Hormone Replacement Therapy

Aug 23, 2022

Hormone Replacement Therapy 101

For menopausal women in the Mount Pleasant and Charleston, South Carolina area, whether to use hormone replacement therapy can be a confusing issue.  Trying to navigate the data about hormone therapy on one’s own can leave a woman more confused than before she started. So, what exactly is hormone replacement therapy?  Hormone replacement therapy (HRT) involves giving back the hormones that are no longer produced by the ovaries after menopause or after surgical removal of the ovaries.   HRT is frequently used by women to relieve bothersome symptoms of menopause such as hot flashes/night sweats, vaginal dryness, or painful intercourse (otherwise called genitourinary syndrome of menopause), prevention of bone loss, insomnia, mood swings, depression and irritability.

Whether or not to use hormone therapy is a personal choice made between a woman and her doctor.  There is no one-size-fits-all approach to hormone therapy and treatment is typically individualized, taking into account the woman’s symptoms, age, her personal medical history, her family medical history, goals, and even cost. This conversation should not be rushed, and the treatment not limited to a prescription handed to the woman with little to no explanation as is often the case.

Many women were fearful of considering HRT after the findings of the Women’s Health Initiative (WHI) of 2001.  This was a large study that suggested a very small, but statistically significant increased risk of breast cancer in women using a combination of a certain type of estrogen (conjugated equine estrogens) and progestin (medroxyprogesterone acetate). Since that time however, more data have emerged that show the benefits of HRT outweigh any possible risk in women who initiate HRT early in menopause and at a younger age. North American Menopause Society Position Statement on hormone replacement therapy states, “Hormone therapy remains the most effective treatment for hot flashes and genitourinary syndrome of menopause.”

What are the risks?

Stroke: In users of HRT, studies show one additional stroke per 1000 women over 5 years.  This risk appears to be associated with oral use of estrogen, and less so with use of estrogen through the skin. The use of oral estrogen in any form, whether it be hormone replacement or birth control pills can increase the risk of certain clotting proteins produced by the liver.  The risk with estrogen replacement taken by mouth is far less than the risk with birth control pills, but still even less when the estrogen is delivered through the skin. 

Blood clots: The risk of a blood clot with HRT is about 1 per 5000 users per year, and again is associated with oral estrogen use as opposed to transdermal.

Uterine cancer: Use of estrogen alone in women who still have their uterus is associated with an increased risk of endometrial cancer (cancer of the lining of the uterus).  Therefore, in women who have not had a hysterectomy (surgical removal of the uterus), it is necessary to also use a progestin or progesterone to protect the uterine lining from the effects of unopposed estrogen.  Said another way, if you have your uterus and are taking estrogen you ALWAYS need a progestin with it!

Breast cancer: Studies from the WHI showed that in women who used HRT with a combination of conjugated equine estrogens and medroxyprogesterone acetate for more than 5 years, there were 6 additional cases of breast cancer per 10,000 women.  Ongoing studies show reduced risk with micronized (natural) progesterone and with using progesterone intermittently, and we will know more as these studies wrap up in the coming few years.

What are the benefits?

Reduction of hot flashes, night sweats, and vaginal dryness, insomnia, irritability, and brain fog.

Relief from vaginal dryness, painful intercourse, and urinary frequency.

Protection from bone loss, osteoporosis, and fractures related to osteoporosis.

Reduction of risk for heart disease, dementia, and type 2 diabetes in women who initiate hormone therapy before age 60 and in the first 10 years of menopause.

What are bio-identical hormones?

Bio-identical hormone is a termed coined in the early 2000s to refer to hormones that are exact replicas (molecularly identical) of the body’s natural hormones.  These hormones are made from plants and are still considered a medication and are usually available only with a prescription. Bioidentical hormones are made from plants such as wild yam or soy and these plant molecules are altered in a laboratory to produce an exact replica of our bodies’ own hormones. Regardless of the term bioidentical, these hormones can carry some of the same risks and side effects of synthetic hormones.

Can the symptoms of menopause be managed without hormone therapy?

There are a variety of non-hormonal therapies to manage the symptoms of menopause.  Some of these therapies are available without a prescription and others require a prescription from your provider.  Be sure to ask your provider about non-hormonal options for management of your menopausal symptoms.

What to avoid

First and foremost, avoid hormone therapy prescribed in a one-size-fits-all approach. Hormone therapy should be tailored to the individual woman’s symptoms, medical and family history, preferences, and goals.

Avoid situations where the risks, benefits, and potential side effects are not thoroughly explained.

Avoid using a provider who doesn’t thoroughly and clearly answer all your questions.

Avoid hormone pellets/implants and pellet clinics.  Hormone pellets are associated with supraphysiologic hormone levels (higher than the normal range).  Maintaining hormone levels in at supraphysiologic levels may increase a woman’s risk of cardiovascular disease and cancer and therefore is not recommended.

In summary, hormone replacement therapy can be a safe and effective answer to relief from bothersome menopausal symptoms. For women in the Mount Pleasant and Charleston, South Carolina area, Menopause Solutions, LLC offers women a level of expertise matched by none in the area. 

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