…downer). Low dose estrogen will also not improve hot flashes or night sweats because there is very little absorption of the estrogen into the body’s blood stream—its effect is localized to the vaginal tissues.
- Systemic Therapy: In contrast to local vaginal treatments, systemic medications are absorbed throughout the body and are used to treat hot flashes and night sweats (often referred to as “vasomotor symptoms”). Because estrogen circulates throughout the body, higher dose medications will also help improve the vaginal symptoms described above. In addition, systemic hormone replacement therapy helps prevent bone loss and osteoporosis. However, HRT shouldn’t be used as the first line of therapy if a women isn’t experiencing any other symptoms of menopause.
Now you may be asking, “What about my hair, skin and weight!?!” Although, many women swear that systemic hormone therapy keeps them looking and feeling younger, it is not recommended to start hormone replacement solely for the management of those symptoms (not my rule, don’t blame me).
How do you take it?
Low dose vaginal estrogen can be taken using a cream, suppository, tablet or ring. Higher dose methods also come in a variety of forms: a vaginal ring, a patch applied to the skin, sprays, creams, oral pills and injections. Each of these medications should be used exactly as described in their packaging—for example, you should never put an oral estrogen pill inside of your vagina. If you do, you will get a systemic dose of estrogen.
When it comes to sex, there is no reason your hormone therapy should get in the way. Some women worry that they or their partner will feel the vaginal ring because it sits in the vaginal canal. If inserted properly, this should not be the case. If you are applying an estrogen cream to the vagina, you should avoid applying the cream directly before having vaginal sex. Doing so can expose a partner to your medication. While there is not perfect science on this, experts suggest waiting 12 hours between applying the cream and having intercourse.
What are the risks?
At this point, you might be thinking, “Is Dr. Christmas trying to pull a fast one or does she have stock in HRT because I know there are some risks.” The answer would be a resounding “no” on both accounts. For most women, hormone replacement is a safe and effective option; however hormone therapy should be avoided in women with risk factors. The risks vary depending on the dose of hormone therapy and route administered. Research suggests that the patch and lower dose forms of HRT carry the lowest risk. Oral doses that circulate estrogen throughout the body are associated with a number of risks, especially when used in women over the age of 65. The North American Menopause Society (NAMS) has created a free app, MenoPro, to help women navigate their options based on risks.
Does HRT cause cancer?
Women who still have a uterus, and are taking one of the systemic dose estrogen options, will also need to take other hormones to protect the uterine lining (this can be done with progestogen therapy or a SERM). Why? Estrogen causes the lining of the uterus to thicken, which can, over time, increase the risk of developing uterine cancer. Women who have had their uterus removed do not need to do this. This is true even for women who have had their uterus removed and still have a cervix. Women who are using low dose vaginal estrogen also do not have to worry about protecting the uterine lining.
Many people think breast cancer when they hear HRT. Systemic hormone replacement therapy has been associated with an increased risk of breast cancer, but experts agree that the risk of HRT causing breast cancer is small. How small? Similar to drinking 1 glass of wine daily or to the risk attributed to obesity and limited physical exercise. To me that is pretty small, especially since I enjoy a glass of wine with dinner, but this is an important consideration for every woman to weigh for herself and with her physician.
How long can I be on hormone therapy?
There is no hard, fast rule for when to stop systemic hormone replacement, but the best available evidence suggests that use in women over the age of 65 may increase the risks mentioned above. Low dose vaginal treatments, on the other hand, can be used indefinitely. In other words, you may take them until the good Lord calls you home or you get to a point where an itchy vagina doesn’t bother you.
My take-home points: hormone replacement use in most women is not only safe, but it is also effective. To start or not to start or even what to start can be confusing. I purposely did not get into specific formulations or dosages because there are far too many options to address here. Options are good, but you need to bring the discussion to your doctor or other healthcare professional. A physician who specializes in menopause management would be especially enthusiastic and informed to go through the options with you. If you are having difficulty finding a physician in your area, the North American Menopause Society lists certified menopause practitioners on their website.
To my knowledge, all of the information above aligns with today’s best available evidence. To understand even more about hormone therapy and the evidence base supporting this information, check out the sources listed below.
- American College of Obstetrics and Gynecology (ACOG) Practice Bulletin No. 141: management of menopausal symptoms. Obstetrics & Gynecology. 2014.
- Lobo RA. Hormone-replacement therapy: current thinking. National Review of Endocrinology. 2017.
- Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013.
- Manson JE, Aragaki AK, Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. Journal of the American Medical Association. 2017.
- The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017.
Edited by Leilani Douglas
Photo by Miguel Bruna on Unsplash