Hormone Replacement Therapy

Hormones are chemicals produced by glands in the body that control when and how certain organs work. In women, the hormone estrogen, produced by the ovaries, plays a key role in the reproductive system. It also affects a woman’s bones and the health of her heart and blood vessels.

During menopause, the ovaries stop producing estrogen and a woman no longer has menstrual periods. The loss of estrogen after menopause or surgery to remove the ovaries causes changes in her body. A woman may notice signs of menopause, such as hot flashes (also called hot flushes) or vaginal dryness. The lower level of estrogen also can increase her risk for fractures and heart attacks. For these reasons, many women whose ovaries are not producing estrogen choose to take hormone replacement therapy to restore estrogen and to protect against bone loss and heart disease.

Like all medications, hormone replacement carries some risks. Not all women who have low levels of estrogen should use it. This pamphlet explains how estrogen affects your body. You and your doctor should decide whether this treatment is right for you.

Your Body’s Own Estrogen

Estrogen is made mainly by the ovaries, two glands on either side of the uterus. The ovaries begin making estrogen when a girl goes through puberty, and continue to do so until menopause. But a woman is never completely without estrogen, even after menopause. It continues to be made by glands and body fat. In fact, women who are overweight sometimes lack the symptoms of menopause because their extra body fat allows them to make estrogen after the ovaries stop functioning.

Estrogen is produced in the ovaries during the entire menstrual cycle. It prompts the lining of the uterus and the endometrium to grow a thick layer of tissue each month. Progesterone is produced in the ovaries during the second half of the menstrual cycle. It further thickens the lining of the uterus. If the egg is not fertilized, it moves from the fallopian tube to the uterus and is absorbed. The levels of both of these hormones then drop. This signals the uterus to shed its lining. This shedding is your monthly period.

In addition to its role in reproduction, estrogen helps bones remain strong and protects against heart attacks. Women before menopause do not develop heart disease as often as men or as often as women after menopause.

Reasons for Decreased Estrogen

Menopause

Menopause is the most common cause of low estrogen in women. Changes linked with menopause often begin several years before periods stop. They may be triggered by gradually decreasing production of estrogen in the ovaries. For many women, this begins at about age 45-50.

At some point, a woman’s ovaries stop producing enough estrogen to thicken the lining of her uterus. At that point, her periods stop. The average age at the last menstrual period is 51, but the age can vary widely. Some women go through menopause at a much younger age.

Removal of Ovaries

A women’s estrogen level will drop if both of her ovaries are removed during surgery. The decrease in estrogen will be dramatic and sudden rather than a slow decline. This sudden loss of estrogen can cause sever symptoms of menopause.

Before Menopause

Even before menopause some women might not produce enough estrogen for a number of reasons. For example, extreme weight loss from anorexia nervosa, an eating disorder, can result in low estrogen production as can too much exercise. This can cause monthly periods to stop.

Effects of Low Estrogen

When estrogen levels are low a number of physical changes take place. This may happen at menopause. Women who are not going through menopause, but whose ovaries don’t produce enough estrogen, may have many of the effects of menopause.

Hot flashes are the most frequent symptoms of menopause. About 75% of all women going through menopause have them. A hot flash is a sudden feeling of heat that spreads over part or all of the body. Your skin may blush or sweat. This often occurs at night and can disrupt sleep. Hot flashes can come and go for several years.

Vaginal and urinary tract changes also may take place. When estrogen levels drop the lining of the vagina may become thinner and less flexible. There may be itching, burning, or discharge. Sometimes sex can be painful as a result. Some women may need to urinate more often. Painful urination, however, may be a sign of a urinary tract infection.

Osteoporosis or bone loss also occurs with reduced estrogen levels. After menopause a woman’s bones slowly lose calcium and protein and may become brittle. As a result of this loss older women are more likely to break bones. The hip, wrist, and spine are most often affected. The most serious impact of hip fractures is the marked increase in death rates that can occur. Up to one in five patients dies within 6 months of hip fracture from problems caused by lack of activity such as blood clots, stroke, heart attack, and pneumonia. Fair skinned, slender white women and Asian women are especially likely to get osteoporosis. Early menopause, low intake of calcium, not enough exercise, and smoking also put women at greater risk for bone loss. Even before menopause low estrogen levels increase the risk. You don’t have to be older to be at risk.

Emotional changes also can occur with low estrogen levels. They may be linked to the physical symptoms that menopause produces or to other factors such as stress. For example, some may be caused by the loss of sleep due to hot flashes.

Cardiovascular (heart and blood vessel) disease is more likely after menopause. It is a leading cause of death of women in the United States. Estrogen appears to help prevent heart disease. Once the ovaries stop producing estrogen a women’s risk of heart and blood vessel disease increases over time to equal that of a man.

Benefits and Risks of Hormone Replacement

Hormone replacement therapy can relieve the symptoms of low estrogen. But like any medication hormone replacement is not risk free. The decision to begin treatment depends on a women’s medical history, her symptoms, and her risk of bone loss and cardiovascular disease. Some women are less likely to develop problems due to low estrogen. Others choose not to use hormones. Only you and your doctor can fully weigh the risk of treatment against its benefits for you.

Benefits

With hormone replacement therapy, hot flashes occur less often and are less sever. They may stop altogether. Hormone replacement can also relieve vaginal dryness and pain during sex. Estrogen given at any time after menopause, or to women with low estrogen for other reasons can help reduce bone loss and protect against heart disease.

Risks and Side Effects

One concern about estrogen use is that it may cause cancer of the endometrium. Women without a uterus don’t have to worry about this. For women with a uterus it is thought that taking progestin with estrogen reduces this risk. In fact, women taking both estrogen and progestin have a lower risk of endometrial cancer than women who take no hormones. On the other hand, there is some question about the role of progestin in heart disease. While estrogens help reduce the risk, it is not known whether progestin may block some of the effect of the estrogen.

Women who choose not to take progestin should be monitored carefully for abnormal bleeding. Your doctor may perform an endometrial biopsy, in which a small amount of the tissue lining the uterus is removed and examined under a microscope.

Most studies suggest no link between hormone replacement therapy and breast cancer. Some studies, though, show that a woman’s chances of developing breast cancer increase a small amount if she has been taking hormones for more than 15 years. Like other women their age, women taking replacement hormones should have regular breast exams and mammograms.

About 10% of women receiving hormones have bothersome side effects. These can include breast tenderness, fluid retention, swelling, mood changes, and pelvic cramping. When progestin is used you may have vaginal bleeding once a month. This may bother some women. Ask your doctor what to expect and contact him or her if unexpected bleeding occurs.

Not for Everyone

Although most women benefit from taking estrogens, not every woman can take them. If you have had breast cancer, endometrial cancer, or liver disease, estrogen usually is not recommended unless your symptoms are so sever that you feel the benefit from taking it is greater than the risk. If you have a blood clotting disorder, have abnormal vaginal bleeding, or think you might be pregnant, tell your doctor.

There are ways to help control bone and heart disease besides hormone replacement therapy. Whether or not you use hormones, eating a balanced diet rich in calcium and low in fat, getting enough exercise, and avoiding alcohol and tobacco can help reduce the rate of bone loss and protect against heart disease. The earlier you begin this healthy life style, the more effective it will be in the long run. Your doctor can recommend other ways to treat the symptoms of menopause.

Taking Hormone Replacement Therapy

If you need hormone treatment, your doctor will explain how many days each month you should use the medication. Hormone treatment is most often prescribed in the form of pills. Sometimes estrogen is given through a patch placed on the skin. Estrogen creams used in the vagina can treat dryness, but do not work as well against other symptoms. New ways to give hormones are being studied. They include vaginal suppositories, injections, and implants.

You should follow your doctor’s advice carefully and be checked regularly. If you have any unexpected vaginal bleeding tell your doctor right away. Follow-up visits will include a blood pressure check, breast and pelvic exams, and a pap test. An endometrial biopsy may also be done.

Most women receive estrogen and progestin. The amount of each hormone needed to prevent low-estrogen symptoms varies from person to person. Changes in the dose may be needed. Treatment may last a number of years, even decades. If you take hormones to guard against osteoporosis and heart disease, long-term treatment is needed. When a woman stops taking replacement hormones, bone loss begins again.

Finally…

Hormone replacement therapy is the best way to prevent some of the health problems that confront women during and after menopause. It is not for everyone. However, benefits must be weighed against the risks that go along with the use of any medication. Talk with your doctor. Together the two of you can decide what kind of treatment, if any, is right for you.

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