by Sheila Kambin, MD
Paoli Hospital Ob/Gyn Specialist

Introduction

Since the WHI study in 2002, many women want to discontinue their hormone therapy. This raises interesting questions such as; will I get my symptoms back and what is the best way to stop. While there is no one tried and true method for stopping hormone therapy, there are some good options. Dr. Sheila Kambin, Paoli Hospital ob/gyn specialist, nicely reviews these choices so that you can consider which may be best for you.

Background
Hormone therapy is primarily indicated to help alleviate the vasomotor symptoms of menopause, known as hot flashes, and for the treatment of vaginal dryness, which can lead to bladder symptoms and sexual dysfunction. Potential benefits of hormone therapy include the treatment of osteoporosis, the long term prevention of Alzheimer's disease, decreased risk of colorectal cancer, improvements in glucose metabolism, osteoarthritis, and even vision, hearing and dental health.  To date, there have been many conflicting studies regarding a woman's cardiovascular health and combined hormone therapy.  A recent well-publicized study did raise the question of potential harmful effects of combined hormone therapy in relationship to a woman's cardiovascular health with extended use over greater than five years.  While these findings are a reason for practitioners to be cautious regarding the extended use of combined hormone therapy, there are many other research trials that have been published over the past several decades that advocate otherwise. 

Why and When Should Women Discontinue Hormone Therapy?
Women may elect to discontinue therapy for many different medical or personal reasons.  After five years of treatment, I discuss with my patients the pros and cons of maintaining or discontinuing treatment with hormones.  As mentioned above, this number is somewhat arbitrary, though it offers patients a conservative timeline for therapy.  Medical reasons for the discontinuation of hormone therapy include but are not limited to known or suspected personal cancer of the breast, known or suspected estrogen-dependent cancer, undiagnosed abnormal genital bleeding, active thrombophlebitis, or thromboembolic disease such as clotting disorders, pulmonary embolus, heart attack, or stroke, and active liver dysfunction or disease.  It should be noted that a family history of breast cancer is not a medically recommended reason to discontinue hormone therapy, although, each patient must be given the opportunity to discuss her concerns with her gynecologist in relation to her individual risk factors and comfort level regarding the continuation or discontinuation of hormone therapy. 

How to Discontinue Hormone Therapy
There are generally no accepted guidelines among practitioners regarding the method of discontinuation of hormone therapy.  There are two practical techniques.  One is abrupt withdrawal and the other is to undergo a slow taper off of the medication.  Except for those patients stopping hormone therapy for medical reasons, I am a strong advocate of the latter technique.   

In order to prevent symptoms from rebounding immediately, women should slowly cut their daily dose of estrogen or combined hormone therapy in half.  This is done over whatever period of time seems tolerable.  For some individuals, this may take only two to four weeks and for others up to six months.  For example, a woman who is taking Prempro at a dose of 0.625/2.5 mg may elect to start taking 0.45/1.5mg tablets for several weeks. If symptoms recur and are intolerable, she may choose to go back up on her dose every other day and try taking the lower dose the remaining days of the week.  From this point, the 0.45/1.5 mg dose can be cut down to the 0.3/1.5mg dose.  Once a woman is on the lowest dose possible, she should try skipping her medication every other day, and tapering even further to two days a week of treatment, then one day, and then finally to complete discontinuation.  For women who are on what is called combined sequential therapy, where a progestin is taken for fourteen days of the month, it is recommended to modify the dosing of the progestin to every two to three months, once taking the lowest dose of estrogen. These patients should end their taper with a final progestin withdrawal bleed. 

What to Expect When Discontinuing Hormone Therapy
Among women who discontinue hormone therapy, the most commonly reported symptoms are joint pain and stiffness, fatigue, return of hot flashes, sleeping difficulty, abdominal bloating, headaches, breast tenderness, and vaginal symptoms.  Approximately twenty-five percent of women who stop hormone therapy will restart due to the above-mentioned symptoms.  One way to help minimize these symptoms is for women to lose weight and continue with or start a healthy exercise program.  Depending on the exact symptom that the woman experiences, different modes of delivery for treatment can be considered.  For women still experiencing disturbing hot flashes, transcutaneous administration of hormone therapy, with patches or gels, can be considered.  For those who are affected more by vaginal dryness, bladder symptoms, or sexual dysfunction, vaginal administration is a very good option.  For other women who still experience symptoms, but wish to remain off hormone therapy, there are alternative therapies such as the use of prescription medications that are nonhormonal or even acupuncture.

Women should be encouraged to be proactive in preventing bone loss once off hormone therapy.  If osteopenia or osteoporosis has already been diagnosed, then consideration should be given to adding a bisphosphonate such as fosamax or actonel to help prevent further bone loss.  For all women, calcium and vitamin D supplementation along with weight bearing exercise should be encouraged.

In Conclusion
It should be pointed out that there is certainly more than one way to discontinue hormone therapy.  Each woman needs to be recognized as an individual when considering the options.  A joint decision between practitioner and patient will lead to the most success in the end.

• Click Here to view a .PDF of this article!
• Return to the Newsletter Archive!
  
  

This article is intended as an information resource providing guidelines for women. As always, check with your own healthcare practitioner with your specific concerns and questions.