What types of therapy are available?

There are many different types of therapy available, so each woman can have an individualized regimen.  

• Pills taken daily are available for ET and EPT.  There is also a pill that has testosterone and estrogen in one dose. 
• Transdermal options use medication absorbed through your skin directly into your bloodstream.  Regimens include:
• patches which are changed weekly or twice weekly
• cream applied daily
• gel applied daily
• vaginal ring changed every 3 months
• Vaginal therapy is also available in the form of cream, capsule, or ring.  Vaginal estrogen therapy helps with symptoms of dryness, burning, and easy bleeding; most therapies are not absorbed in large amounts systemically, so are not used to treat systemic symptoms such as hot flashes.
• Subcutaneous pellets can be inserted underneath the skin, and usually require a new pellet every 3 to 4 months.  These pellets are compounded, or made for each individual patient.

What are the risks?

The Women’s Health Initiative (WHI) was widely reported in the media.  Subsequent analysis of the WHI and other studies paint a much different picture than was first reported.  Of course, the media didn’t give as much attention to that!  There are still a multitude of studies ongoing. Some of the studies referenced here include:

• WHI – Women’s Health Initiative
• Nurses’ Health Study
• CSCH County Study
• MIRAGE – Multi-Institutional Research in Alzheimer’s Genetic Epidemiology
• WHIMS – Women’s Health Initiative Memory Study

1. Stroke - 8 per 10,000 women per year on EPT, and 12 on ET.  (percentage increase was 41% and 39% respectively)

2. Blood clots or VTE (venous thromboembolism) – the highest risk was noted in the first 2 years after starting therapy, and declined with continuing use. 11 per 10,000 women per year on EPT, and 2 on ET (47%)

3. Invasive Breast Cancer – an increased risk was seen after 5 years of use of EPT.  4 to 6 per 10,000 women per year (26%).  This translates to a 0% chance of breast cancer secondary to EPT the 1st 4 years, then a 0.06% risk per year thereafter.  The risk is additive, so after 10 years of increased risk (15 years after start of ET/EPT), the risk is 0.6%.  The WHI data surprisingly showed  that women on ET alone actually had a slightly lower risk of breast cancer compared to women who did not use hormones.

What are the benefits?

1. Relief of vasomotor and other symptoms such as night sweats, hot flashes, mood swings, decreased energy, depressed mood, joint aches, headaches, heart palpitations, and memory loss.

2. Prevention of vaginal atrophy which occurs after months to years of estrogen deficiency.  The lack of estrogen leads to thinning of the tissue and narrowing of the vagina.  Symptoms include vaginal dryness, irritation, burning, itching, easy bleeding, or pain with intercourse. 

3. Maintenance of cardiovascular health.  If starting hormones within 5 to 10 years of menopause, coronary artery disease (CAD) risk decreases by 50% for both EPT and ET.  Estrogen helps maintain the lining of the vessels by preventing build-up of plaques.

4. Reduced risk of Diabetes.  15 per 10,000 women per year for EPT, 14 for ET.

5. Reduced risk of Osteoporosis related fracture.  Estrogen helps maintain strong bones by maintaining levels of bone-building and repairing cells.  1 of 2 women will have an osteoporosis related fracture in her lifetime!

6. Reduced risk of dementia.  65% decrease in risk of Alzheimer’s disease in women over the age of 65, if ET or EPT is started at the onset of menopause. 

7. Reduced risk of colon cancer.  Studies show a 20% reduced incidence among women who had ever used hormone replacement therapy compared with nonusers and a 34% reduction among current users.

What are “Bio-identical Hormones?”

Typically, this phrasing refers to hormones which are mixed or made at compounding pharmacies for an individual.  Some people claim that these hormones are “natural” or “bio-identical” and therefore safer.  These hormones are usually extracted from soy or yams, then changed chemically to the form which is identical to that made in the human body.  The same can be said of many of the FDA-approved hormones (pills, patches, gels, creams, vaginal ring)! In addition, there are few studies on the use of compounded hormones, and no established safety profile.  Therefore, we assume the same risks and benefits as standard hormone therapy, realizing that the risks may actually be worse or the benefits decreased.  There is also more room for error when mixing hormones individually.  The benefit of compounded hormones is the ability to combine several into one formulation that is not available with standard FDA-approved medications, such as testosterone and estrogen in a gel or cream form.  “Bio-identical” progesterone does not absorb well through the skin, and studies have shown that, for this reason, it does not provide the endometrial protection needed.  FDA-approved Prometrium is a pill that provides the progesterone that the human body makes, and this does provide the endometrial protection needed for women on EPT.

What other options are available?  Do they work?

For vasomotor symptoms (hot flashes, night sweats) and depressed mood, SSRI’s or SNRI’s (types of antidepressants) may be used instead of hormones.  These may work well for some women, but not for others.  Natural products such as soy, black cohosh, and other supplements may also work well for some women while not providing any relief for other women.  These natural supplements have not been studied as extensively as estrogen, but most well executed studies have shown no more effect than placebo (“sugar-pill”).

For treatment or prevention of other symptoms associated with menopause, there are many different types of medications or lifestyle changes.  Talk with your Gynecologist about your risk factors, and he or she will work with you to develop a prevention and treatment plan.