The medication that is most effective at treating the symptoms of menopause is estrogen. In a woman with a uterus, progesterone must be used along with estrogen to protect the uterus from uterine cancer. There are many ways of getting these hormones into the body. There are pills, patches, and creams that all have their place. For some women formulations that are specifically designed for hormone replacement therapy (HRT) may be the best option; for others a low dose birth control pill may work the best.
The same low dose birth control pills that are used for contraception can be very beneficial for the treatment of menopausal symptoms, especially in younger women. These pills are a combination of estrogen and progesterone and are much higher dosage than traditional HRT. It is not uncommon for women in their 40’s and early 50’s to require the kind of dosage of hormones that are found in birth control pills to get adequate symptom relief. The risks of the birth control pills are small but higher than traditional hormone replacement therapy. Women that smoke cigarettes, have liver disease, history of blood clots, or other contraindications to birth control pills should not use this approach.
There are pills that contain a combination of both estrogen and progesterone that work well for many women. The most common pill is the brand Prempro. The advantage to the combination pills is the convenience of only needing to take one pill per day. The disadvantage is that they come in fixed dosages. Some women will require a dose of HRT that is not available as a combined pill, in this case taking a separate estrogen pill and progesterone pill may be necessary.
There are also patches available. There are patches that combine both estrogen and progesterone, there are also patches that have the single dose hormone. Some women like the patches because they don’t have to take a pill every day, others do not like the sensation of having a patch on their skin or get skin irritation and prefer the pills. The medication is the same with similar risks and benefits regardless if it is taken as a pill or a patch.
There is also estrogen vaginal creams available. These work very well to relieve vaginal symptoms of the menopause such as vaginal dryness, irritation, itching, or pain with intercourse. The estrogen vaginal creams do not help much for hot flushes, night sweats, or mood changes that can often occur with the menopause. Because the systemic absorption of estrogen vaginal cream is very low, this can be used safely without adding progesterone. This is a great solution for women with vaginal symptoms of menopause but little or no systemic symptoms.
There are also hormone creams available. These are problematic because there is unpredictable absorption of the hormones which makes dosing difficult. It is particularly worrisome that the progesterone does not get absorbed adequately to protect the uterus. This can put women who use hormone creams at risk for uterine cancer. There are some people who advocate the use of progesterone creams alone as a treatment for menopause. These are typically providers outside of mainstream of medicine. They typically have their own specially formulated progesterone cream that they claim can solve problems of menopause. There is no scientific data that these creams work any better then placebo (a cream with no hormone at all). These products are a waste of money and do not produce real results.
The most common estrogen used for hormone replacement therapy is Premarin. This is a natural product that is obtained from horses. Premarin stands for “pregnant mare urine”. Pregnant horses spill large amounts of estrogen in their urine. Premarin is obtained from the urine of pregnant horses, it is isolated and put in a pill, cream, or patch form for use. There is no residual urine byproducts found in the Premarin. Estradiol is a synthetic form of estrogen that is available. There are other estrogens that are derived from plant products. Bio-identical hormones are hormones that are synthesized in the lab that have identical chemical structure to the hormones in the human body. Every company claims that their particular type of estrogen is the safest and most effective. The truth is there is really no difference between any of these choices in either the risk of the medication or its effectiveness. I recommend using the product you feel most comfortable with that is also covered by insurance.
The most common progesterone is Provera which is a brand name for medroxy-progesterone acetate. It works well, is very safe, and is inexpensive. There are other choices of progesterones available as well. Prometrium is one example. Some of these alternatives can be very expensive. There is no data that any progesterone has an advantage over any other. I recommend using a progesterone that you feel comfortable with and is covered by insurance.