Hormone therapy: Is it right for you?
Hormone therapy
was once routinely used to treat
menopausal symptoms and protect long-term health. Then
large clinical trials showed health risks. What does this
mean to you?
By Mayo Clinic Staff
menopausal symptoms and protect long-term health. Then
large clinical trials showed health risks. What does this
mean to you?
By Mayo Clinic Staff
Hormone replacement therapy — medications containing female
hormones to replace the ones the body no longer makes after menopause — used to
be a standard treatment for women with hot flashes and other menopause
symptoms. Hormone therapy (as it's now called) was also thought to have the
long-term benefits of preventing heart disease and possibly dementia.
Use of hormone therapy changed abruptly when a large clinical
trial found that the treatment actually posed more health risks than benefits
for one type of hormone therapy, particularly when given to older
postmenopausal women. As the concern about health hazards attributed to hormone
therapy grew, doctors became less likely to prescribe it.
Hormone therapy is no longer recommended for disease prevention,
such as heart disease or memory loss. However, further review of clinical
trials and new evidence show that hormone therapy may be a good choice for
certain women, depending on their risk factors.
What are the benefits of hormone therapy?
The benefits of hormone therapy depend, in part, on whether you
take systemic hormone therapy or low-dose vaginal preparations of estrogen.
·
Systemic hormone therapy.
Systemic estrogen — which comes in pill, skin patch, gel, cream or spray form — remains the most effective treatment for relief of troublesome menopausal hot flashes and night sweats. Estrogen can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse. Although the Food and Drug Administration (FDA) still approves estrogen for the prevention of the bone-thinning disease called osteoporosis, doctors usually recommend medications called bisphosphonates to treat osteoporosis.
Systemic estrogen — which comes in pill, skin patch, gel, cream or spray form — remains the most effective treatment for relief of troublesome menopausal hot flashes and night sweats. Estrogen can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse. Although the Food and Drug Administration (FDA) still approves estrogen for the prevention of the bone-thinning disease called osteoporosis, doctors usually recommend medications called bisphosphonates to treat osteoporosis.
·
Low-dose vaginal products.
Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms and some urinary symptoms, while minimizing absorption into the body. Low-dose vaginal preparations do not help with hot flashes, night sweats or protection against osteoporosis.
Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms and some urinary symptoms, while minimizing absorption into the body. Low-dose vaginal preparations do not help with hot flashes, night sweats or protection against osteoporosis.
Long-term systemic hormone therapy for the prevention of
postmenopausal conditions is no longer routinely recommended. But some data
suggest that estrogen can decrease the risk of heart disease when taken early
in postmenopausal years:
·
In a recent Danish study, after 10 years
of treatment, women receiving hormone replacement therapy early after menopause
had a significantly reduced risk of mortality, heart failure or heart attack,
without any apparent increase in risk of cancer or stroke.
·
A randomized, controlled clinical trial —
the Kronos Early Estrogen Prevention Study (KEEPS) — exploring estrogen use and
heart disease in younger postmenopausal women was recently completed, with
results expected soon.
For women who experience menopause naturally, estrogen is
typically prescribed along with progesterone or progestin (progesterone-like
medication). This is because estrogen alone, when not balanced by progesterone,
can stimulate growth of the lining of the uterus, increasing the risk of
uterine cancer. Women who have had their uterus removed (hysterectomy) don't
need to take progestin.
What are the risks of hormone therapy?
In the largest clinical trial to date, a combination
estrogen-progestin pill (Prempro) increased the risk of certain serious
conditions, including:
·
Heart disease
·
Stroke
·
Blood clots
·
Breast cancer
A related clinical trial evaluating estrogen alone (Premarin) in
women who previously had a hysterectomy found no increased risk of breast
cancer or heart disease. The risks of stroke and blood clots were similar to
the combination therapy.
Hormone therapy, particularly estrogen combined with a
progestin, can make your breasts look more dense on mammograms, making breast
cancer more difficult to detect. Also, especially when taken for more than a
few years, hormone therapy increases the risk of breast cancer, a finding
confirmed in multiple studies of different hormone therapy combinations, not
just limited to a combination estrogen-progestin pill (Prempro).
The risks of hormone therapy may vary depending on whether
estrogen is given alone or with a progestin, and depending on your current age
and age at menopause, the dose and type of estrogen, and other health risks
such as your risks of heart and blood vessel (cardiovascular) disease, cancer
risks and family medical history.
All of these risks should be considered in deciding whether
hormone therapy might be an option for you.
Who should consider hormone therapy?
Despite the health risks, systemic estrogen is still the most
effective treatment for menopausal symptoms. The benefits of hormone therapy
may outweigh the risks if you're healthy and:
·
Experience moderate to severe hot flashes
or other menopausal symptoms
·
Have lost bone mass and either can't tolerate
or aren't benefitting from other treatments
·
Stopped having periods before age 40
(premature menopause) or lost normal function of your ovaries before age 40
(premature ovarian insufficiency)
Women who experience an early menopause, particularly those who
had their ovaries removed and don't take estrogen therapy until at least age
45, have a higher risk of:
·
Osteoporosis
·
Coronary heart disease (CHD)
·
Earlier death
·
Parkinsonism (Parkinson's-like symptoms)
·
Dementia
·
Anxiety or depression
·
Sexual function concerns
Early menopause typically lowers the risk of most types of
breast cancer and ovarian cancer. For women who reach menopause prematurely,
protective benefits of hormone therapy usually outweigh the risks.
Your age, type of menopause and time since menopause play a
significant role in the risks associated with hormone therapy. Talk with your
doctor about your personal risks.
Who should avoid
hormone therapy?
Women with current or past history of breast cancer, ovarian
cancer, endometrial cancer, blood clots to the legs or lungs, stroke or liver
disease should usually not take hormone therapy. Women taking hormone therapy should
not smoke.
Women who aren't bothered by menopause symptoms and started
menopause after age 45 do not need hormone therapy to stay healthy. Instead,
talk to your doctor about strategies to reduce the risk of conditions such as
osteoporosis and heart disease, which might include lifestyle changes and
medications other than hormone therapy for long-term protection.
If you take hormone therapy, how can you reduce risk?
Talk to your doctor about these strategies:
·
Find the best product and delivery
method for you. You can take
estrogen in the form of a pill, patch, gel, vaginal cream, or slow-releasing
suppository or ring that you place in your vagina. If you experience only
vaginal symptoms related to menopause, estrogen in a low-dose vaginal cream,
tablet or ring is usually a better choice than an oral pill or a skin patch.
·
Minimize the amount of medication
you take. Use the lowest
effective dose for the shortest amount of time needed to treat symptoms, unless
you're younger than age 45, in which case you need enough estrogen to provide
protection against long-term health effects of estrogen deficiency. If you have
lasting menopausal symptoms that significantly impair your quality of life,
your doctor may recommend longer-term treatment.
·
Seek regular follow-up care. See your health care provider regularly to ensure that
the benefits of hormone therapy continue to outweigh the risks, and for
screenings such as mammograms and pelvic exams.
·
Make healthy lifestyle choices. Include physical activity and exercise in your daily
routine, eat a healthy diet, maintain a healthy weight, don't smoke, limit
alcohol, manage stress, and manage chronic health conditions such as high
cholesterol or high blood pressure.
If you haven't had a hysterectomy and are using systemic estrogen
therapy, you'll also need a progestin. Your doctor can help you find the
delivery method that offers the most benefits and convenience with the least
risks and cost.
What can you do if you can't take hormone therapy?
You may be able to manage your menopausal symptoms by healthy
lifestyle approaches, such as keeping cool, limiting caffeinated beverages and
alcohol, and by practicing paced relaxed breathing or other relaxation
techniques. There are also alternative medicine approaches, such as tai chi,
yoga and acupuncture. Work with your doctor to find a healthy, effective
approach that works for you.
The bottom line: Hormone therapy isn't all good or all bad
To determine if hormone therapy is a good treatment option for
you, talk to your doctor about your individual symptoms and health risks. Be
sure to keep the conversation going throughout your menopausal years. As
researchers learn more about hormone therapy and other menopausal treatments,
recommendations may change. If you continue to have bothersome menopausal
symptoms, review treatment options with your doctor on a regular basis.
IMPORTANT WARNING:
Estrogen increases the risk that you will
develop endometrial cancer (cancer of the lining of the uterus [womb]). The
longer you take estrogen, the greater the risk that you will develop
endometrial cancer. If you have not had a hysterectomy (surgery to remove the
uterus), you should be given another medication called a progestin to take with
estrogen. This may decrease your risk of developing endometrial cancer, but may
increase your risk of developing certain other health problems, including
breast cancer. Before you begin taking estrogen, tell your doctor if you have
or have ever had cancer and if you have unusual vaginal bleeding. Call your
doctor immediately if you have abnormal or unusual vaginal bleeding during your
treatment with estrogen. Your doctor will watch you closely to help ensure you
do not develop endometrial cancer during or after your treatment.
In a large study, women who took estrogen with
progestins had a higher risk of heart attacks, strokes, blood clots in the
lungs or legs, breast cancer, and dementia (loss of ability to think, learn,
and understand). Women who take estrogen alone may also have a higher risk of
developing these conditions. Tell your doctor if you smoke or use tobacco, if
you have had a heart attack or a stroke in the past year, and if you or anyone
in your family has or has ever had blood clots or breast cancer. Also tell your
doctor if you have or have ever had high blood pressure, high blood levels of
cholesterol or fats, diabetes, heart disease, lupus (a condition in which the
body attacks its own tissues causing damage and swelling), breast lumps, or an
abnormal mammogram (x-ray of the breast used to find breast cancer).
The following symptoms can be signs of the
serious health conditions listed above. Call your doctor immediately if you
experience any of the following symptoms while you are taking estrogen: sudden,
severe headache; sudden, severe vomiting; speech problems; dizziness or
faintness; sudden complete or partial loss of vision;double vision; weakness or
numbness of an arm or a leg; crushing chest pain or chest heaviness; coughing
up blood; sudden shortness of breath; difficulty thinking clearly, remembering,
or learning new things; breast lumps or other breast changes; discharge from nipples;
or pain, tenderness, or redness in one leg.
You can take steps to decrease the risk that
you will develop a serious health problem while you are taking estrogen. Do not
take estrogen alone or with a progestin to prevent heart disease, heart
attacks, strokes, or dementia. Take the lowest dose of estrogen that controls
your symptoms and only take estrogen as long as needed. Talk to your doctor
every 3 to 6 months to decide if you should take a lower dose of estrogen or
should stop taking the medication.
You should examine your breasts every month
and have a mammogram and a breast exam performed by a doctor every year to help
detect breast cancer as early as possible. Your doctor will tell you how to
properly examine your breasts and whether you should have these exams more
often than once a year because of your personal or family medical history.
Tell your doctor if you are having surgery or
will be on bed rest. Your doctor may tell you to stop taking estrogen 4 to 6
weeks before the surgery or bed rest to decrease the risk that you will develop
blood clots.
Talk to your doctor regularly about the risks
and benefits of taking estrogen.
Why is this
medication prescribed?
\
Estrogen
is used to treat hot flushes ('hot flashes'; sudden strong feelings of heat and
sweating) in women who are experiencing menopause ('change of life', the end of
monthly menstrual periods). Some brands of estrogen are also used to treat
vaginal dryness, itching, or burning, or to prevent osteoporosis (a condition
in which the bones become thin and weak and break easily) in women who are
experiencing or have experienced menopause. However, women who need a
medication only to treat vaginal dryness or only to prevent osteoporosis should
consider a different treatment. Some brands of estrogen are also to relieve
symptoms of low estrogen in young women who do not produce enough estrogen
naturally. Some brands of estrogen are also used to relieve the symptoms of
certain types of breast and prostate (a male reproductive gland) cancer. Estrogen
is in a class of medications called hormones. It works by replacing estrogen
that is normally produced by the body.
How should this
medicine be used?
Estrogen
comes as a tablet to take by mouth. It is usually taken with or without food
once a day. Estrogen is sometimes taken every day and sometimes taken according
to a rotating schedule that alternates a period of time when estrogen is taken
every day with a period of time when estrogen is not taken. When estrogen is
used to relieve the symptoms of cancer, it is usually taken three times a day.
Take estrogen at around the same time(s) every day. Follow the directions on
your prescription label carefully, and ask your doctor or pharmacist to explain
any part you do not understand. Take estrogen exactly as directed. Do not take
more or less of it or take it more often than prescribed by your doctor.
Your
doctor may start you on a low dose of estrogen and gradually increase your dose
if your symptoms are still bothersome, or decrease your dose if your symptoms are
well-controlled. Talk to your doctor about how well estrogen works for you.
Ask
your pharmacist or doctor for a copy of the manufacturer's information for the
patient.
Other uses for this
medicine
This
medication may be prescribed for other uses; ask your doctor or pharmacist for
more information.
What special
precautions should I follow?
- tell
your doctor and pharmacist if you are allergic to any brand of oral
estrogen, any other estrogen products, any other medications, or any of
the ingredients in estrogen tablets. If you will be taking Estrace® brand tablets, tell your doctor
and pharmacist if you are allergic to aspirin or tartrazine (a food color
additive). Ask your pharmacist or check the manufacturer's patient
information for a list of the inactive ingredients in the brand of
estrogen tablets you plan to take.
- tell
your doctor and pharmacist what prescription and nonprescription
medications, vitamins, and nutritional supplements you are taking or plan
to take. Be sure to mention any of the following: amiodarone (Cordarone,
Pacerone); certain antifungals such as itraconazole (Sporanox) and
ketoconazole (Nizoral); aprepitant (Emend); carbamazepine (Carbatrol,
Epitol, Tegretol); cimetidine (Tagamet); clarithromycin (Biaxin);
cyclosporine (Neoral, Sandimmune); dexamethasone (Decadron, Dexpak);
diltiazem (Cardizem, Dilacor, Tiazac, others); erythromycin (E.E.S,
Erythrocin);fluoxetine (Prozac, Sarafem); fluvoxamine (Luvox);
griseofulvin (Fulvicin, Grifulvin, Gris-PEG); lovastatin (Altocor,
Mevacor); medications for human immunodeficiency virus (HIV) or acquired
immunodeficiency syndrome (AIDS) such as atazanavir (Reyataz), delavirdine
(Rescriptor), efavirenz (Sustiva), indinavir (Crixivan), lopinavir (in
Kaletra), nelfinavir (Viracept), nevirapine (Viramune), ritonavir (Norvir,
in Kaletra), and saquinavir (Fortovase, Invirase); medications for thyroid
disease; nefazodone; phenobarbital; phenytoin (Dilantin, Phenytek);
rifabutin (Mycobutin); rifampin (Rifadin, Rimactane, in Rifamate);
sertraline (Zoloft); troleandomycin (TAO); verapamil (Calan, Covera,
Isoptin, Verelan); and zafirlukast (Accolate). Your doctor may need to
change the doses of your medications or monitor you carefully for side
effects.
- tell
your doctor what herbal products you are taking, especially
- tell
your doctor if you have or have ever had yellowing of the skin or eyes
during pregnancy or during your treatment with an estrogen product,
endometriosis (a condition in which the type of tissue that lines the
uterus [womb] grows in other areas of the body), uterine fibroids (growths
in the uterus that are not cancer), asthma, migraine headaches, seizures,
porphyria (condition in which abnormal substances build up in the blood
and cause problems with the skin or nervous system), very high or very low
levels of calcium in your blood, or thyroid, liver, kidney, gallbladder,
or pancreatic disease.
- tell
your doctor if you are pregnant, plan to become pregnant, or are
breast-feeding. If you become pregnant while taking estrogen, call your
doctor immediately.
talk to your doctor about
the risks and benefits of taking estrogen if you are 65 years of age or older.
Older women should not usually take oral estrogen unless they are also taking
other hormones. Oral estrogen taken without other hormones is not as safe or
effective as other medications that can be used to treat the same condition.
- if
you are taking estrogen to prevent osteoporosis, talk to your doctor about
other ways to prevent the disease such as exercising and taking vitamin D
and/or calcium supplements.
What
special dietary instructions should I follow?
Talk
to your doctor about eating grapefruit and drinking grapefruit juice while
taking this medicine.
Talk
to your doctor about ways to increase the amount of calcium and vitamin D in
your diet, especially if you are taking estrogen to prevent osteoporosis.
What should I do if
I forget a dose?
Take
the missed dose as soon as you remember it. However, if it is almost time for
the next dose, skip the missed dose and continue your regular dosing schedule.
Do not take a double dose to make up for a missed one.
What side effects
can this medication cause?
Estrogen may cause side effects. Tell your doctor if any of
these symptoms are severe or do not go away:
·
breast pain or tenderness
·
upset stomach
·
vomiting
·
heartburn
·
constipation
·
diarrhea
·
gas
·
weight gain or loss
·
leg cramps
·
nervousness
·
depression
·
dizziness
·
burning or tingling in the arms or legs
·
tight muscles
·
hair loss
·
unwanted hair growth
·
spotty darkening of the skin on the face
·
difficulty wearing contact lenses
·
swelling, redness, burning, itching, or
irritation of the vagina
·
vaginal discharge
·
change in sexual desire
·
cold symptoms
Some side effects can be serious. If you experience any of
these symptoms or those listed in the IMPORTANT WARNING section, call your
doctor immediately:
·
bulging eyes
·
sore throat, fever, chills, cough, and other
signs of infection
·
pain, swelling, or tenderness in the stomach
·
loss of appetite
·
weakness
·
yellowing of the skin or eyes
·
joint pain
·
movements that are difficult to control
·
rash or blisters
·
hives
·
itching
·
swelling of the eyes, face, tongue, throat,
hands, arms, feet, ankles, or lower legs
·
hoarseness
·
difficulty breathing or swallowing
Estrogen
may increase your risk of developing cancer of the ovaries or gallbladder
disease that may need to be treated with surgery. Talk to your doctor about the
risks of taking estrogen.
Estrogen
may cause growth to slow or stop early in children who take large doses for a
long time. Estrogen may also affect the timing and speed of sexual development
in children. Your child's doctor will monitor him or her carefully during his
or her treatment with estrogen. Talk to your child's doctor about the risks of
giving this medication to your child.
Estrogen
may cause other side effects. Call your doctor if you have any unusual problems
while taking this medication.
If
you experience a serious side effect, you or your doctor may send a report to
the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting
program online [at http://www.fda.gov/Safety/MedWatch] or by
phone [1-800-332-1088].
What should I know about storage and disposal of this mpedication?
Keep
this medication in the container it came in, tightly closed, and out of reach
of children. Store it at room temperature and away from excess heat and
moisture (not in the bathroom). Throw away any medication that is outdated or
no longer needed. Talk to your pharmacist about the proper disposal of your
medication.
In case of
emergency/overdose
In
case of overdose, call your local poison control center at 1-800-222-1222. If
the victim has collapsed or is not breathing, call local emergency services at
911.
Symptoms of overdose may include:
·
upset stomach
·
vomiting
·
vaginal bleeding
What
other information should I know?
Keep
all appointments with your doctor.
Before
having any laboratory test, tell your doctor and the laboratory personnel that
you are taking estrogen.
Do
not let anyone else take your medication. Ask your pharmacist any questions you
have about refilling your prescription.
It
is important for you to keep a written list of all of the prescription and
nonprescription (over-the-counter) medicines you are taking, as well as any
products such as vitamins, minerals, or other dietary supplements. You should
bring this list with you each time you visit a doctor or if you are admitted to
a hospital. It is also important information to carry with you in case of
emergencies.
Brand names
·
Amnestrogen® (esterified estrogens)¶
·
Cenestin® (conjugated synthetic A estrogens)
·
Enjuvia® (conjugated synthetic B estrogens)
·
Estrace® Tablets (estradiol)
·
Estratab® (esterified estrogens)
·
Evex® (esterified estrogens)¶
·
Femogen® (esterified estrogens)¶
·
Menest® (esterified estrogens)
·
Ogen® Tablets (estropipate)
·
Ortho-est® (estropipate)
·
Premarin® Tablets (conjugated estrogens)
Brand names of
combination products
·
Covaryx® (containing Esterified Estrogens,
Methyltestosterone)
·
Essian® (containing Esterified Estrogens,
Methyltestosterone)
·
Estratest® (containing Esterified Estrogens,
Methyltestosterone)
·
Femtest® (containing Esterified Estrogens,
Methyltestosterone)
·
Menogen® (containing Esterified Estrogens,
Methyltestosterone)
·
Menrium® (containing Chlordiazepoxide,
Esterified Estrogens)¶
·
Milprem® (containing Conjugated Estrogens,
Meprobamate)¶
·
PMB® (containing Conjugated Estrogens,
Meprobamate)¶
·
Premarin® with Methyltestosterone (containing
Conjugated Estrogens, Methyltestosterone)
·
Syntest® (containing Esterified Estrogens,
Methyltestosterone)
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