Facts About Hormonal Replacement Therapy

When you enter the early stages of menopause, the question of hormone replacement therapy (HRT) arises. The two female hormones, estrogen and progesterone (often in its synthetic version, the progestins), are certainly the most widely prescribed therapies utilized by physicians for the relief of menopausal symptoms and the prevention of certain hormone-related conditions of aging. Medical research during the past 50 years has created many different types and dosage regimens of hormones. Such therapies vary in terms of absorption, frequency of usage and dosage.

Many women are confused or uninformed about their choices of hormonal therapy. They don’t know what to ask at medical visits to determine which hormonal regimens, if any, would suit them best. As a result, the best treatment combination for each individual woman may not be possible. Each woman should explore options and fine tune an individual approach until the best regimen is determined. This book will give you basic information about hormonal replacement therapy that can help you, with your physician, to make an intelligent and informed decision about using HRT. First, the history of hormonal replacement therapy in this country will be discussed; then, the steps to follow before beginning HRT. Detailed information is provided about the different types of estrogen, progesterone and even androgen therapy, as well as the various monthly schedules that can be utilized when taking HRT. Finally, helpful tips are given on how to adjust to HRT as well as on how to comfortably and safely discontinue HRT if you desire to do so.

History of HRT

The use of hormones after menopause is a recent innovation in human history. Relatively few women even survived the rigors of more primitive societies to face the issue of postmenopausal aging. How long a woman lived did not depend on sophisticated hormonal therapies synthesized in a laboratory, but rather, on a combination of good genes, familial longevity, a healthy lifestyle with adequate nutrition, balanced responses to stress and a balance of physical activity and rest. Only since the turn of the century have women begun to outlive their menopause and continue to do so for several decades.

Scientists first isolated estrogen and progesterone in the laboratory in their purified state during the 1920s. In the decades before this advance, physicians prescribed various formulations of the whole gland. Animal ovaries were powdered, pulverized and liquefied and then given by health care providers to women who had gone through surgical menopause or to those who suffered from menstrual cramps. Use of hormones remained limited throughout the 1930s and 1940s. By the 1950s and 1960s, the benefits of estrogen in treating menopausal symptoms were understood and appreciated and its use became widespread. A number of books and articles were written during this era about estrogen’s many benefits, both real and fancied. Many women benefited from the relief estrogen brought from unpleasant hot flashes, vaginal dryness, mood swings and other symptoms. Women were told that estrogen would even enhance their attractiveness and youthfulness. However, very little was understood or communicated to women about the risks of using estrogen.

The first adverse reports about estrogen therapy surfaced in 1975. Several research studies published that year linked estrogen use in postmenopausal women with cancer of the lining of the uterus (also called the endometrium). In those studies, women who used estrogen were four to eight times more likely to develop this cancer. Fearful of cancer, postmenopausal women avoided estrogen in dramatic numbers, and physicians were equally hesitant about prescribing it. This decline lasted for several years until further research studies showed that the combined use of estrogen and progestins (synthetic forms of progesterone) offered women excellent protection against the development of cancer of the uterine lining. In the regimens tested, women used estrogen 25 days each month, adding a progestin the last 10 to 14 days of the monthly treatment schedule.

Today, physicians prescribe estrogen and some form of synthetic or natural progesterone to combat early and postmenopausal symptoms. Physicians currently are able to use HRT with much greater wisdom and very little risk. Many research studies done on HRT now enable physicians to prescribe specific types of hormones and dosage regimens for each individual woman’s needs. A 1994 Gallup Poll indicated that 40 percent of all menopausal women in the United States use HRT. This low percentage appears to be related to poor compliance, myths or fears about estrogen use, the wish to pass through menopause naturally, and lack of support for finding the right regimen for the individual woman.

Working with Your Physician

Steps to Follow Before Starting HRT

If you are considering beginning HRT therapy, schedule an initial health evaluation to determine if any risk factors exist that the use of hormones could aggravate. In addition to determining the suitability of your using HRT, a good medical evaluation will identify any undiagnosed health issues that can then be adequately treated.

A pre-HRT evaluation may vary in its components depending on your medical status and what specific menopause-related health problems your physician is most concerned about. Tests used in evaluating a woman for HRT may include the following:

    1. A complete physical examination, including a pelvic exam and a breast exam.

    2. A PAP smear to determine a cancerous or precancerous lesion of the cervix.

    3. Blood tests to check liver function, blood sugar, cholesterol, triglyceride, calcium and phosphorus levels, as well as tests of thyroid function.

    4. Complete blood count to check for anemia, as well as a urinalysis.

    5. Mammography and professional breast examination to check for breast cancer. Mammograms done by experienced radiologists are capable of detecting 90 percent of all breast cancers.

    6. Bone density studies (dual x-ray absorptiometry, DEXA) to help determine the level of bone loss. This is an important test for women who may be at higher risk for osteoporosis.

    7. A review of your family medical history to gather clues about your risk of cardiovascular disease, osteoporosis, and breast and other cancers.

    8. Endometrial biopsy or vaginal ultrasound may be done to check for hyperplasia (overgrowth) of the uterine lining and endometrial cancer. A progesterone challenge test may also be done after menopause to check for endometrial hyperplasia.

If the results of these tests do not contraindicate the use of HRT and you decide to use hormonal therapy, expect frequent follow-up visits with your doctor. He or she will want to monitor the amount of hormones you are taking and their effect on menopausal symptoms, as well as your general health. Most physicians recommend annual visits. At this time, you should discuss any remaining symptoms or possible side effects that have developed since beginning HRT. Blood pressure will be monitored at each visit and a breast and pelvic exam done to check the health of these tissues. Most importantly, it is an excellent time to ask your doctor any questions that you may be concerned about. It is crucial that you tell your doctor any concerns or issues that you may have regarding your therapy. If you are not satisfied with your physician’s answers or feel that your physician is standoffish or abrupt, you may wish to seek another opinion or doctor in your community. Unexpressed concerns that are not discussed with your physician may delay the diagnosis and treatment of health problems that can arise during the course of treatment. The best results occur when a true partnership exists between doctor and patient.

Estrogen Therapy

Estrogen is taken as a supplement to compensate for the lack of estrogen circulating through your body as your ovaries begin to age. A great deal of research has resulted in three forms of natural and synthetic estrogen that are synthesized in the laboratory (produced in our bodies as estradiol, estrone and estriol). Not only are different types of estrogen available, but they can be administered by different routes which allow for great flexibility. These three major types of estrogen are usually differentiated in clinical practice based on their routes of administration which include oral, transdermal and cream.

Oral Estrogen Tablets

Many women take estrogen by mouth in pill form, known as “oral estrogen” Estrogen tablets are the most commonly used form of ERT. The estrogen tablets available on the market in the United States are composed of different forms of estradiol and estrone. As you may remember, estradiol is the main type of estrogen manufactured by the ovaries, and estrone is the primary type of estrogen that we produce after menopause. Estriol, the weakest and probably safest type of natural estrogen, is difficult to find in the United States, although it is more easily available in Canada and Europe. Estriol can be order by physicians through the Women’s International Pharmacy in Madison, Wisconsin.

The most commonly prescribed estrogen tablet is Premarin (Wyeth-Ayers Laboratories), a conjugated equine estrogen derived from a pregnant mare’s urine. It has been available since 1941, and much of the medical research has been done using this product. As a result, the benefits and side effects of Premarin are very well understood. Another benefit of Premarin is that it comes in a wider variety of doses than any of the other estrogen products. This allows for much more flexibility in determining the optimal treatment dosage for each woman user. Besides Premarin, currently available are generic, conjugated estrogen and synthetic and semisynthetic estrogen compounds. Other products include Ogen (Abbot), which contains estrone, and Estrace (Meade Johnson), which contains estradiol.

Women should avoid using nonsteroidal synthetic estrogens. One of these drugs, called diethylstilbestrol (DES), was used several decades ago to prevent miscarriage in women with high risk pregnancies. Unfortunately, many female children of these women have subsequently developed vaginal and cervical abnormalities including cancer. Most doctors also avoid estrogen tablets combined with a tranquilizer such as Menrium (Roche). Librium, the medication used to help treat mood problems in this particular formulation, is habit forming and can cause drowsiness. Because estrogen is used on an almost daily basis, the addition of tranquilizers can produce undesirable side effects with long term use.

The use of estrogen in pill form has some drawbacks. In the traditional regimen, women use estrogen 25 days per month with one week off (much like the birth control pill). During this “off” time, some women find that their menopausal symptoms, such as hot flashes, recur. Other women dislike having to track pill intake. These two problems can be remedied by placing the woman on continuous therapy, where she is taking estrogen every day of the month. Obviously, women who dislike having to take a tablet each day would do better switching to another route of administration.

A more serious drawback to the use of oral estrogen is that after ingestion, a large amount of estrogen is concentrated in the digestive tract. When estrogen passes through the intestinal tract, intestinal bacteria transform the estrogen chemically. This can change the type as well as the potency of the estrogen that is reabsorbed back into the body. Once the estrogen is reabsorbed, it enters the blood circulation and is transported to the liver. In the liver, estrogen is again metabolized and converted to the other forms before it finally enters the general circulation. How efficiently this occurs depends on the health of the liver. Many nutritional factors such as fat, sugar, alcohol and B-complex vitamin intake affect liver function, as does pre-existing liver disease. Women with a history of liver or gallbladder disease or hypertension and clotting problems (which are affected by various actions in the liver) may do well to avoid oral estrogen. They might instead use another route that circumvents the digestive tract and instead, disperses estrogen into the general circulation.

For those women who can assimilate oral estrogen without a problem, the most commonly prescribed dose is 0.625 mg. However, some women need higher doses such as 0.9 mg or 1.25 mg to attain symptom relief. Occasionally, women drop their doses in half to 0.3 mg to avoid side effects, but this dose may not be enough to benefit bones and avoid bone loss. Only trial and error will tell you which dose works best for you. Women who have already had a hysterectomy can take estrogen tablets alone because they obviously have no risk of developing uterine cancer. Women who have an intact uterus should always take a formulation that includes progestin for at least 10 to 13 days of each month for cancer protection.

Transdermal Estrogen

The transdermal system, marketed under the name Estraderm (IBA Pharmaceuticals), was created to avoid the problems inherent in oral estrogen’s first pass through the liver. In this innovative system, estrogen is absorbed into the general circulation through a medicated patch on the skin. This method avoids the initial pass through the digestive tract and liver, so women with liver and gallbladder disease are more likely to be able to tolerate ERT. This is also true for women with hypertension and clotting problems, provided clotting factors are normal.

Another benefit is that the patch dispenses estrogen continuously, rather than in one large burst like the tablet. The delivery of estrogen into the body throughout the day and night more closely resembles your body’s own estrogen production. Because the body is receiving estrogen on a continuous basis, a woman is less likely to suffer from symptoms which can occur with estrogen pill when hormones are stopped for a week each month.

What does the patch look like? Many women compare it with a small, round, clear Band-Aid that is several inches in size. It is placed on the skin of the abdomen, buttocks or thigh and changed twice a week. Each patch contains a reservoir of estrogen placed in a membrane that releases estrogen at a controlled, standardized level. The nonabsorbent patch allows for greater freedom because it can be kept on while you shower or bathe.

Unlike the estrogen pill, there is not as much flexibility of dosage range. Basically, the transdermal patch is available in two dosages: 0.05 mg and 0.1 mg. Some women find they do not tolerate these dosages well and develop side effects. A new transdermal patch called Vivelle, manufactured by Ciba Pharmaceuticals, may solve this problem for some women. It will be available in four dosages from 0.0375 mg to .1 mg and has been scheduled for consumer use in the fall of 1995. To decrease the amount of hormone released from the patch, part of the backing can be occluded by a small piece of ordinary adhesive bandage. This reduces the total surface area of the skin exposed to the hormone. Some women prefer to use oral estrogen because it is less expensive than the patch. Finally, ten percent of all patch users develop skin irritation from the patch’s adhesive. To reduce the likelihood and severity of the skin reaction, apply the patch on different areas of your skin. The buttocks area seems to tolerate the patch best. Be sure to wait at least a week before reusing a prior site. During times of acute irritation, you can change the patch more frequently, every 12 to 24 hours; if needed, talk to your doctor about ways to relieve skin irritation. You may also want to remove the patch before swimming or soaking in a hot tub and reapply it once you have dried your skin.

As with oral estrogen, the patch is used in conjunction with progesterone if the woman still has an intact uterus, and progesterone should be taken for the recommended number of days each month. The patch appears to be as effective in relieving menopausal symptoms as the oral estrogen tablets. Studies to date suggest that its effect on calcium absorption and blood lipids are almost identical to oral estrogen.

Estrogen Vaginal Cream

The use of estrogen vaginal cream is much more limited in its clinical applications. Estrogen cream is primarily applied to the vagina and urethral area to prevent atrophy and breakdown of the tissues caused by lack of natural estrogen. Though estrogen is absorbed from the vaginal mucosa into the bloodstream and can affect other parts of the body, the effects tend to be undependable. Occasionally, however, my patients complain of more generalized side effects from using the vaginal cream, such as breast tenderness or mild fluid retention. These side effects often occur early in the course of treatment. Because of the vaginal atrophy that exists when women first begin treatment, estrogen tends to be absorbed rapidly. This can cause the blood levels of estrogen to rise significantly. However, once the estrogen thickens the vaginal walls and changes the cellular pattern of the mucous membranes to a more youthful and healthier condition, estrogen absorption into the bloodstream slows down. (It may or may not restore lubrication; the use of a lubricant cream or gel may still be needed.) Not only will estrogen thicken the vaginal wall, making it less traumatized by sexual intercourse or foreplay, but it also reduces the incidence of bladder infections.

Another benefit of the vaginal cream is that, like the transdermal patch, it does not make an initial pass through the liver. As a result, the use of estrogen vaginal cream may not aggravate liver or gallbladder disease, hypertension or clotting tendencies, unless clotting factors are abnormal. However, women with pre-existing breast cancer or who are also positive for estrogen receptors may not be good candidates for estrogen vaginal creams. This is currently being debated and the controversy may be resolved by using small topical doses with low risk.

Premarin cream is one of the most commonly used vaginal creams, although other brands are available. Premarin cream comes with an applicator that allows for the use of two to four grams per day (as calibrated by the applicator). One half to one full applicator of Premarin cream will delivery 1.25 to 2.5 mg of estrogen to the vaginal tissues. Many women find, however, that they function quite well at smaller doses, often as little as oneeighth of an applicator.

Initially, you may want to use estrogen cream daily, at least for the first week or two. Be sure that the most sore or abraded areas come directly in contact with the cream, either through placement of the applicator or by applying the cream to sore and tender areas with your fingers. After healing has begun and sexual activity is more comfortable, many women reduce usage to two or three times per week. Use it as often as required to keep your vaginal tissues healthy and functional.

Vaginal cream has several drawbacks, none of which are serious. The creams tend to be messy and can leak into your underwear. Estrogen vaginal cream should not be used as a lubricant or applied prior to lovemaking. Some men are concerned about the adverse effects of absorbing estrogen through their penis if the cream is still in the woman’s vagina during sexual activity. Estrogen cream can, however, be inserted following lovemaking, particularly just prior to retiring at night.

If you are concerned about using estrogen for protection against osteoporosis or cardiovascular disease, estrogen vaginal cream is inadequate to meet these goals. You will have to use additional estrogen, either by the transdermal or oral routes to keep your blood levels of estrogen consistently high enough to confer protection. In addition, a course of progesterone needs to be used, at least every three months, to “clean out” the uterus and allow the lining to shed. The addition of progesterone will help mature the lining of the uterus and thereby prevent the buildup of cells that can lead to hyperplasia or even cancer.

Rarely, androgen cream is also prescribed in very small dosages, usually in 1 or 2 percent concentration, to help prevent vaginal discomfort and soreness. It is also used to help restore sexual desire or libido, a fairly common problem in menopausal women. It has certainly been an issue for many of my patients because it affects their quality of life, as well as the pleasurable aspect of their intimate relationships. Like estrogen cream, androgen cream is applied daily for a week or two and then decreased to twice weekly applications. Care must be taken not to overdose, since masculinization side effects such as excessive hair growth or clitoral enlargement can occur.

Alternative Routes for Estrogen Administration

You may also hear of several other routes of estrogen delivery. These methods tend to be used rarely or are more readily available in other countries.

Intramuscular Injection. Intramuscular injection was used occasionally before the development of the transdermal patch, and may still be used for women who can neither take oral estrogen nor the transdermal patch. This method does have several disadvantages. The injection delivers large amounts of estrogen directly into the bloodstream, then diminishes to lower levels with time. Thus, there is not a continuous delivery of the hormone to the body that the transdermal patch now makes possible. Finally, injections are usually given at monthly intervals and require administration in a physician’s office which are expensive in terms of time and money.

Subcutaneous Pellets. A subcutaneous pellet of estrogen therapy, used during the 1960s and 1970s, is not currently a method of treatment. The hormone was impregnated into a solid pellet which was then implanted by a small incision into the subcutaneous fat of the buttocks or abdomen. The pellets would dissolve slowly, releasing hormone into the fatty tissues. Research is now oriented toward trying to improve types of implants, as well as the more controlled release of the hormone into the system. Thus, it is possible that subcutaneous implants will be used once again for ERT.

Buccal Estrogen. A low-dose estrogen tablet has been developed that can be placed directly against the mucous membranes inside the mouth. The tablet dissolves rapidly and the estrogen that is released from the tablet is absorbed directly into the bloodstream. Estrogen released by this method is sufficient to relieve common symptoms such as hot flashes. It is still pending approval by the US Food and Drug Administration.

Estrogel. Estrogel is a form of estrogen replacement therapy used frequently in France. The estrogen is in a gel-base that is rubbed on the skin of the abdomen and absorbed into the body. The dose can be varied easily by changing the amount of gel used.

Progesterone Therapy

Before the 1980s, all progesterone therapy had to be administered by injection. Women who required progesterone treatments for specific medical problems had to go to the doctor’s office for every treatment. The development of oral progesterones made this hormone more readily available. Initially, progesterone was combined with estrogen in birth control pills for younger women. Progesterone’s important role in preventing endometrial cancer in postmenopausal women on ERT was discovered in the 1970s. It rapidly became part of the standard hormonal regimen for postmenopausal women who still had their uterus intact. The traditional form of treatment does not, however, use the same natural form of progesterone produced by the ovaries. Instead, a synthetic form called a progestin is used. It was not until recently that some physicians actually began to use natural progesterone for postmenopausal support. In this section, I will discuss both the synthetic and natural forms of progesterone.

Oral Progestins. Oral tablets of synthetic progesterone are the most widely prescribed form of progesterone. The progestins change the cells of the uterine lining from a pattern of rapid growth to a more mature form. The cells become secretory in nature, which prepares the uterus to nourish and maintain an early pregnancy during the active reproductive years. With the proper dose and ratio to estrogen, once a woman stops progesterone the uterine lining is sloughed off and a menstrual period or bleeding episodes occur. All of the accumulated proliferated cells, tissue and blood leave the body. No pile up of abnormal cells occurs and the uterine lining is left healthy and ready for the next month’s estrogen therapy, therefore reducing the risk of uterine cancer.

Reaching this beneficial goal requires only small doses of progestins, usually doses of 5 to 10 ma. Some women need slightly higher or lower doses. Women who develop side effects such as fatigue and depression may need to drop their dose to as low as 1.25 mg per day, while others must use up to 10 mg per day to achieve the best therapeutic effects.

Progestins can be used for other aspects of menopause in addition to their normal role in preventing uterine or endometrial cancer. For example, physicians often prescribe progestins for women making the transition into menopause who have excessive bleeding due to an imbalance of female hormones. Women may produce too much estrogen without ovulating. This causes heavy periods, which can last as long as 10 to 20 days, or even longer. Progestins taken for one week each month or for 10 to 12 days are usually effective in controlling this bleeding. They are also used during the early menopausal years when a woman is no longer bleeding. Progestins are given as a “challenge test” to see if the lining of the uterus is still being stimulated. If you bleed after stopping the progestins, your body is still producing estrogen. In this case, the progestins must be used on a monthly basis, even without additional estrogen therapy. The risk of endometrial cancer is higher in women taking no hormones than those on HRT because of a woman’s unopposed endogenous estrogen.

The most commonly used brand of progestins is Provera (Upjohn). Norlutate (Parke-Davis) is also frequently prescribed, but it may cause side effects similar to androgens such as oily skin and acne. A third progestin currently on the market is Amen (Carnick).

Oral Micronized Progesterone. Synthetic Progestins were used originally instead of natural progesterone because they may be taken orally. Unfortunately, natural progesterone cannot be ingested because it is destroyed during digestion and never reaches the bloodstream. In recent years, a new micronized form of progesterone is available that is protected from destruction by stomach acid and enzymes and can be absorbed and utilized by the body. Made from the natural progesterones found in yams and soybeans, oral micronized progesterone has gained wide acceptance by physicians as a treatment for premenstrual syndrome (PMS). I began to prescribe natural progesterone over a decade ago to my PMS patients, and I am very pleased by the response to this treatment. It seems to be particularly helpful in controlling the emotional symptoms of PMS such as anxiety and mood swings.

Menopausal women are beginning to use this form of progesterone more frequently because it causes fewer side effects than the synthetic progestins. While the progestins can cause depression, fatigue, bloating, breast tenderness, and also adversely affect blood cholesterol levels, the natural progesterone seems to cause fewer adverse reactions. However, natural progesterone may still cause drowsiness because of its sedative effect on the brain.

The main drawback to natural progesterone is its expense. It is more expensive than the synthetic progestins, a deterrent for women on a tight budget. In menopausal women, dosages of 200 mg daily can be effective, although the dose can vary in either direction. Like the synthetic progestins, it is used 10 to 13 days per month and appears to confer an equal amount of protection against uterine cancer. Besides the oral form, it can also be obtained as a rectal or vaginal suppository. PMS patients use this route of administration successfully, as vaginal suppositories allow excellent local intake of progesterone into the uterus. Ask your physician about natural progesterone if it seems like it might be the right form of progesterone for you.

Progesterone Skin Cream. Pro-Gest®Cream is applied to the skin and absorbed into the general circulation. Recent research has shown that it not only elevates progesterone levels, but it also elevates DHEA levels in the body. Because it is absorbed through the skin, it bypasses the liver, thereby escaping liver metabolism. Unlike the synthetic progestins, there are few side effects reported by its use.

Pro-Gest cream is applied to the skin twice daily in one quarter to one half teaspoon amounts. It is generally used on rising and before going to bed at night. It can be applied to any area of your skin. Many women will rub it into their chest, abdomen, arms or back. If the cream is absorbed rapidly (under two minutes), it means that the body needs a higher dose and a slightly higher amount may be used. Few physicians have any experience using Pro-Gest cream to date and it is more likely to be used by physicians knowledgeable about alternative therapies. You may want to check with physicians practicing alternative therapies in your area to find one prescribing progesterone topical cream.

General Guidelines of Hormonal Use

Understand and follow these principles if you wish to obtain the best results from HRT. These relate to dosage, route of administration, regimen and frequency, choice of physician, and proper cessation.

Choose the Lowest Dose that Works

In general, use the lowest possible dosage of both estrogen and progesterone that will relieve your symptoms and prevent longterm health problems associated with hormonal deficiency such as osteoporosis and cardiovascular disease. Medical research has shown this to be 0.625 mg for the Premarin oral tablet and 0.05 mg for the estrogen transdermal patch. If you start at higher doses, you are more likely to encounter side effects such as anxiety, mood swings, fluid retention and breast tenderness. Many women who could benefit from HRT discontinue it because of unpleasant (and often unnecessary) side effects.

Some women find that even the tiniest dosage of estrogen normally prescribed, 0.3 ma, provides adequate symptom relief. However, such a low dosage may not provide sufficient protection against the development of bone loss or cardiovascular disease. Thus, women with high risk factors for developing either problem should not use this minimal dosage. To know your risk potential, have your physician perform the appropriate tests. If you feel comfortable at the smaller dosages, you may wish to combine estrogen with the alternative therapies described later in this book. At the other end of the spectrum, you may feel your best only when using estrogen in the high dose ranges. If you have experienced a surgical menopause below the age of 40, you may need more estrogen than women who go through natural menopause at a later age. Obviously, with estrogen, one dosage does not fit all women and therapy must be carefully individualized to each woman’s needs.

Progesterone should also be used in the lowest possible dose to prevent side effects. This is particularly true for the synthetic progestins, which can cause the most problems. As mentioned earlier, I have had patients drop their dosages to as low as 1.25 mg to avoid common progestin-induced side effects such as fatigue, depression and bloating. I’ve also seen physicians increase the dosage to as high as 15 to 20 mg per day on a short term basis to stop heavy menstrual bleeding in a woman making the transition into menopause. Your physician will order the lowest dose to confer protection against uterine cancer, yet one that is comfortable for you. This may require some fine tuning and tests such as a vaginal ultrasound under the guidance of your physician.

Choose the Route of Administration that Is Most Comfortable

Some women find it difficult to remember to take one or two pills each day. They may, occasionally, miss days. This does not create the same potential problem that missing a day or two of birth control pills will, because menopausal women do not have to worry about unplanned pregnancies (unless they are in the early stages of menopause). However, if you find pill taking too challenging or unpleasant, then you are better off asking your physician about the alternative routes of administration such as the estrogen transdermal patch or progesterone cream.

Choose the HRT Regimen that Suits You Best

Traditionally, estrogen was taken only three weeks per month with one week off. Provera, a common progestin, was added during the last 10 to 13 days of the regimen to prevent the development of endometrial cancer. Taking one week off estrogen each month reduces the time during which the uterine lining is exposed to estrogen, therefore, reducing the risk.

However, some women find that menopausal symptoms, such as hot flashes, recur during this “off” week. In addition, many women dislike the bleeding, similar to a regular menstrual period, that occurs within a few days after the hormones are stopped. Even though the bleeding tends to be lighter and even diminishes or stops over time, many women find it an annoyance.

While some physicians still use the traditional three weeks on, one week off regimen with their patients, other regimens have become very popular in recent years. With one protocol, estrogen is taken every day and a progestin is added on an intermittent basis, usually during the first 12 days of the calendar month. More than two-thirds of the women on this regimen, if they have a uterus, experience bleeding when administration of progestin stops after the twelfth day. With combined continuous therapy, both estrogen and low doses of progestins are used on a daily basis without stopping. Women on this regimen may experience irregular bleeding during the first six months of treatment, which then diminishes. With both continuous and combined continuous therapy regimens, bleeding often doesn’t persist indefinitely. For many women, bleeding becomes lighter and stops entirely after a few years. This occurs as the endometrium eventually becomes inactive.

Both these regimens appear to protect women against the development of uterine cancer as well as does the “on-off regimen.” Also, constant daily hormonal intake protects women better from recurrence of menopausal symptoms.

Pick a Physician Who Will Tailor HRT to Your Needs

One of the most important factors in developing a successful menopause relief program is to work with a physician who is knowledgeable and dedicated to helping you achieve the best therapeutic results. How does one find such a physician? You might try asking your friends for a referral. Choose several physicians and interview them to determine if their philosophy of HRT and personality fit with you. Ask many questions and evaluate the responses. Remember, this relationship between you and your physician will be a long term one.

Attaining the goal of the best HRT regimen for you may require considerable tinkering over time with both dosages and formulations until the right results are achieved. Though some women adapt easily and effortlessly to their hormonal regimen, others need the expertise and help of an empathetic physician to achieve the results they desire. However, if you have made the decision to use HRT and believe strongly that these hormones can provide you with real benefits, it is worth the time and persistence. The benefits that HRT can provide are discussed in detail in the following chapters.

Stop Hormone Use Gradually

What if you’ve been on HRT for some time and now feel that it’s time to stop using it? While many women stay on HRT indefinitely, other women do not feel the need to continue with HRT after using it for a short period of time. Once the initial symptoms are relieved and the body is adjusted to the postmenopausal period, they may wish to see how they feel without hormones. Others dislike the side effects that develop with HRT, so choose to discontinue it. Whatever the reason for stopping HRT, don’t do it abruptly. This can cause a severe recurrence of symptoms (such as hot flashes) as your body reacts to the rapid decline in estrogen. Just as during the early postmenopausal period, the pituitary pumps out high levels of FSH in an attempt to make your body produce the estrogen that has suddenly disappeared. Hot flashes and night sweats can reappear as the pituitary-hypothalamic axis goes off balance.

Be sure to stop HRT use very slowly. I often recommend cutting the dose of estrogen by one-half each month for one or two months. Then cut back to every other day for a month, followed by twice a week for a month, and finally to once a week for a month. Continue to take your progesterone on your regular schedule until you have stopped the estrogen entirely, then discontinue it. If your symptoms recur in too uncomfortable a fashion, you can always begin HRT use again.

Using HRT in the safest and most comfortable dosage and regimen for your individual needs will provide the best therapeutic results with the least risks and side effects. What you can expect in terms of symptom relief from your HRT program is discussed in the next chapter.

Types of Estrogen

  • Oral estrogen tablets

  • Transdermal estrogen patch

  • Estrogen vaginal cream

  • Intramuscular injection

  • Subcutaneous pellets

  • Buccal estrogen

  • Estrogel

Types of Progesterone

  • Synthetic progestins

  • Oral micronized progesterone

  • Vaginal or rectal progesterone suppositories

  • Progesterone skin cream

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Written by Susan M. Lark MD

Explore Wellness in 2021