Hormone Replacement

Menopausal Hormone Therapy

(Adapted from a patient information leaflet issued by SAMS in 2005)

During the past few years, the results of certain studies of the effects of menopausal therapy have received widespread coverage in the media. This has caused some confusion about the place of hormones in treating problems associated with the menopause.

In September 2004, the South African Menopause Society published a consensus statement outlining present knowledge about the use of hormone therapy in the menopause. This article sums up that statement and is intended to help women make decisions about the use of hormone therapy. It is not intended to be a general treatise on menopause management but more of a guide to the advantages and disadvantages of menopausal hormone therapy that will serve as a starting point to help you with your own approach to the menopause. All decisions you make should be made in discussion with your doctor.

FORMS OF HORMONE THERAPY

Menopausal hormone therapy can be given as estrogen only replacement or as a combination of estrogen and progestin (progesterone). Women who have not had a hysterectomy should always take the combination as the progestin protects the lining of the uterus, controls bleeding and prevents cancerous change. Patients who have had a hysterectomy should take estrogen without progestin.

In order to understand more easily the degree of risk or benefit in using hormones these figures are given as incidence per 10000 users per year. i.e. the number of extra cases or fewer cases expected in a sample of 10,000 women taking hormone therapy when compared to 10,000 non-users.

ADVANTAGES OF HORMONE THERAPY

Prevention of Hot Flushes:

This is the main reason for the use of menopausal hormone therapy. It is the only treatment that,, in clinical trials, has been shown consistently to have a beneficial effect. Hot flushes and other associated symptoms - such as night sweats and palpitations - occur in most, but not all, women as they enter menopause. They last for a variable amount of time, eventually disappearing in most, but again not all, women. It has been shown that in most cases, low doses of hormones are effective and one should always use the lowest dose necessary to achieve relief.

Prevention of vaginal dryness and atrophy (shrinkage):

This is a common problem in menopausal women and can be adequately treated by using local estrogen preparations in the vagina. The absorption of these agents is extremely low and they are considered safe if used correctly.

Prevention of osteoporosis:

Hormone therapy has been shown to be extremely effective in preventing the bone loss associated with early menopause, increasing bone density where it is already low, and decreasing the risk of fractures. This effect however is lost fairly soon after stopping therapy. There are other proven alternatives for prevention and treatment of osteoporosis which should also be considered if this is the only reason for considering hormone use.

Prevention of colorectal cancer:

Recent studies have shown that hormone therapy combining estrogen with a progestin slightly decreases the risk of colorectal cancer (six fewer colo-rectal cancers per 10,000 users per year in the hormone group). This was not shown with estrogen only therapy.

DISADVANTAGES OF HORMONE THERAPY

Increased risk of venous thrombo-embolism:

The risk of venous thrombo-embolism (clots in the veins of the legs, lungs or retina of the eye) is doubled with hormone therapy (18 extra thromboses per 10,000 users per year). This is most often seen in the first year of use and is not affected by duration of use. Advancing age, obesity and a previous history of venous thrombosis increase the risk.

Increased risk of stroke:

Both estrogen only therapy and estrogen with progestin are associated with an increase in stroke risk (eight extra strokes per 10,000 users per year). This increase is only seen in women above the age of 60.

Increased risk of breast cancer:

There is a small increase in the risk of breast cancer in users of estrogen combined with a progestin. This slightly increased risk is not seen for the first five years of use. After that, the increase is about eight extra breast cancers per 10,000 users per year. The increase appears to disappear within five years of stopping hormone therapy. This increased risk does not appear to be present with users of estrogen without progestin.

AREAS OF INSUFFICIENT EVIDENCE

Heart Disease:

Hormone therapy does not offer protection against heart disease in women who have previously had heart disease. There have been insufficient studies in younger women without heart disease to assess whether hormone therapy has a role in prevention of later heart disease. At this stage hormone therapy should not be taken if the only reason for doing so is to prevent heart disease.

Alzheimers Disease:

The evidence at this stage is conflicting and therefore there is no firm conclusion about the role of hormone therapy in preventing Alzheimer's disease.

IN CONCLUSION

As with most interventions, there are benefits and drawbacks to taking menopausal hormone therapy. Treatment needs to be tailored to each woman's needs. The guiding principle should be to take the smallest possible dose for the shortest time necessary.

There appear to be very few problems related to its use for the first five years. After that, women - with guidance from their doctors - should try and come off therapy and see how they cope without hormones. Should symptoms once more become severe, therapy can be resumed - but should be re-assessed yearly.

Special investigations such as mammography, bone density assessment and cholesterol measurement can help you and your doctor assess your individual health profile and decide on correct management. It is also important to realize that lifestyle interventions such as correct diet, exercise, and stress relief are essential to health and well being in the menopausal years.