HORMONE REPLACEMENT THERAPY - A Personalized Approach 

HORMONE REPLACEMENT THERAPY - A Personalized Approach

 
Amy Ochino, MD

Spokane, WA

 
Today, hormone replacement therapy (HRT) is often underutilized because of poor public image and perceptions.  It isn’t for everyone, but it can help a great number of women transition into menopause.  It is a personal decision to be made between a woman and her health care provider.

 
The average age of menopause is 51 years.  We define menopause as the absence of menses for a twelve month period of time.  The years preceding menopause, called perimenopause, are usually a three to five year period in which menopausal symptoms can begin.  This is the time of life that can be characterized by menstrual cycle changes, hot flushes, night sweats, mood changes and vaginal dryness.

 
Options for HRT depend on a woman’s symptoms.  Some women are lucky enough to go through their change of life with minimal concerns.  These women may not need any transition relief with HRT.  Many women, however, feel that their quality of life is much improved with the addition of HRT to help them through these hormonal fluctuations.

 
Traditionally, both estrogen and progesterone are discussed when considering HRT.  The treatment recommendation depends on whether or not a woman has had a hysterectomy.  Estrogen is the most helpful in relieving menopausal symptoms (hot flushes, night sweats, vaginal dryness, and mood changes); but, in women with a uterus, estrogen alone can lead to overgrowth of the uterine lining.  This can lead to a precancerous or even cancerous condition of the uterus over a long period of time.  To protect the uterine lining from overgrowth, the addition of progesterone is used.  If a woman has had a hysterectomy, progesterone is not necessary, but can still be used.  For example, the naturally sedating effect of some progesterone preparations can be utilized to help women with insomnia.

 
Another point of discussion is which menopausal symptoms are most concerning to the individual patient.  HRT can be used to treat the entire body (systemic HRT) to treat hot flushes,  night sweats,  mood changes,  etc…  or it can be used to treat only a specific symptom (local HRT) such as vaginal dryness or painful intercourse. 

 
Once a woman has decided to opt for HRT, she will need to decide what preparation would fit her lifestyle the best.  The preparations for HRT have increased tremendously in recent years and HRT is available in many forms.

 
1-Oral HRT such as pills

2-Topical HRT such as creams, gels and patches

3-Vaginal HRT such as ring inserts, vaginal creams, and vaginal tablets. 

 
Each of these preparations has a different dosing schedule ranging from 2 times daily to weekly to every 3 months.  A woman will need to discuss her lifestyle with her health care provider to decide which preparation is right for her.  Keep in mind that often times a few different preparations are trialed before the perfect match is achieved. 

 
After beginning HRT, it may take up to 3 months to see complete resolution of symptoms.  This is a time to be patient.  A follow up appointment at the 3 month mark is recommended to discuss persistent symptoms or possible side effects of HRT.  Adjustments in dosing or a change in preparation will often need to be made.  It is a good idea to keep track of symptoms or concerns (write them down if needed) so that changes can be made most effectively at this visit.

 
HRT dosing is not an exact science.  I counsel my patients by telling them that finding the correct HRT regimen and dose is like finding the perfectly fitting comfortable little black dress.  Once you have found it life is good, but the shopping can be tedious!

 
While HRT is a viable option for most women, some women should not use HRT.  This includes women with the following conditions-

1-      a history of breast cancer

2-      unexplained or irregular vaginal bleeding until it has been evaluated

3-      a history of blood clots or pulmonary embolism

4-      active liver disease

Other women should use caution when using HRT and they must weigh the risks and benefits of the medication with their health care provider.  This includes women with the following conditions-

1-      a strong family history of breast cancer

2-      a history of other female cancers (such as ovarian or uterine of vaginal cancer)

3-      active connective tissue disorders (such as lupus, scleroderma, etc,,,)

4-      a history of stroke or heart attack

5-      uncontrolled high blood pressure or diabetes

6-      a history of chronic migraine headaches

 
This list is not inclusive, thus it is extremely important to provide a full medical history prior to beginning HRT.  Annual visits, to review changes of your medical history, are important since some changes may warrant discontinuation, or modification of HRT. 

 
As our population ages and life expectancy increases, women can expect to spend more than 1/3 of their life after menopause.  Using HRT to help transition through the change of life can greatly improve the quality of these years.  Open communication between women and health care providers is integral to the success of menopausal management.