Hormones and Menopause

Cathy had been waking up during the night feeling hot and sweaty. That left her tired all day. Then she began to feel hot on and off during the day also, so she went to see her doctor. The doctor told her she was having hot flashes—a sign that she was going through perimenopause, the time around menopause. Her doctor talked about different ways to control the symptoms. One was using estrogen for a short time. Cathy and her doctor talked about the risks, as well as the benefits. Cathy said she remembered something in the news about using hormones around menopause. She was uncertain. What’s a woman to do?

A hormone is a chemical substance made by a gland or organ to regulate various body functions. To help control the symptoms of menopause some women can take hormones, called menopausal hormone therapy (MHT). MHT used to be called hormone replacement therapy or HRT. Some women should not use MHT. There are many things to learn about hormones before you make the choice that is right for you.

Cathy’s doctor told her to call back for a prescription if she decided to try using hormones to control her symptoms. After reading pamphlets from her doctor’s office, Cathy talked to her friends. Lily, who had surgery to remove her uterus and ovaries, has been taking estrogen since the operation. Sandy said she’s had a few hot flashes, but isn’t really uncomfortable enough to want treatment. Melissa’s doctor thinks she should not use estrogen because her younger sister has breast cancer. Each friend had a different story. Cathy needed more information.

Which hormones are used for menopause?

Cathy has a lot of questions, starting with the basics—what is menopausal hormone therapy?

During perimenopause, the months or years right before menopause, levels of two female hormones, estrogen and progesterone, in a woman’s body go up and down irregularly. This happens as the ovaries struggle to keep up with the needs of an aging woman’s body. The symptoms of menopause might result from these changing hormone levels. After menopause, when a woman’s ovaries make much less estrogen and progesterone, the symptoms of menopause may continue. Menopausal hormone therapy may help control these symptoms. A woman whose uterus has been removed can use estrogen alone to control her symptoms. But a woman who still has a uterus must take progesterone or a progestin (synthetic progesterone) along with the estrogen. This will prevent unwanted thickening of the lining of the uterus and also reduce the risk of cancer of the uterus, an uncommon, but possible result of using estrogen alone.

Why take these hormones? Why not?

Cathy’s doctor said the plus side of taking estrogen is that it is the most effective treatment for hot flashes, night sweats, and vaginal dryness. And it will help keep her bones strong. Cathy thought that those certainly seemed like good reasons to use MHT. But she wondered, is there a down side?

Menopause is a normal part of aging. It is not a disease or something that has to be treated. Women may decide to use menopausal hormone therapy because of its benefits, but there are also side effects and risks to consider. Two benefits of menopausal hormone therapy are:

• treating some of the bothersome symptoms of menopause
• preventing or treating osteoporosis

But for some women there are noticeable side effects:

• breast tenderness
• spotting or a return of monthly periods
• cramping
• bloating

By changing the type or amount of the hormones, the way they are taken, or the timing of the doses, your doctor may be able to control these side effects. Or, over time, they may go away on their own.

For some women there are also serious risks (see chart). These risks are why you need to think a lot before deciding to use menopausal hormone therapy.

Although the risks are small for any one woman, you need to take them into account. Much of the following chart on benefits and risks is based on one important clinical trial, the Women’s Health Initiative (WHI). This study looked at estrogen (conjugated equine estrogens) used alone or with a particular progestin (medroxyprogesterone acetate). Some other types of estrogen, progesterone, or progestin may have been tested in smaller clinical trials to see if they have an effect on heart disease, breast cancer, or dementia. Others have not.

Because the average age of women participating in the trial was 63, more than 10 years past the average age of menopause, some experts now question whether the WHI results apply to women around the time of menopause. The WHI study found that in every 10,000 women using estrogen plus progestin, there would be 7 more heart attacks than in every 10,000 women not using these hormones. Other research has suggested that if MHT is begun around the time of menopause, it might not increase the risk of heart disease as much as in older women in the WHI. This is a subject for further study.

Benefits and Risks of Menopausal Hormone Therapy—July 2006

Here is what scientists can say right now about the benefits and risks of MHT. Remember—which hormones you use, the way you take them, and the dose might affect these benefits and risks.

* Women who have had a hysterectomy have had their uterus removed.

How would I use the hormones?

Cathy’s friend Lily takes her estrogen in pill form, but Cathy has trouble swallowing pills. She hasn’t yet decided whether or not to use hormones, but if they only come as a pill, that would be part of her decision.

Estrogen comes in many forms and dosages. You could use a skin patch or vaginal tablet or cream, take a pill, or get an implant, shot, or vaginal ring insert. Progesterone or progestin is often taken as a pill, sometimes in the same pill as the estrogen. It also comes as a patch, shot, IUD (intrauterine device), vaginal gel, or suppository.

The form your doctor suggests may depend on your symptoms. For example, patches or pills can relieve hot flashes, night sweats, and vaginal dryness. They will also slow or prevent bone loss and help delay osteoporosis while you are using them. Other forms— vaginal creams, tablets, or rings—are used for vaginal dryness. The vaginal ring insert might also help some urinary tract symptoms. But, the dose found in these other forms is probably too low to relieve hot flashes.

What are “natural hormones?”

Cathy’s friend Susan thinks she is not at risk for side effects from menopausal hormone therapy because she uses “natural hormones” to treat her hot flashes and night sweats. Cathy asked her doctor about them.

The natural hormones Susan uses are estrogen and progesterone made from plants such as soy or yams. Some people also call them bioidentical hormones because they are supposed to be chemically the same as the hormones naturally made by a woman’s body. So-called natural hormones are put together (compounded) by a compounding pharmacist. This pharmacist follows a formula decided on by your doctor.

Drug companies also make estrogens and progesterone from plants like soy and yams. Some of these are also chemically identical to the hormones made by your body. You get these from any pharmacy with a prescription from your doctor.

One difference between the natural hormones prepared by a compounding pharmacist and those made by a drug company is that the compounded natural hormones are not regulated and approved by the U.S. Food and Drug Administration (FDA). So, we don’t know much about how safe or effective they are or how the quality varies from batch to batch. Hormones made by drug companies are regulated and approved by the FDA.

There are also “natural” treatments for the symptoms of menopause that are available over-the-counter, without a prescription. Some of these are made from soy or yams. They are not regulated or approved by the FDA.

Cathy’s doctor told her that there is very little reliable scientific information from clinical trials about the safety of bioidentical hormones, how well they control the symptoms of menopause, and whether they are as good or better to use than FDA-approved estrogens, progesterone, and progestins.

What’s right for me?

There is no “one size fits all” answer for all women who are trying to decide whether to use menopausal hormone therapy (MHT). You have to look at your own needs and weigh your own risks.

Ask yourself and your doctor these questions:

• How much are you bothered by menopausal symptoms such as hot flashes or vaginal dryness? Like many women your hot flashes or night sweats will likely go away over time, but vaginal dryness may not. MHT can help if your symptoms are troubling you.
• Are you at risk for developing osteoporosis? Estrogen might protect bone mass while you use it. However, there are other drugs that can protect your bones without the same risks as MHT.
• Do you have a history of heart disease? Using estrogen and progestin can increase your risk.
• Do you or others in your family have a history of breast cancer? If you have a family history of breast cancer, check with your doctor about your risk.
• Do you have a history of gall bladder disease or high levels of triglycerides? Some experts think that using a patch will not make your triglyceride (a type of fat in the blood)level go up or increase your chance of gall bladder problems. Using an estrogen pill might.
• Do you have liver disease or a history of stroke or blood clots in your veins? MHT might not be safe for you to use.

Then, like Cathy, talk to your doctor about how best to treat or prevent your symptoms or the diseases for which you are at risk. Ask about your other choices. Remember, these too may have risks and benefits. If you decide to use MHT, the FDA suggests that you use the lowest dose that works for the shortest time needed.

If you are already using menopausal hormone therapy and think you would like to stop, first ask your health care provider how to do that. Some doctors suggest tapering off slowly.

Whatever decision you make now about using MHT is not final. You can start or end the treatment at any time. If you stop, some of your risks will probably lessen over time, but so will the benefits. Discuss your decision about menopausal hormone therapy each year with your doctor at your annual checkup.

Unanswered Questions

Don’t forget at your checkup to ask your doctor about any new study results. Research on menopause is ongoing. Scientists are looking for answers to questions such as:

• How long can a woman safely use menopausal hormone therapy?
• Are some types of estrogen or progesterone safer than others?
• Is one form of such hormone therapy (patch, pill, or cream, for example) better than another?
• Is MHT safer if you start it around the time of menopause instead of when you are older?

For now, we know that each woman is different, and the decision for each one will probably also be different. But, almost every study gives women and their doctors more information to answer the question: Is menopausal hormone therapy right for me?

For More Information

Other resources on menopausal hormone therapy include:

National Institutes of Health (NIH)
Menopausal Hormone Therapy Information
www.nih.gov/PHTindex.htm

NIH MedlinePlus
The National Library of Medicine, NIH, has a website, www.medlineplus.gov, with information on many health subjects, including menopause. Click on Health Topics. Choose any topic you are interested in, such as menopause or menopausal hormone therapy, by clicking on the first letter of the topic and scrolling down the list to find it.

American College of Obstetricians and Gynecologists
409 12th Street, SW
Box 96920
Washington, DC 20090-6920
202-638-5577
www.acog.org

North American Menopause Society
P.O. Box 94527
Cleveland, OH 44101
440-442-7550
800-774-5342 (toll-free)
www.menopause.org

For more information on health and aging, including menopause, contact:

National Institute on Aging Information Center
P.O. Box 8057
Gaithersburg, MD 20898-8057
800-222-2225 (toll-free)
800-222-4225 (TTY/toll-free)
www.nia.nih.gov
www.nia.nih.gov/Espanol

To sign up for regular email alerts about new publications and other information about the NIA, go to: www.nia.nih.gov/HealthInformation

Visit NIHSeniorHealth (www.nihseniorhealth.gov), a senior-friendly website from the National Institute on Aging and the National Library of Medicine. This website has health information for older adults. Special features make it simple to use. For example, you can click on a button to have the text read out loud or to make the type larger.

July 2006

Reprinted March 2008