HRT and Breast Cancer

Whether or not HRT increases the risk of breast cancer is still unresolved. Studies suggest that five years of treatment is associated with minimal risks but there may be a small risk if HRT is continued for more than 10 years. Numerous studies are under way to evaluate the risk more clearly.

The possible effect of HRT on breast cancer should be considered against the background of a one in 12 lifetime risk of developing this disease, compared with a one in four risk of having a heart attack. A woman’s risk of hip fracture has been estimated to be about one in six – equivalent to the combined lifetime risk of developing breast, womb and ovarian cancer.

Other factors such as family his­tory and benign breast disease may also influence the risk of breast cancer, although these need not be a contraindication to HRT. Current medical research suggests that there may be a link between inherited genes and breast cancer. Therefore a positive history of breast cancer in a close relative may be an important indicator of your own increased risk of breast cancer.

An interesting point is that women who develop breast cancer while taking HRT appear to be more likely to survive than women who are not on HRT. This may reflect a difference in the type of cancer that evolves or could arise from increased detection of early cancers which would not normally develop. Only further research will reveal the true answer.

However, it is important to be aware of your individual risk; the more risk factors you have from the list, the greater your risk. If you are at high risk of breast cancer, have minimal risk of heart disease or osteoporosis, then you may decide against HRT. If you have severe men­opausal symptoms you might choose to take HRT for just a few years. The choice is very much an individual one, depending on your personal circumstances.

HRT for women treated for breast cancer

There are increasing moves to offer HRT to women who have been treated for breast cancer. The decision to start treatment is based on the individual merits of each case, but may be recommended if symptoms of oestrogen deficiency are particularly severe. HRT does not appear to interfere with tamoxifen, a drug used in the treatment of breast cancer and which has some properties similar to those of oestrogen.

Risks vs Benefits of HRT – How to Decide

For women having a difficult time through the menopause, the options for treatment are numerous. There are many other non-hormonal drugs available but none has proven to be as effective as HRT.

This does not mean that every menopausal woman should take HRT – many do not need any treatment at all.

Even if you are considering HRT, it is important to balance its favourable action on osteoporosis and heart disease against the increased risks of cancer. Overall, the effect of HRT is to reduce deaths in users by over 40 per cent. Obviously this figure is slightly meaningless in the sense that everyone dies eventually, but it does show that the life expectancy of HRT users is greater than that of non-users.

Facts and figures aside, your personal decision to take HRT depends on weighing your indi­vidual needs and requirements against any possible risks associated with the treatment. If the benefits outweigh the potential risks, then go ahead. If the balance is less clear, you may wish to discuss alternative options or seek the opinion of a specialist. Some women with obvious risks, such as a very strong family history of breast cancer, may still choose HRT if they are at risk of osteoporosis or suffer severe menopausal symptoms.

The important factor is infor­mation – without this it is impossible to decide which is the best path for you to take. Do not be afraid of seeking out information, and if you do not understand it, ask. Be careful to select the right sources as the amount of misinformation in the general press provokes confusion.

You can always try HRT for a few months and see how its suits you. Take it for at least three months before making your assessment, as it can take that long before your body settles down to the hormonal changes.

Remember also that there are several different regimens; if you started with tablets but find it hard to remember to take them every day, try the patches – you may need to try several different combinations before finding the one that suits you best. Similarly, the initial dose or type of oestrogen or progestogen may need to be altered if you experience side effects.

Do not feel that you have to persevere if HRT just does not suit you. There are numerous alternatives to HRT, but none is a substitute for a healthy lifestyle with a good diet and adequate exercise.

Side Effects of HRT

Side effects of oestrogen

Bloatedness, breast tenderness, nausea and vomiting are symptoms associated with high levels of oestrogen, and are not uncommon when starting treatment. If they have not settled after the first two or three months the oestrogen dose may need lowering. These symptoms are more common in women who start HRT while still menstruating and will tend to occur at times when their ovaries are producing normal amounts of hormones. As a result of this conflict of HRT and the body’s own production of hormones, women who start HRT before their natural periods have ceased are more likely to experience side effects and irregular bleeding than post­menopausal women.

Side effects of progestogens

‘Premenstrual’ symptoms affect up to 20 per cent of women receiving continuous oestrogen and cyclical progestogens. Breast discomfort, depression, nausea, irritability, fluid retention and headaches are notice­ably linked to the course of proges­togen. Altering the dose or type of progestogen can give relief, as can switching to the combined oes-trogen/progestogen patches which use much lower doses of hormones. If symptoms are particularly severe, the progestogen course could be taken every three months. Altern­atively the duration of the progestogen could be shortened, but reducing the course to less than ten days diminishes the protective effect against cancer of the womb and can provoke irregular bleeding.

Changing to a continuous combined HRT can also improve symptoms because, although the progestogen is taken every day, the dose is usually lower than for cyclical regimens.

Irregular bleeding

Unless the progestogens in HRT are synchronised with your body’s own production of progesterone, irregular bleeding can be a problem, particularly if you start HRT before the menopause.

Weight gain

Although many women are con­cerned that HRT will make them gain weight, studies show that HRT users put on less weight than do non-users after the menopause. A few women are sensitive to oral oestrogens, particularly if the dose is too high, causing them to retain fluid and gain weight.

Headaches

Fluctuating hormone levels can trigger migraine and headaches. These fluctuations are common with oral forms of HRT, particularly if you are not absorbing the drug for some reason. If HRT aggravates your headaches, switching to a non-oral form such as patches, gel or implants may solve the problem.

The Pros and Cons of HRT Skin Patches

Oestrogen

Skin patches provide a means of delivering the hormones directly to the bloodstream through the skin. As they do not pass through the stomach and the liver first, as tablets do, the required dose is much lower, reducing side effects. Patches are applied once or twice weekly, depending on the brand. They are generally well tolerated although some, particularly the older style patches containing alcohol, can cause skin irritation.

To use patches, remove the patch from its backing sheet and stick onto clean, dry skin, free from talcum powder, bath oils or body cream. The best site is the upper buttocks. Press the patch firmly on the skin for about 10 seconds, then run your fingers around the edges to ‘seal’ it. Keep the patch on when you have a bath or go swimming, although it can be removed temporarily for half an hour or so if you prefer – keep the backing sheet to stick the patch onto until you need it again.

Cover the patch when sunbathing and remove the patch if you are using a sunbed. When replacing patches, change the site so that you are not sticking the patch in the same place each time.

Oestrogen/progestogen combinations

Double patches are available either as separate pouches of oestrogen and progestogen or combined in a single patch. Use oestrogen-only patches twice weekly for the first 2 weeks of the cycle, followed by the double patches for the last 2 weeks of the cycle.

– Advantages of patches: The main advantage of the patches is that side effects are minimised because the dose of hormones is much lower than oral therapy. The hormones from patches are gradually released into the bloodstream producing minimal fluctuations.

– Disadvantages of patches: The disadvantage is that, at present, the doses of oestrogen and progestogen in the combined patches are fixed, so dose adjustments are difficult.

Occasionally, patches do not stick very well, particularly in hot, sticky weather, but you can easily remedy this by covering the patch with two inch surgical tape.

Although it is normal for the skin underneath the patch to redden, a few women develop a severe skin reaction that prohibits further use. Switching to a different brand can occasionally help.

The Pros and Cons of Tablet HRT

Oestrogen

HRT is most commonly prescribed in tablet form. If you have had a hysterectomy, only oestrogen treatment is necessary and should be taken every day, without a break, at about the same time. There are many different brands of oestrogen tablets available on prescription containing varying types of oestrogen. Some are fixed-dose regimens, others try to mimic the menstrual cycle by changing the dose over each 28-day course.

Progestogen

If you have not had a hysterectomy, you need to take a course of progestogen tablets, every month for about 10 to 14 days. They are available in calendar packs combined with the oestrogen tablets so you do not have to work out when to take them. They are also packaged separately so that they can be taken with the woman’s own choice of oes­trogen. If used in this way, one simple regimen that many doctors recommend is to take the proges­togens for the first 10 to 14 days of each calendar month, i.e. starting the 1st of March, 1st of April, etc. This has the advantage that you can adjust the type and dose of oestro­gen and progestogen more easily. As your ‘period’ should start around the middle of the month, your doctor will easily be able to tell if you have any irregular bleeding that may need further investigation. Women whose last natural period was more than one year ago can take progestogens continuously, every day, with oestrogen as a ‘no bleed’ regimen.

– Advantages of tablets: Tablets are easy to take and their effects are quickly reversed if you decide to discontinue treatment.

– Disadvantages of tablets: It is not always easy to remember to take tablets every day, and even more difficult to remember them when away from home. Forgotten tablets can trigger fluctuations in hormone levels and irregular bleeding. The higher doses of hormones, necessary to account for huge losses in the passage through the gut and lever, can increase side effects. Nausea is a more common side effect of tablets than other routes but can be minimized by taking the tablet with food or at bedtime. Rarely, oral oestrogens are so poorly absorbed that menopausal symptoms are not controlled and an alternative type of HRT is recommended.

What to Expect during HRT

At your follow-up visit, expect to give another detailed medical history relating to any changes in your symptoms, side effects, or any other problems that have developed in relation to your therapy. Your blood pressure should be measured and a general examination includ­ing your breasts and abdomen should be done at each visit. Pelvic examinations should be performed annually and a Pap smear should be done every one to two years.

Often, the question arises of whether or not to take an endometrial sampling (endometrial biopsy) as a means of screening for uterine cancer or correcting hormone dose. I feel that if you are taking your progestin in an adequate dose, and your bleeding pattern is normal, there is no reason for doing an annual sampling. However, if you are one of those women who take estrogen only, who have their uterus intact, and who do not take progestin for some specific reason (some women with their uterus intact refuse progestin because of its side effects), I would recommend having an endometrial sample every year. You should also anticipate having a baseline mammogram taken when you first begin therapy and an annual mammogram thereafter.

It is my recommendation that once you start HRT, you visit your physician at least every six months. If the examinations listed above are done, and no problems occur in the interim, you need only those biannual visits. However, if you experience any side effects such as breakthrough bleeding, you should report them to your physician and anticipate that an endometrial sample may be taken.

It is also important that your doctor closely monitor the amount of estrogen you are taking and its effects on you. This monitoring may require testing your blood estrogen levels and measuring your cal­cium levels to assure that you are not losing calcium, which can lead to losing bone. One way of determining calcium levels is with the urine calcium creatinine test. Bone density testing is a method of determining bone loss that is very important for women at risk for osteoporosis. It shows whether bone mass has been maintained or improved with therapy. If bone density test results show that bone loss is continuing, then the method and/or type of HRT should be changed.

The Pros and Cons of HRT Implants

Oestrogen

Small pellets of oestrogen, inserted into the fat under the skin, last for about six months. This simple pro­cedure can be done at your local surgery or in the hospital outpatient department. You are given an injection of a local anaesthetic to numb the skin before a small cut is made, usually in the lower abdomen. After the implant is inserted the wound is closed with a stitch or piece of tape. If you have a stitch, your doctor will remove it about five days later. If Steristrips were used, gently peel them off yourself after five days and cover the wound with a sticking plaster until it has fully healed. Try not to do anything too strenuous immediately after an implant insertion, because occasion­ally they fall out.

Testosterone

Testosterone is the male hormone but the ovary also produces small amounts. The precise role of tes­tosterone in women remains unclear but a few doctors recommend the addition of testosterone implants for women with sexual problems. There is some evidence that testosterone increases interest in sex, although some authorities dispute this. Oes­trogen replacement alone will restore poor libido caused by oestrogen deficiency but the option of additional testosterone is available for those who favour it.

Advantages of implants: The advantage of implants is that you do not have to remember to use HRT. They dissolve slowly and provide stable levels of the hormone with minimal fluctuations. The pellet fully dissolves after five to six months, when it needs replacing. Implants produce the highest levels of oestrogen, although these usually still remain within the normal premeno­pausal range. This has the potential advantage of stimulating a greater increase in bone density than other forms of HRT.

Disadvantages of implants: The main disadvantage is that, if this method does not suit you, it is virtually impossible to remove the pellet once implanted.

An occasional problem is that the implants last increasingly shorter periods of time after each insertion so that, for some women, menopausal symptoms return two or three months after the last implant. When oestrogen levels are measured, they are very high and it seems that these women have developed some immunity to the effects of the implant. The only way to treat this is to reduce the dose of the implant gradually and restore normal levels of oestrogen.

Women needing progestogens will have to take regular courses, as with other regimens. If you stop using implants, you should still continue progestogens until there is no bleeding. This can be up to two years or more after the last implant because implants continue to stimulate the lining of the womb long after their effects on menopausal symptoms have ceased.

What Are The Risks Of HRT?

If HRT is so effective why don’t more people take it? First, not everyone needs it; second, not everyone wants to take it; third, a small number of women should not take it; and finally, many women who would benefit from it are concerned about risks and side effects.

It is imperative to find out the facts before you decide about any form of treatment. Women’s magazines often prove to be the most important source of information on hormone therapy but they do not always get it right. In one questionnaire more than 50 per cent of women expressed an opinion that HRT increased the risk of heart attacks, strokes, breast cancer and cancer in general. Furthermore, many women starting HRT discon­tinued treatment within the first three months because of side effects – return of ‘periods’, feeling bloated, weight gain, nausea, breast tenderness and headaches.

What many of the magazines do not discuss is all the benefits of HRT -relief from menopausal symptoms, and reduction in risk of fractures, heart attacks and strokes; although cancer can occur, the risk needs to be put into perspective. Similarly, many of the side effects experienced settle down after the first few months of treatment or respond to simple adjustments of dose or a change of hormones.

It is also important to have realistic expectations; if HRT does not work, it may be because the dose of hormones is too low but it could be that oestrogen deficiency is not the sole cause of all the symptoms.

All these problems need to be addressed before starting HRT to ensure that treatment is not discon­tinued for the wrong reasons.

Cancer of the womb (endometrial cancer)

Early HRT treatment schemes were associated with a fourfold increase in the risk of endometrial cancer. Oestrogen replacement therapy thickened the lining of the womb, which could subsequently turn cancerous. Although the survival rates of this special type of cancer were very high (99 per cent at five years) the risk of developing cancer increased with each year of oestrogen use.

A breakthrough in research showed that ‘opposing’ the oestro­gens with the addition of proges­togen cycles created a ‘period’ which effectively removed the lining of the womb and any potentially cancerous cells.

Further studies have confirmed that an adequate dose and duration of treatment with progestogen reduce the risk of endometrial cancer at least to that of non-HRT users, if not lower.

Ovarian and cervical cancers

Both these cancers are more common than endometrial cancer but there is no evidence that HRT has any beneficial or detrimental effect, nor is having these cancers a reason to withhold HRT.

Venous thrombosis (blood clots in veins)

Modern diagnostic techniques have meant that more cases of venous thrombosis are accurately identified. For many years it has been believed that HRT is associated with little, if any, increased risk of venous thrombosis. However, recent research using these new techniques suggests that women taking HRT who have a family history or past personal history of venous thrombosis, who are overweight, immobile or who have severe varicose veins, may be more likely to develop blood clots in the veins than women who are not taking HRT.   This risk appears particularly to affect women just starting HRT and, like all other risks, should be balanced against the benefits of long-term treatment.

Making the Most of HRT and Nonhormonal Therapy

You should not rely entirely on hormones or other medications to enhance the quality of life after menopause. It is within your power to take very practical measures that can prevent or alleviate many of the symptoms that occur.

For example, there is a natural approach to take against osteoporo­sis. Remember that osteoporosis is preventable if you can control two main processes. First, you can develop as much bone as possible during your first forty years, before menopause. Second, you can reduce the rate of bone loss that may occur after menopause.

Success in doing these things often requires some changes in life­style that call for dedication and persistence. But, studies have shown conclusively that an inappropriate diet, lack of weight-bearing exer­cise, and heavy cigarette smoking contribute to loss of bone. If you are willing to make a few changes in your lifestyle, you could protect your skeleton.

There is still the problem of hot flashes and the question of whether, they can be alleviated without drugs. Hot flashes are one of the most disabling symptoms of menopause. They can interfere with the quality of a woman’s life and even with her ability to function. There is no doubt that HRT remains the most effective method known for dealing with this symptom.

For women who cannot tolerate taking estrogens, or who are not medically permitted to take HRT, the fact that nonhormonal medica­tions are not generally effective can be a desperate medical dilemma. Biofeedback training may provide some relief in such cases. With this process women learn to control and manipulate various body mech­anisms, such as heart rate, blood vessel diameter, and muscle tension, which are usually controlled without your awareness by your autono­mous nervous system. Research in biofeedback training is still in its early stages, but we hope that in the future it may offer a nonpharmacologic means of reducing the discomfort of hot flashes.

Work continues as well with progressive relaxation training, a fairly recent method for learning how to relieve stress and tension through practiced relaxation, which may bring some relief. While new tech­niques are under study, you can try other minor changes in your lifestyle to reduce the severity or the number of your hot flashes. Changing the kind of clothes you wear may help. Give up heavy sweaters and try layering clothing instead. Alter your activities when­ever possible to reduce stress. Attempting to gain some conscious control of your hot flashes through relaxation therapy may be produc­tive. A good relaxation therapist can teach you how.

Avoiding Cardiovascular Disease

As we will discuss later, the use of estrogen in HRT does appear to be associated with a distinct reduction in the risk of cardiovascular disease. Other factors can also be employed to reduce the incidence of this disease.

Other ways of combating heart disease without estrogen include stopping smoking. Smoking is the most harmful of all habits and probably the most significant cause of coronary heart disease. Another method is gaining control of the stresses in your life and working toward reducing your negative responses to them if you cannot elimi­nate the stresses themselves.

Enhanced Well-Being

Exercise also produces this special feeling of well-being. Often termed “runner’s euphoria” or “swimmer’s high,” athletes some­times cite this sense of well-being as one of the benefits of pursuing their sport. Many people start an exercise program, lose interest, and drop out. Quitting is most likely to occur during the first three months of an exercise program, which is a shame, because most studies show that the mood-enhancing effects of exercise develop strongly after three months of regular exercise. After several months, you usually achieve physical fitness as well. If you hang in there, you can expect to feel better, enjoy all of your activities more, combat exhaustion from work, and perhaps relieve menopausal discomforts.

Menopause and Hormone Replacement Therapy

Hormone replacement therapy (HRT) does exactly what its name suggests – it replaces the hormones that a woman’s body ceases to produce after the menopause.

Eternal youth

HRT has been touted as an ‘elixir of life’, a magic potion that can reverse the effects of ageing, keeping a woman young forever. HRT is not the answer to eternal youth, but it can make many women feel younger. Successful treatment of exhausting hot flushes and sleepless nights restores energy. In turn, feeling better means it is easier to take regular exercise and follow a healthy diet, both of which have their own benefits.

Critics are sceptical that the menopause requires any medical intervention and see it as a natural event that should run its own course. This is fuelled by the fact that not every woman becomes severely oestrogen-deficient after ‘the change’. Although the ovaries are the main source of oestrogen, the adrenal glands produce small amounts and oestrogen is also formed in fat. These extra-ovarian sources are insufficient to restore fertility but may be adequate to prevent the development of severe menopausal symptoms.

Fear of cancer, particularly breast cancer, is another cause for concern but studies suggest that the risks are minimal if HRT is taken for less than 10 years. Even then, the evidence for increased risk is controversial.

Many women accept these risks once they realise the benefits of HRT, although some find it hard to cope with a return of monthly ‘periods’ and the regular pill taking that many regimens require.

Progesterone protection

Although oestrogen replacement effectively relieves the symptoms of the menopause, it is not without its problems. Doctors noticed a sudden increase in cancer of the lining of the womb, the endometrium, that was clearly linked to treatment. The oestrogen was stimulating growth of the endometrium resulting in the formation of potentially cancerous cells. In a percentage of women, true cancer developed but in a form that, in most cases, responded to treatment. Fortunately, a simple means of prevention was found -a 12-day course of synthetic progesterone (called progestogens) taken each month ‘opposes’ the oestrogens creating an artificial bleed similar to a ‘period’, which expels any cancerous cells. Women who have had a hysterectomy are not at risk of endometrial cancer and can safely take ‘unopposed’ oestrogens.

Refuting myths

Many of the fears associated with HRT are due to its effects being confused with those of the oral contraceptive pill. In fact, they are entirely different.

The oral contraceptive pill contains high doses of synthetic oestrogens which are up to eight times more potent than the natural oestrogens used for HRT. These high doses are necessary to prevent the ovaries releasing an egg each   month, producing a contraceptive effect. A disadvantage of synthetic oestrogens is that they make blood more sticky, increasing the risk of clots and thromboses in veins and arteries, which can lead to heart attacks and strokes. In contrast, natural oestrogens have minimal effects on blood clotting, and the dose used for HRT is equivalent to the amount produced in the body during the normal menstrual cycle. Natural oestrogens reduce the risk of clots in arteries, so heart attacks and strokes are less likely to occur. The risk of a clot in the veins (venous thrombosis) in a woman taking HRT is the same risk as she would have during her re­productive years, although this is greater than for a postmenopausal woman who is not using HRT.

Because of these important differ­ences, women who were unable to take the ‘pill’ can safely take HRT.

Unfortunately many myths surround the use of HRT and misinformation abounds, even within the medical profession. Research shows that women obtain most of their information from non-experts, especially the media, so it is not surprising that there is so much confusion about HRT.

Who Benefits from HRT?

There are two main reasons why you may wish to take HRT. First, you may want to obtain relief from hot flushes, night sweats, sleepless nights, depression, painful intercourse, bladder problems and other symptoms of the menopause. However, you do not need to have symptoms to benefit from HRT. The second, and probably the more important, reason to take it is the protection that it provides against increased risks of osteoporosis and heart disease associated with post­menopausal oestrogen deficiency.

HRT for menopausal symptoms

These often rapidly respond to HRT, sometimes within a few days, although it can take longer for the hot flushes to settle down. It does not matter which type of oestrogen replacement you take, providing the amount is sufficient to relieve symptoms.

Protection against osteoporosis and heart disease

About 15 years after the menopause, fractures and heart attacks increase because oestrogen levels are insufficient to have a protective effect. Ideally, substitute protection against these conditions needs to start as soon as the levels of oest­rogen fall.

This will be around the age of 50 for the natural menopause but may be earlier if you have had a hysterectomy or an early menopause.

Risk factors for osteoporosis

– Age

– Alcohol intake

– Bed rest

– Caffeine intake

Diet lacking in calcium

– Early menopause

– Family history

– History of amenorrhoea

– Lack of exercise

– Little exposure to daylight

– Number of years since menopause

– Number of pregnancies

– Oral contraceptives

– Previous fracture(s)

– Racial origin: white women are more susceptible than black

– Smoking

– Thyroid overactivity

– Use of oral steroids

Risk factors for heart disease

– Age

– Alcohol intake

– Diabetes

– Early menopause

– Family history

– High blood pressure

– High cholesterol

– Lack of exercise

– Number of years since menopause

– Oral contraceptives

– Personality

– Previous heart attack

– Smoking

Doctors currently recommend between 5 and 10 years of treatment with HRT for therapy to be of sustained value. Longer-term use would probably provide greater protection, but this needs to be balanced against an individual’s tolerance of HRT and associated risks.

The decision whether or not to take long-term HRT can only be made by assessing the balance of your individual risks versus possible benefits. The benefits of HRT will depend on your personal circum­stances, and your individual risk of fractures or heart disease.

Menopause Guide – What Hormone Replacement Therapy Can Do for You

Most of the changes that happen to your body when your hormone production slows down can be prevented, and many others can be reversed.

Exciting scientific advances in the last fifty years have given rise to whole new groups of hormonal and nonhormonal medications for use during and after menopause. These are not remedies prescribed over the telephone or obtained over the counter, but ones that must be discussed with and carefully prescribed by your own physician and taken under your doctor’s supervision.

There is nothing new about the theory of “rejuvenation” therapy. Ancient Egyptians introduced organotherapy, or glandular therapy, and ate the penis of the ass for this purpose. Ancient Greeks and Romans changed the prescription to asses’ testicles. Early scientists of the 1800s added other ideas to that kind of treatment. More than one hundred years ago, in 1888, a seventy-two-year-old famous French physiologist, Brown-Sequard, reported that he had rejuvenated him­self by taking injections of “testicular juice.” He wrote that he achieved greater body vigor, improved bladder and intestinal func­tion, and that his wife used the testicular extract to combat feminine discomforts.

By the close of the nineteenth century, ovarian therapy started, with ovarian juice, powdered ovaries, and powdered ovarian tablets pre­scribed for surgical menopause, dysmenorrhea, and obesity. In 1926, A. S. Parkes and C. W. Bellerby, two scientists in Great Britain, extracted female hormone from an ovary for the first time. They named it estrin. A few years later, a German chemist, A. Butenandt, isolated and synthesized a pure form of estrogen and progesterone. He won the Nobel Prize for his work. Now that these hormones were available, physicians prescribed them for a wide range of women’s symptoms.

The wholesale prescription of this treatment became so popular that by the 1960s many books and articles ascribed all sorts of value to it, but did not describe any of the risks. The use of these powerful hormones escalated. Physicians and women alike were shocked when, in December 1975, scientific papers were released showing a causal relationship between hormone therapy and cancer of the uterus.

Women became afraid to use these medications. Fear, coupled with confusion and combined with a lack of comprehensive information, reigned. The only redeeming feature of this frightening dilemma was that scientists, physicians, and paramedical specialists finally began to conduct intensive research on the phenomenon of menopause. As a result, today physicians are able to reassure women because they have a fuller understanding of how menopause works. They now know much more about how the hormones function, how they can safely be prescribed, and what other forms of observation and treatment are necessary for their female patients.

While hormone replacement therapy (HRT) for postmenopausal women continues to be somewhat controversial, it is growing in popu­larity. Earlier, we described how the ovary starts to lose certain hor­mones and what happens to women as a result. Remember, too, that this hormone deficiency is more severe in some women than in others. The purpose of HRT is to make up for that deficiency. Not all women can take HRT, and not all women need to. For women who can, and who choose to, HRT holds the promise of preventing or reversing many of the negative effects on the body caused by the lack of estrogen.

Different Ways to Take HRT

HRT can be taken in a variety of ways. There are advantages and disadvantages to each of the different methods.

Pills

The most often prescribed and easiest method of taking HRT is via a tablet or capsule. This traditional method of taking the drug can create a problem. After you swallow the pill, the hormone enters the stomach and intestine, where it is absorbed into the circulatory system that leads to the liver. A problem can occur because the hormone undergoes change within the bowel before absorption and is absorbed as an altered substance with either reduced potency or different ef­fects. Once transported directly to the liver in large amounts, the hormone can again be changed by the liver. It can also stimulate various actions in the liver itself, some potentially good and some possibly harmful. Either way, the hormone, metabolized in the liver, enters the general circulation of the body and begins to work. Its benefits and risks depend on whether its composition was changed in the liver and to what degree. Pros and cons of tablet HRT.

Shots (Intramuscular Injections)

One method of bypassing the liver is to inject the hormone directly into the muscle. The hormone can be mixed into other substances that will cause it to absorb into the system slowly, which helps to lengthen the intervals between shots from daily to once a month. There are some disadvantages to this method. The main one is that there is a high level of hormones in the blood shortly after the injection, which diminishes over time. Thus, there is an imbalance in the treatment‘s overall benefit, because there may be too much hormone in the blood right after the shot is administered and too little later in the cycle. At present, shots cannot be spaced more than a month apart, and some women find that having to go to the doctor’s office to get an injection that often is disadvantageous because of the extra expenditure of time and money.

Implants (Subcutaneous Pellets)

Implants were popular in the 1960s and 1970s. They are outdated today. Since they may return in a new form, you should know how they work. The hormone combines with a solid material and is shaped into a pellet. The physician inserts the pellet into the subcutaneous fat through a small incision in the woman’s lower abdominal wall or the top of her buttock. The pellets dissolve slowly and the hormone is absorbed through the fatty tissue. Over the years, there were many different strengths and mixtures of hormones used as implants. There are potential disadvantages. First, they may be difficult to remove, if removal becomes necessary because of possible side effects such as infection at the site of insertion. Further, the lifespan of the implant is capricious, so it is very difficult to know how long they will work and when they should be replaced. Research is underway to create better release mechanisms for implants, and it is likely that implants will be one of the practicable methods of the future. Pros and cons of HRT implants.

Vaginal Creams (Vaginal Application)

Hormones can be applied directly to the vaginal area. Women who experience localized vaginal discomforts, such as dryness or itching, can obtain relief with this method. When women take estrogen vaginally, the hormone is absorbed through the vaginal epi­thelium into the blood system, which can be an advantage if the estrogen is needed, or a disadvantage if they should not be taking estrogen anyway, as is the case with women who have breast cancer and who therefore are not candidates for HRT. Because of this absorption, vaginal creams are not prescribed for women who should not take estrogen, but they can even be a problem for women who can take estrogen. These creams are impractical, because the amount of estro­gen absorbed is so variable and the body may absorb too much.

Patches and Creams (Transdermal Systems) Research in France in the early 1970s led to a breakthrough in the understanding of the absorption of hormones. It proved that estrogen creams rubbed onto the skin would be absorbed easily, enter into the circulatory system, and work well. The result is the availability of two newer ways to replace estrogen: a cream and a transdermal, or through-the-skin, patch.

The percutaneous cream contains specific strengths of hormones to be applied over a specified area of the body. In this way, a specific dose of the hormone can be administered on a daily basis. The hormone gets into the circulatory system without going through the liver so that the side effects generated by liver metabolism can be avoided. One disadvantage is that it can be messy. Moreover, a woman may acciden­tally vary the amount of skin she covers when applying the cream, which would result in a dose that is different one day from the next. Or the cream could be rubbed off before it is fully absorbed, with the same poor result.

Interestingly, there were early complaints by male partners of women using these creams because the men began to notice breast growth in themselves! This growth was presumably from couples lying close together and the cream accidentally being rubbed onto the man’s chest. The newer formulations of the cream have a rapid drying property that practically eliminates these rubbing-off and transfer problems.

Transdermal skin patches are the most recent breakthrough in estro­gen therapy. These specially devised patches place estrogen directly on the surface of the skin without the messiness or uneven coverage/ dosage of creams. The patches are similar in appearance to those that heart patients wear containing ever-ready nitroglycerin. The estrogen transdermal patch is a multilayered system. Beneath an outer imper­meable layer of plastic lies a reservoir of estrogen dissolved in alcohol, covered by a layer of permeable plastic.

This design is ingenious: It prevents the estrogen from seeping through the outside of the patch, while permitting it to seep inside to the skin, which gradually absorbs it. A ring of adhesive holds the patch onto the skin. The amount of estrogen given to a woman can be controlled by the size of the patch and the amount of estrogen that is inside the reservoir. These quarter-sized patches must be changed twice each week, every three to four days, so that they deliver a constant amount of estrogen. Women change these quickly them­selves. They are worn on the hip, upper thigh, or lower abdomen.

One disadvantage of the patch is that it may irritate the skin under it, which is a problem for about one in twenty women. This problem can often be alleviated by moving the patch to a new spot on the skin each time a new one is applied. The advantage of the patch and the skin cream is the ease with which the doctor can check the amount of estrogen in the blood at subsequent follow-up visits to fine-tune the dosage to meet the needs of each individual woman. Pros and cons of HRT skin patches.

How to Take HRT

The choice of different regimens for HRT depends on whether or not you have had a hysterectomy.

Women with a womb

Continuous oestrogen plus cyclical progestogen

This is the most common regimen. Oestrogens are taken continuously, without a break, either daily in tablet form, once or twice weekly in patch form, a gel or, occasionally, as an implant. Progestogens are added every month, either as a 10 to 14 day course of tablets, or as a double patch combined with oestrogen, replaced twice weekly for two weeks. Calendar packs are available to help you remember when to take the progestogens.

The choice of different regimens for HRT depends on whether or not you have had a hysterectomy.

Women with a womb

Continuous oestrogen plus cyclical progestogen

This is the most common regimen. Oestrogens are taken continuously, without a break, either daily in tablet form, once or twice weekly in patch form, a gel or, occasionally, as an implant. Progestogens are added every month, either as a 10 to 14 day course of tablets, or as a double patch combined with oestrogen, replaced twice weekly for two weeks. Calendar packs are available to help you remember when to take the progestogens. If oestrogens and progestogens are prescribed separ­ately, most doctors recommend that you begin the progestogen course on the first day of every calendar month. All these regimens should result in a withdrawal bleed near, or shortly after, the progestogen course. You should report any bleeding occurring at other times to your doctor.

More recently, long cycle HRT has been introduced. This involves taking oestrogens every day as usual, but only taking the progestogen course every three months, i.e. four with­drawal bleeds every year. Unfort­unately a week of placebo (dummy) tablets is included in the packet and some women notice a return of their symptoms during this time. As a result of this, some doctors recommend skipping the placebo week. The other disadvantage is that a relatively high dose of progestogen is necessary which can lead to side effects as well as heavy and/or prolonged bleeding. Despite this, long cycle HRT can still be useful for women who are not yet able, or are unable, to take the no-bleed HRT and who wish to reduce the number of withdrawal bleeds.

Continuous oestrogen plus continuous progestogen

One approach to overcome the regular withdrawal bleeds is to take a combination of oestrogen and pro­gestogen continuously – taking both hormones together prevents any thickening of the lining of the womb so a withdrawal bleed is unnecessary. Unpredictable bleeding is not un­common during the first few months, sometimes heavy and prolonged.

However, in most women who continue on this treatment, the bleeding usually settles within 12 months. Bleeding is less likely the longer a woman has been post­menopausal before she starts this regimen. For this reason, continuous combined regimens are only recommended for women who have been postmenopausal for at least one year. In these cases continuous combined HRT can be highly satisfactory, although missed pills are frequently associated with some spotting.

Postmenopausal women who have been taking cyclical HRT and who wish to change to a ‘no-bleed’ regimen should start the new tablets at the end of a withdrawal bleed, i.e. several tablets into a fresh pack of their old cyclical HRT. This reduces the likelihood of any further bleeding because the lining of the womb will be thin. A recent advance has been to give continuous oestrogens to women using the levonorgestrel-releasing intrauterine system (IUS), used for contraception. This has the particular advantage for women who are still menstruating and at risk of pregnancy. Further, the progestogen is released locally so side effects are few. Similar to other no-bleed regimens, irregular bleeding in the early months can be a problem but most women have no bleeding within one year. Although the IUS is used for contraception, at the time of writing it is not licensed for use as HRT combined with oestrogens.

As a result of the limited use of no-bleed HRT, the long-term effects of this treatment on cancer of the womb, or indeed on osteoporosis, heart disease and breast cancer, have yet to be fully evaluated.

Cyclical oestrogens

An early regimen advocated oes­trogen treatment for three out of every four weeks, omitting pro­gestogen therapy. This method is associated with increased risk of cancer of the womb and a return of menopausal symptoms during the oestrogen-free week. For these reasons it is neither safe nor effective. If you are using this regimen, see your doctor and change to a recommended one.

Women who have had a hysterectomy

Continuous oestrogen

Hysterectomised women have the advantage of not requiring proges­togens, which reduces side effects and maximises benefits. The choice of treatment is daily oestrogen tablets, once or twice weekly patches, oestrogen gel or six-monthly implants.

Doses of oestrogen

The correct dose of oestrogen depends on the reason for taking it. Relief of severe symptoms obviously requires a higher dose than relief of mild   symptoms.   Many   women wonder why levels of hormones are not tested; the simple answer is that, because normal levels of oestrogen vary so much, it is more appropriate to monitor symptom control. If symp­toms are not adequately controlled, the dose of oestrogen needs in­creasing; if side effects are a problem, the dose is too high. There is a minimum daily dose of oestrogen necessary to protect bone loss. The doses in the various preparations are as follows:

– 0.625 milligram conjugated oestrogens (daily tablets)

– 2 milligrams oestradiol (daily tablets)

– 40-50 micrograms oestradiol (once/twice weekly patches)

– 1.5 milligrams oestradiol – two metered doses (daily gel)

– 50 milligrams  oestradiol   (six-monthly implant).

Doses of progestogen

The correct dose of progestogen is critical because it can almost completely eliminate the risk of cancer of the womb. A minimum duration of 12 days of treatment is recommended but the dose depends on the type of progestogen:

– 0.7-2.5 milligrams norethisterone

– 150 micrograms L-norgestrel

– 10-20 milligrams dydrogesterone

– 5-10 milligrams medroxyproges­terone acetate

– 200-400 milligrams micronised progesterone.

When to start HRT

It is never too late to start HRT; older women with fractures or heart disease will still benefit. But the most rapid loss of bone occurs soon after the menopause and the risk of heart disease starts to increase, so the earlier you start HRT, the better. If you start HRT while you are still menstruating, some adjustment of the timing of the progestogen phase may be necessary to prevent irregular bleeding.

When to stop HRT

If you use HRT just to control menopausal symptoms you will probably need to take it for two to three years, although occasionally it may be necessary to continue for as long as five years. For long-term protection against osteoporosis and heart disease, at least five years, and possibly up to 10 years, of treatment are recommended. If you are happy taking HRT there is no reason why you should not continue treatment indefinitely, so long as you are aware of the possible increased risks associated with long-term use.