In the past hormone therapy was one size fits all. There were a
small number of pills and limited doses available. Now women have
multiple options from which they and their healthcare providers can
choose. The dosing options are more varied as well. This allows for much
better tailoring to meet a woman’s individual needs. In this article,
Dr. Sueny Seeney, describes the newer choices. — Beverly
Vaughn, MD, Medical Coordinator, Menopause and You Program
Hormone therapy, commonly known as HT, is a treatment used to provide
the estrogen and progestin that the body is producing in much lower
quantities because of menopause, premature ovarian failure, or surgical
removal of the ovaries.
In appropriate patients, HT can be the best treatment for many common
menopausal symptoms such as hot flashes, night sweats, and vaginal
dryness. It is also FDA approved for the treatment of osteoporosis. But,
it also has risks.
HT is normally prescribed at the lowest possible dose needed to control
the symptoms. Therefore it may take a while to establish the best
possible dose for each individual. Talking to a healthcare provider
about all options can help determine how and if HT should be prescribed.
Types of HT
HT comes in a variety of forms:
Most women begin with pill form because it’s easy to take, easy to stop,
easy to adjust the dose, and discreet. Reasons for choosing or changing
to an alternative include side effects (such as nausea), interference
with other medications, unsatisfactory control of symptoms, and
remembering to take it every day.
There are many different HT pills available. Some contain just estrogen
or progestin/progesterone and others contain a combination. These
typically contain higher doses of hormones than patches because the pill
has to be broken down by the stomach and liver before being delivered
into the bloodstream.
HT skin patches are worn on any location below the waist. Skin patches
allow a gradual absorption of hormones through the skin. Since they
don’t have to travel through the stomach and liver first, the dose is
lower than the dose in pills, which may result in fewer side effects.
Although the patch is easy to stop and typically has fewer side effects
than the pill, it may be visible, cause skin irritation, or fall off.
Women also need to remember to change it once or twice a week.
Implants containing estrogen, typically in pellet form, are surgically
inserted under the skin where the hormones are broken down and delivered
into the body at variable rates. This involves a minor surgical
procedure done in a physician's office approximately once every six
months with the use of a local anesthetic.
Implants are long-lasting and eliminate the need for patient compliance
with dosing schedules. They are also useful for women who have trouble
absorbing hormones in other forms. However, implants are not easy to
remove if the woman chooses to stop or to alter the dosage. Progestin or
progesterone tablets will also be needed. Effectiveness may be lessened
with continuous use.
Gels and Sprays
These work the same way as patches by delivering hormones through the
skin. Although gels are easy to stop, they can be messy, and the correct
amount needs to be applied each time. Gels are not commonly prescribed
for women who have experienced premature menopause.
Creams and Tablets
Creams use a plastic applicator, a bit like a syringe, to deliver a
measured dose of estrogen cream into the vagina to relieve dryness,
itchiness, and bladder dysfunction. There is a vaginal tablet that can
also be used. Neither, however, protects against osteoporosis, nor do
they help alleviate hot flashes and night sweats.
For vaginal symptoms only and for those concerned about taking estrogen,
these local methods are generally worth trying. However, if symptoms are
more general, a form of treatment which circulates throughout the whole
body may be indicated.
Femring®, a vaginal ring, can be inserted by a healthcare provider or
the individual into the vagina and worn for three months at a time. This
provides both relief of hot flashes and vaginal symptoms. There is
another ring, known as Estring®, which is placed in a similar manner.
The vaginal ring delivers a very low dose of estrogen each month with
very little absorption in the rest of the body. This is useful where the
main postmenopausal complaints are related to thinning of the vaginal
walls, vaginal dryness, and to problems with the urinary tract.
Some pills and patches have progestin in them. For those that do not, a
progestin or progesterone product need to be taken as well in order to
protect the uterine lining. If a woman has had a hysterectomy, use of
the progestin/progesterone is not required. Implants, gels, sprays and
the Femring® also require progestin/progesterone. The Estring® because
of the lower dose, does not.
Taking Hormone Therapy
Pills and patches are forms of combined HT (estrogen and
progestin/progesterone). This can be recommended for women who are
experiencing menopausal symptoms and are still having periods, but it
can also be used in women who have ceased their menses. Using combined
HT usually involves taking a form of estrogen every day of the month,
and progestin/progesterone is added for only part of each month. It is
meant to mimic the natural menstrual cycle and patients may have light
or menstrual-like bleeding on the days the progestin is not taken.
Continuous Combined HT
Continuous HT involves taking both estrogen and progestin/progesterone
daily. While there is usually no “period,” irregular bleeding can occur
the first few months, but usually subsides within a year. Spotting or
bleeding can sometimes be corrected by adjusting the dose, the regimen,
or the type of hormone products used.
It may be necessary to work through several different types of HT before
finding the best solution. It is also possible to prescribe each
component of HT separately to tailor the mix of hormones to each
individual’s needs. It’s important to consult a healthcare provider to
learn more about HT’s benefits and risks in order to choose the
appropriate and most effective regimen.
This article is part of the Menopause and You library,
a Web-based program sponsored by Women’s Health Source.
It is intended as an information resource providing guidelines for
women. As always, check with your own healthcare practitioner with your
specific concerns and questions.
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