Posted by Article on 10/28/2001, 7:48 pm

Hormone Replacement Therapy by Thomas L Lyons, MD In this day of the "pill popping" generation versus the "back to nature" groups, the idea of hormone replacement therapy has become one associated with more myths, rumors, and anecdotal solutions than actual physiologic data. The fear of cancer seems to be greater than the expectation of relief from the noxious symptoms associated with menopause. What Is Menopause? Before we can discuss hormonal replacement, we need to define the problem we need to solve. Although the "change of life" is many different things to different people, menopause is defined as that time when a woman has not had a menstrual period for one entire year. This event corresponds to the cessation of function of the ovaries, and, therefore, the lack of production of the hormones that women produce: namely, estrogen and progesterone. The climacteric is a descriptive term that includes not only cessation of bleeding but also the surrounding symptomatology associated with this passage in life. Also, if a woman has had her ovaries removed surgically (oophorectomy), she is considered to have reached menopause by virtue of losing the diseased ovarian tissue. What Happens at Menopause? In the USA, the average age at which menopause occurs is 51 years, but this is only an average. Menopause can happen as early as 35 or as late as 60. Before menopause actually occurs, though, women experience a period of time called 'peri-menopause'. This refers to the years leading up to the menopause itself. Symptoms that can occur during peri-menopause include sleep disturbances, hot flashes, palpitations, vaginal dryness, changes in skin and hair, decreased libido, memory loss, mood swings and depression. Any or all of these symptoms may be present in a patient for as long as ten years, making this problem one of the most pervasive in the adult life of women. At the same time, a few women experience virtually none of the aforementioned symptoms. When a woman with symptoms is surrounded by women who haven't had them, she can feel out of place, conspicuous, uneasy, and at a loss to explain what is happening to her. A woman who had surgical removal of her ovaries does not go through peri-menopause; she gets there all at once. Why Hormonal Therapy? The persuasive medical reasons for considering hormonal therapy as associated with preventing bad things from happening as a woman's natural hormones diminish. The most common of these bad things are the increasing occurrence of osteoporosis, or the loss of calcium from the bones, and the increase in problems with ischemic heart disease or heart attack in women who are menopausal. Obviously, there are many reasons why these problems occur in individuals, including family history of problems, diet, weight, smoking history and so on, but there does appear to be a catalytic effect in women who lack estrogen. The mechanism of the action is not completely defined in either instance, and the cardiovascular protective effects have come into question in certain groups, but there remains a suggestion from the American College of OB/Gyn that hormone replacement is appropriate in most situations. Certainly blood cholesterol profiles are significantly improved in women who are on hormonal replacement versus those who are not. There have even been suggestions that HRT is helpful against Alzheimer's. What About Cancer? The inevitable question remains whether or not hormonal therapy is safe and if it will cause cancer. This issue has been studied extensively in the past and still does receive an impressive amount of study and evaluation. There is also constant discussion of this risk in the lay literature and in the media. It would be helpful, therefore, to evaluate some of these recent studies and see what truly has been found. Many large studies have been done, including several that evaluate the risk of breast cancer and the use of estrogen replacement. Basically, these studies have shown that the risk of breast cancer is no different in women who use hormones for less than ten years vs. those who do not use any at all. The risk is very slightly higher in women who use estrogen for ten or more years. Interestingly, however, the risk of dying from breast cancer is lower in the hormone group vs. the non-hormone group. There appears, therefore, not to be a significant risk for the patient with regard to breast cancer in taking hormonal therapy. Cancer of the lining of the uterus, endometrial cancer, is also reputed to be more frequent in women on hormones. This is an inaccurate assumption. It is generally recommended that women who are on estrogen therapy and who have a uterus should take progesterone with their estrogen to reduce overall occurrence of an overgrowth of the uterine lining. This may also improve the incidence of irregular bleeding in some patients. Is it not absolutely necessary for a woman on hormonal replacement with estrogen to take progesterone, and many patients do not. There are some women who do not feel well on progesterone or who have medical contraindications to using these hormones. There are excellent studies, the largest of which is from the CDC in Atlanta, that show clearly that endometrial cancer risk is reduced in women on combined estrogen/progesterone hormonal therapy when these agents are administered over a prolonged period of time. My Doctor Won't Start Me on Hormones Because I Had Endometriosis! This is one of the most common situations that we encounter here at the CEC. There is no evidence that estrogen and/or progesterone cause endometriosis. There is a rising body of evidence that hormonal activity may exert a permissive role on endo only. In other words, there are a multitude of causes for this disease, many of which are not known, but the effect of estrogen on endometriosis is not a direct one. This probably explains why the "medical menopause" drugs that are so frequently prescribed have such a variable effect on the symptoms of endometriosis. They do not change the progress of the disease whatsoever. If we remove ovaries from a woman during surgery, it has long been my policy to place that patient on estrogen replacement immediately after surgery (generally in the Recovery Room). There certainly can be some variations, but by and large, most patients should be able to return to normal hormonal status as soon as possible. Of course the large majority of our endometriosis patients are treated with excision of their endometriosis and maintenance of their uterus, tubes and ovaries, so hormonal management of these individuals is not necessary. What About "Natural" Hormones? Estrogen and progesterone can be derived from natural plant sources such as soy and yams. Also, the drug Premarin is produced from the urine of pregnant mares, which of course is a natural source. Suffice it to say that all of the hormones on the market today closely mimic the natural mammalian hormones from the body. If they didn't, they would not be effective. We are fortunate that we are able to have many difference sources for these substances and can really be very precise in creating the environment needed for each individual. Hormone replacement therapy can be administered via pills, patches, creams, injections, and various inserts that are available from pharmacies only. Over-the-counter agents that claim to possess the same amounts of estrogen or progesterone as in prescription medicines are probably not to be believed. However, if they are effective at producing a symptom-free patient, then their role should be considered. I'm Still Confused. What Should I Do? Ask your doctor to sit down and discuss these issues with you. Hormone replacement therapy can be very important to your overall health and must be tailored to meet your needs and desires. It is absolutely imperative, however, that you are comfortable with your options and make an informed decision about this alternative. This can only happen when there is good communication between patient and provider.

Link: Online Article