Hormone Replacement Therapy for Menopause

• Natural menopause: Natural menopause is signaled by 12
• Induced menopause: Induced menopause occurs when menses stop after either surgical removal of both ovaries or medical ablation of ovarian function by treatments such as chemotherapy or radiation therapy.
• Early menopause: Early menopause is menopause that occurs between ages 40 and 45.
• Primary ovarian insufficiency (POI): POI is menopause that occurs when a woman’s ovaries stop functioning normally before the age of 40 because of a problem with the ovarian follicles.

Women with early menopause or primary ovarian insufficiency should be considered for treatment with hormone therapy until the average age of menopause (51 years in the U.S.) to prevent the health consequences of the loss of estrogen at a young age.

There are two main types:

Systemic hormone therapy

Systemic estrogen therapy comes in various forms: pill, ring, skin patch, gel, cream, and spray, and they typically contain a higher dose of estrogen that is absorbed throughout the body. It can be used to treat any of the common symptoms of menopause.

Low-dose vaginal estrogen

Low-dose vaginal preparations of estrogen also come in various forms: cream, tablet, or ring. These formulations minimize the amount of estrogen absorbed by the body. They are usually used to alleviate local vaginal and urinary symptoms of menopause.

If the uterus is still in place, unopposed, estrogen-only therapy can stimulate growth of the lining of the uterus (the endometrium) and increase the risk of uterine cancer. Progesterone needs to be concurrently prescribed to counterbalance the stimulatory effect of progesterone. The exception to this is when low-dose vaginal estrogen is used; it can be used at any age with minimal risk without the need for opposing progesterone. If the uterus has been removed (hysterectomy), progesterone is not be needed.

Other hormone therapy used to alleviate symptoms or conditions of menopause includes progesterone-only therapy, in the form of a custom-crafted oral capsules, vaginal gels, and topical creams, and testosterone therapy as a transdermal patch (for sexual interest/arousal disorder), both given to selected postmenopausal women.

Like any medical therapy, there are some side effects to hormone therapy. The most common side effects of estrogen therapy include bloating, breast tenderness or swelling, nausea, indigestion, headaches, leg cramps, and vaginal bleeding. The most common side effects of progesterone therapy also include mood swings and acne. Side effects most often improve over time, so it is a good idea to persevere with therapy for at least three months if possible. Many women believe that weight gain is a side effect of hormone replacement therapy; there is no evidence to support this. Weight is often gained during menopause, but this happens regardless of whether HRT is being taken or not.

There are also risks with hormone therapy, and they depend on the type of hormone, dosage, length of use, and individual health conditions. Some of these risks are blood clots, breast cancer, heart disease, and stroke. These risks are low, but higher in women over age 60. When deciding on HRT, it is important to understand its benefits and risks; the benefits of HRT usually outweigh the risks for most women.

To minimize serious health risks, hormone therapy should be used at the lowest dosages for the shortest time needed to achieve treatment goals. The gynecologist should re-evaluate the treatment plan periodically to confirm that HRT should be continued.

There is a lack of safety data supporting the use of hormone therapy in breast cancer survivors. Non-hormonal therapies should be the first line approach in the management of symptoms of menopause in these women.