When a woman goes through menopause the ovaries stop producing the hormones estrogen and progesterone. This can lead to significant symptoms. Hormone replacement therapy (HRT) involves replacing the hormones that are no longer being produced. Symptoms of menopause including hot flushes, night sweats, and vaginal dryness can be treated with HRT. Hormone replacement therapy can be very good at reducing symptoms and is very safe for most women. Like any medication, hormone replacement has potential risks and side effects.
Our thinking about hormone replacement therapy underwent a dramatic change in the last decade. We used to believe that HRT not only relieved the symptoms of menopause but also had significant health benefits. It was once thought that hormone replacement therapy decreased the risk of many diseases, allowing women to live longer and healthier lives. At that time we recommended HRT in much the same way as a multivitamin. We felt all post-menopausal women should be taking it. Data came out that made us rethink our approach to HRT. The best data shows that women that receive hormone replacement have a slight increase risk of heart attack, stroke, and breast cancer. This increased risk is very small but it probably does exist. The statistics say that for every 10,000 women that take HRT there will be 7 “events” more than if they did not take the hormones. “Events” include things like heart attack, stroke, and breast cancer. 7/10,000 is a small risk but it is not zero.
The current recommendation regarding hormone replacement therapy is to think of it like most medications. There are potential benefits for some women but also small potential risks. Some women have relatively few symptoms from menopause others have significant symptoms. If the menopause symptoms are interrupting quality of life, HRT should be considered. For some women, sleep is interrupted by night sweats. This can be very disturbing and cause tiredness during the day. Some women have severe hot flashes that interrupt there ability to function to their full potential. Still others have significant vaginal changes that cause discomfort or interrupt their sexual well being. Hormone replacement therapy can relieve these types of problems and may certainly be worth considering. Other women go through menopause with little or no issues, for these women HRT is probably not indicated. The benefit and risks need to be weighed to decide if HRT is right for any individual.
Most women will have an improvement of symptoms over time. For this reason hormone replacement therapy is usually not a lifetime commitment. I recommend for my patients to try going off the HRT every other year and see how they feel. If they feel fine off the hormone replacement they can stop them for good. If the symptoms are still present they should restart the HRT.
There are many ways that HRT is given. The hormone that relieves the symptoms is estrogen. The dose of estrogen necessary to relieve the symptoms of menopause will vary from woman to woman and will likely decrease over time. Estrogen given by itself increases the risk of uterine cancer and should not be given alone in a woman with a uterus. Estrogen is always given along with progesterone in a woman with a uterus. The progesterone protects the uterus form the estrogen and the risk of uterine cancer is not increased when HRT is given in this way. The exception to this is estrogen vaginal cream which has a local effect on vaginal symptoms. The vaginal cream is not absorbed into the blood stream in a dose that increases the risk of uterine cancer and can be given without progesterone. The estrogen vaginal cream works well for vaginal symptoms but dose not improve hot flushes or night sweats. If a woman has had a hysterectomy, estrogen can safely be given alone and there is no need to add progesterone.