by Lisa Tedder 

In July, we discussed how the hormones estrogen, progesterone and testosterone function in the female body and what happens during perimenopause and menopause. As we continue the discussion, this month’s column focuses on hormone replacement therapy (HRT), a hot topic on social media and among women as recent research has evolved our understanding of the benefits and potential risks.

Past misconceptions of the risks of HRT have led to fear and underutilization of a therapy that could relieve many of the symptoms women experience throughout perimenopause and post menopause. This month, we are discussing HRT with Dr. Kelsey Shnaekel, a physician at St. Bernards Medical Center, who is board certified in obstetrics and gynecology and is a certified menopause practitioner with The Menopause Society.

Who is a good candidate for hormone replacement therapy?

For most women, experts agree that HRT helps to control moderate to severe menopause symptoms when initiated within 10 years of the onset of menopause or when a woman is under the age of 60. An evaluation of the patient’s health and goals by a qualified menopause provider followed by a discussion and shared decision making is pivotal for optimal results. “A majority of women are excellent candidates for at least local vaginal therapy,” said Shnaekel.

What does hormone replacement therapy involve? What options do women have?

There are a variety of options for HRT. Systemic hormone therapy is a type of HRT that affects the entire body to manage menopause symptoms that affect multiple body systems (hot flashes, night sweats or mood changes, etc.), unlike local hormone therapy which is focused on specific areas like the vagina. This type of therapy using estrogen and progesterone can be administered through pills, patches, gels, sprays or vaginal rings. Local vaginal estrogen therapy can be administered through creams or vaginal tablets. 

What are the pros for hormone replacement therapy?

There are many benefits for HRT. For appropriately counseled patients, HRT reduces symptoms such as hot flashes, night sweats, vaginal dryness and improves poor sleep, irritability and the brain fog that goes with it. Women can experience relief from vaginal issues like thinning of tissues and dryness. HRT is a good treatment for the bladder problems women often experience like recurrent urinary tract infections and overactive bladder spasms and urgency. Along with exercises focused on strength training and weights, diet and supplements with vitamin D and calcium, HRT can help prevent the bone loss that leads to bone fractures later in life. There are cardiovascular benefits if HRT is started within 10 years of menopause as the protective effect of estrogen largely accounts for why women develop heart disease later than men. It can also reduce the risk of developing diabetes along with a healthy diet and regular exercise.  

What are the cons?

Hormone therapy can cause breast tenderness, nausea and irregular bleeding or spotting. Other risks include stroke, blood clots, uterine cancer or breast cancer although these risks vary depending on a patient’s specific factors, health history, family history and the form of hormone therapy administration.

“In general, women who have breast cancer, uterine cancer, unexplained uterine bleeding, liver disease, a history of blood clots or cardiovascular disease such as strokes or heart attacks should not use hormone therapy,” said Shnaekel.

How long should you take HRT?

There is no cookie-cutter right time to stop hormone therapy. Women can choose to stop or decrease therapy based on changes in their health or family history. Although not proven by studies, slowly decreasing your dose of estrogen over several months or even over several years may reduce the chance that your hot flashes will return. You and your healthcare professional will work together to decide the best time to stop therapy. Generally, the longer the duration of therapy, the greater the risks, specifically for breast and uterine cancer. 

Is it ever too late to start HRT?

Most experts agree that if a woman has never been on HRT, initiation of therapy after age 60 has greater risks. Also, women 10 years or more past menopause will not see the same benefits as if they had started sooner.  

Are certain therapy delivery methods less likely to cause problems such as blood clots, etc.?

“Excellent question. There are therapies that are less associated,” said Shnaekel. “Patches have a slightly lower risk of blood clots but do have risks.”

Is there anything else you want women or your patients to know about hormone replacement therapy?

“Many women are good candidates for hormone therapy and all women deserve to at least have a conversation with their physician regarding options and risks and benefits of therapy,” said Shnaekel. “Not everyone will elect to use hormones, and that’s very reasonable. For those that don’t, there are other lifestyle modifications, over the counter options, or non-hormonal options for them. Please don’t suffer alone or in silence.”

The biggest takeaway for women is to have a basic understanding of the hormonal changes they will undergo at some time in their life and what health consequences they will face as a result. It is so important to find a doctor who not only listens to your problems and concerns, but who has the training and experience to discuss your treatment options versus your potential benefits and risk to arrive at a shared decision for care. For additional information, visit The Menopause Society at menopause.org.