MEDICATIONS: HORMONE THERAPY FOR MENOPAUSAL SYMPTOMS: THE FIRST FEW YEARS

Menopause is the time in a woman's life when menstruation, the monthly menstrual periods, end (usually at about age 51). Following menopause, a woman's ovaries (the twin organs that produce and release an egg during each monthly cycle) stop producing the sex hormones estrogen and progesterone. These sex hormones control menstruation and affect the body in many different ways.

As estrogen in particular drops to very low levels, your body may respond in several ways:

· You may experience hot flashes, which can make your face red and cause a sudden sensation of body warmth and then coldness as perspiration cools off.

· Your sleep may be interrupted.

· Your vaginal tissues may become thinner, which can cause vaginal dryness, itching and pain during sexual intercourse.

· Your bones often become thinner and lose calcium, which can lead to spine fractures, a curved spine (dowager's hump) and hip fractures, which are a major cause of hospitalization in elderly women.

· Your brain may respond to a lack of estrogen by causing mood swings, some memory loss, irritability, a lack of well-being, or depression.

· Your cholesterol level in your bloodstream may increase.

What the Latest Studies Are Telling Us

In 2002, the first part of the Women's Health Initiative (WHI) study indicated that prolonged use of hormone therapy with estrogen plus progestin (a synthetic form of progesterone) caused a slight increase in the risk of breast cancer. In women in this age group (average — 65 years) estrogen combined with a progestin also caused a slight increase in heart disease and strokes, and a slight decrease in the risk of fractures and colon cancer. For some women, there was a slight increase in breast cancer and heart disease in the first few years of hormone therapy. In August 2003, The Million Women Study from the United Kingdom confirmed the initial WHI study.

The second part of the Women's Health Initiative Study examined the use of estrogen alone in women who had previously had a hysterectomy. This study showed that using estrogen alone for up to five years did not increase the risk of breast cancer. While this study is reassuring, other studies suggest that longer use of estrogen alone might still be associated with an increased risk of breast cancer.

In addition, a recent analysis of the women in the estrogen-only arm of the WHI study indicated that when estrogen treatment was initiated between age 50-59, these women did not show an increased risk of breast cancer. Furthermore, these same women did not appear to have an increased risk of heart disease, and there is a suggestion that the risk for heart disease in this group may have been slightly reduced.

Another important part of menopause that many women experience but that these studies did not address, are the symptoms of menopause (i.e., hot flashes, night sweats, vaginal dryness and irritation, and painful intercourse). These symptoms usually occur during the first few years after the menopause, but may last longer for some women. For these symptoms, nothing is more effective than estrogen.

Menopause Symptoms Can Be Managed in Two Phases

In the first phase (for the short term), prevention of bone loss (osteoporosis) can begin along with estrogen treatment for specific menopause symptoms such as hot flashes and vaginal dryness. *After the first phase, women should discuss the risks and benefits of continuing hormone therapy (for the long term) with their doctor.

Remember that the short-term goals of treatment are different from the long-term goals. Short-term therapy is designed to relieve symptoms; long-term therapy helps to prevent bone loss. If you take hormones for less than three to five years, the risks are relatively low. If you are concerned about bone loss and are thinking about taking hormone therapy for more than five years, consult with your doctor to see whether hormone therapy or an alternative treatment is best for you.

Ways to Take Hormone Therapy

Hormone therapies come in a variety of combinations, dosages and forms. Many women take a pill form of estrogen combined with a synthetic form of progesterone called a progestin. Estrogen-only therapy is also prescribed for certain patients, especially for a woman who has had her uterus removed (a hysterectomy).

Forms of estrogen in low doses, such as vaginal rings, creams or tablets, can help treat certain vaginal symptoms. Hormone patches, gels, intrauterine devices, and slow-release capsules are some of the other forms in which hormones are given.

Alternatives to Hormone Therapy for the Early Symptoms of Menopause

Several alternative treatments for the prevention and treatment of menopausal symptoms are also available, although none are as effective as estrogen.

Hot Flashes

· A group of compounds called SSRIs (Selective Serotonin Reuptake Inhibitors)

· Gabapentin (also called Neurontin)

· Megestrol acetate (progestin-like compound)

· Medroxyprogesterone acetate (a progestin)

· Herbal medications and soy products have not been shown to be effective in scientific studies but many women report benefits

Vaginal Dryness and Painful Intercourse

· Small amounts of vaginal estrogen, in the form of a vaginal cream or ring, are effective, with only small amounts absorbed into the bloodstream.

· Two non-prescription agents can help with symptoms without the use of hormones: Vaginal moisturizers help to add moisture to vaginal tissues but do not cause the same thickening as estrogen does; and water soluble lubricants reduce the pain from sexual intercourse

Alternative Treatments for Long-Term Health Risks of Menopause

Bone Loss

· Bisphosphonates: This class of compounds decreases the rate of bone loss and prevents and treats bone loss.

· Selective Estrogen Receptor Modulators (SERMs): This class of compounds targets bone. Early studies suggest that they may also reduce the risk of breast cancer and heart disease.

· Calcitonin: This agent is used to treat bone loss in women who are more than five years past the time of menopause.

· Parathyroid Hormone: This hormone appears to be a very potent way to build additional bone on your skeleton. It is used primarily for the treatment of severe osteoporosis (bone loss) and taken by injection.

In addition to medications, you should get 1,200 to 1,500 mg of calcium each day (through a diet rich in calcium and supplements, as needed). Women over 70 should get at least 800 IU of vitamin D; women under 70 should talk with their doctors before taking vitamin D.* Also, regular exercise each day can further protect your bones.

Cardiovascular Disease

· Statins: A group of compounds that lower lipid (fatty substances like cholesterol) levels in your blood. These have been shown to lower the risk of cardiovascular disease in people with abnormal lipid levels and those with a family history of heart disease.

Colon Cancer

· Testing for blood in the stool

· Periodic colonoscopy or sigmoidoscopy (procedures to explore inside the bowel)

*At the time of this printing, the Women's Health Initiative calcium and vitamin D and risk of fractures study was released. The data are complex and have not yet been integrated with data from other calcium and vitamin D studies. A group of experts will likely evaluate the data and come to a consensus about calcium and vitamin D supplementation. As this consensus statement becomes available, it will be made available in future versions of this document.

The Importance of Healthy Lifestyle Choices

The Hormone Foundation strongly recommends good nutrition, weight loss when needed, regular exercise, alcohol in moderation, and no smoking, as these are important steps to staying healthy and the best ways to prevent disease.

Talk With Your Doctor

The Hormone Foundation recommends that each postmenopausal woman discuss with her doctor the best treatment for her, taking into account her medical and family history.

Questions You Might Ask Your Doctor During Your Next Visit

· How do I get relief for changes in my body due to the menopause?

· How long might these changes last?

· Will I need medical treatment? Or can I treat the symptoms with changes in my lifestyle?

· What can I do to prevent bone loss?

· What are the benefits and risks of taking hormones?

· Are there non-hormone treatments to treat my menopause symptoms?

· Are there other ways to take hormones besides pills?

· Are there herbs or other natural ways to treat my menopause symptoms?

· What difference does my health history and my family's health history make in the type of treatment I should consider?

· Can I get pregnant in the time leading up to the menopause?

The Hormone Foundation is the public education affiliate of The Endocrine Society, whose mission is to serve as a resource for the public by promoting the prevention, treatment and cure of hormone-related conditions.