Despite being prescribed for more than half a century, HRT’s benefits and risks aren't entirely known. It's estimated that 35 percent to 40 percent of postmenopausal Canadian women use HRT. Many of these women discontinue using HRT within 1 year for a variety of reasons. However, many also feel that the therapy is critical to thier continued health after menopause. This article looks at the treatment and how it is used.
Hormone replacement therapy (HRT) partially replenishes the hormones that diminish with menopause. It does so by providing a low dose of estrogen, often in combination with progestin — a natural or synthetic form of progesterone that simulates its effects — if your uterus is intact.
HRT has been available for more than 50 years, and its uses have expanded during that time. It has been most commonly used for controlling menopausal symptoms. Today, it’s also often used for longer-term protection against diseases you’re at risk of after menopause, such as osteoporosis.
If you're starting to experience menopausal signs and symptoms, such as irregular periods, hot flashes and vaginal dryness, your doctor may recommend that you take HRT short term — for a few years — to relieve those symptoms. Your doctor may also suggest that you take HRT longer than that for protection against health risks such as osteoporosis.
If you decide to take HRT, what you take in part depends on whether you’ve had your uterus removed (hysterectomy):
- If you've had a hysterectomy. If your uterus has been removed, estrogen is given alone, without a progestin. This estrogen-only therapy is called unopposed estrogen or ERT — for estrogen replacement therapy. ERT comes in a variety of forms — including pill, patch, cream or vaginal ring (for vaginal symptoms) — and can be customized to fit your needs. If estrogen alone isn't adequately controlling your symptoms, androgen may sometimes be prescribed along with estrogen.
- If you haven’t had a hysterectomy. If you still have your uterus, you'll usually be advised to take a progestin along with estrogen. Estrogen stimulates growth of your uterine (endometrial) lining, which if left unchecked, may become cancerous. Progestin balances estrogen's effect on the uterus. If you take a progestin with estrogen, you are not at an increased risk of developing uterine cancer. This estrogen-progestin therapy is sometimes referred to as combination therapy or hormone replacement therapy (HRT).
Forms of HRT
Women most commonly take HRT as a pill — either as a single estrogen-progestin pill or as two separate pills. However, other forms are available: You can use an estrogen patch, cream or vaginal ring (for vaginal symptoms). You can also take a progestin as a pill, as part of a combination patch including estrogen or, occasionally, as a vaginal gel.
Both estrogens and progestins also come in natural and synthetic forms:
- Natural. Natural forms of HRT are identical in structure (bio-identical) to hormones produced by your body.
- Synthetic. Synthetic hormones differ in structure from the hormones produced by your body, but imitate the important actions of those hormones.
Natural does not necessarily mean better than synthetic. Each can affect your body in a different way. For example, in some women, natural progesterone may produce fewer side effects — such as bloating or fluid retention — than do some synthetic progestins. However, synthetic estrogen may cause fewer side effects than does natural estrogen in some women. Synthetic estrogen has also been more widely studied for its effectiveness in postmenopausal women.
You generally take HRT in one of two schedules:
- Cyclic.A cyclic method provides estrogen daily and a progestin 10 to 14 days of the month. This usually leads to predictable, monthly vaginal bleeding, at least in the initial years you use it.
- Continuous. A continuous method provides low doses of estrogen and progestin daily and, though it doesn't cause monthly bleeding, may result in irregular spotting, particularly during the first year of use. Over time, bleeding ceases sooner when using the continuous cycle.
Another option includes taking estrogen daily and a progestin for 10 days every 3 months.
HRT is also prescribed in a number of dosing strengths. Low-dose regimens may be as effective as higher-dose regimens in reducing symptoms, preventing and treating osteoporosis, and improving cholesterol. However, some women may need to take the higher doses of estrogen for a period of time to relieve hot flashes. This dose can be tapered over time to a lower dose.
If you decide to take HRT, it's best to get an annual physical exam and mammogram to monitor your health status and review ongoing pros and cons of HRT for your particular situation.