Hormonal Therapy for Women, Frequently Asked Questions

WHAT IS HORMONE THERAPY?

Hormone therapy (HT), estrogen and progesterone, provides women with the female hormones that decrease and are lost as women get older. When the hormone estrogen is given alone, it is usually referred to as "ERT." When the hormone progesterone is combined with estrogen, it is generally called "HT." Previously this was known as hormone replacement therapy (HRT). Estrogen is a female hormone that brings about changes in various organs in the body. Progesterone is a female hormone that prepares the uterus for a pregnancy each month. During the change-over to menopause ("perimenopause") these hormone levels start to decrease. This causes many uncomfortable symptoms (see below). When the ovaries stop producing estrogen and progesterone, menstrual periods come to an end. At this point, the woman has experienced menopause. Menopause is complete when a woman misses 12 consecutive menstrual periods.

WHAT ARE THE BENEFITS OF HORMONE THERAPY?

Hormone therapy has been used to relieve the short-term symptoms of menopause. These include:

  • Hot flashes.

  • Depression.

  • Memory loss.

  • Correcting irregular menstrual periods.

  • Night sweats.

  • Tiredness.

  • Mood disturbances.

  • Thinning of scalp hair.

  • Disturbed sleep.

  • Vaginal dryness.

  • Painful intercourse.

  • Loss of breast tissue.

Evidence shows that HT may be helpful in preventing colon cancer and bone loss (osteoporosis).

WHAT ARE THE SHORT-TERM RISKS OF HORMONE THERAPY?

  • Some women report side effects from taking Hormone Therapy, including:

  • Feeling sick to stomach (nausea).

  • Fluid retention.

  • Swollen breasts.

  • Acne, when taking HT with progesterone.

  • Unusual vaginal discharge and bleeding (if the uterus is present).

  • Headaches.

  • Some women think HT will make them gain weight. Research now shows this is not true. Some women do gain weight during menopause, but this is because their metabolism slows down as they age. They also may not be increasing their amount or level of physical activity as they get older.

  • Short-term benefits or side effects should become noticeable within days, weeks, or sometimes months after treatment begins.

LONG-TERM RISKS

These will not be easily noticeable for each individual woman. There are many factors involved that can contribute to long-term risks and side effects.

CANCER

There is concern that HT can increase the risk of some cancers, including endometrial cancer (lining of the uterus), breast, and certain (but not all) ovarian or cervix cancers, such as endometriod ovarian cancer.

When estrogen is taken alone, it raises the risk of endometrial cancer, if the uterus is still present. Adding progestin with estrogen (HT) can greatly reduce this risk. Progestin is added to prevent the overgrowth (hyperplasia) of cells in the uterine lining. Women who still have an intact uterus are generally given this combined therapy and should not take estrogen hormone alone without progesterone.

HT with estrogen and progestin has been linked to an increased risk of invasive breast cancer. Women who use estrogen plus progestin for four years or longer are more likely to develop breast cancer than women who have not used them for as long. This indicates that the therapy may have a cumulative effect.

The decision to take HT should be based on an overall look at the risk and benefits, and how they fit with your personal and genetic health profile.

Conditions that increase the underlying risk of developing breast cancer include:

  • Family history of breast cancer.

  • Early age of the first menstrual period (menarche).

  • Late age of child bearing.

  • High fat diet.

  • Late menopause.

  • Obesity.

  • Increased breast density on mammograms.

  • Certain non-cancerous (benign) breast lesions.

  • Excessive use of alcohol.

  • Extensive radiation exposure to the chest.

These factors need to be considered when deciding to take HT. If you are currently taking HT and have concerns, talk with your caregiver as soon as possible.

BREAST DENSITY

Taking both estrogen and progestin also can affect a woman's breast density. Increased breast density from HT makes it hard for a radiologist to read some special breast x-rays (mammograms). This leads to the need for follow-up mammograms, ultrasound or MRI (magnetic resonance imaging), or taking breast tissue samples that are surgically removed (biopsies). Increased density also is a concern because studies have shown that women age 45 and older, whose mammograms show at least 75 percent dense tissue, are at increased risk for breast cancer. However, it is not known if increased breast density due to HT carries the same risk for breast cancer as having naturally dense breasts.

About 25 percent of women who use combined HT have an increase in breast density on their mammograms. This is compared to about 8 percent of women taking estrogen alone. One study showed that stopping HT for about 2 weeks before having a mammogram improved the readability of the mammogram. But further research is needed to confirm the usefulness of this approach.

HEART DISEASE

In the past, taking HT (estrogen plus progestin) was thought to help protect women against heart disease. However, recent findings show that taking HT poses more risks than benefits. HT could increase a woman's risk for:

  • Heart disease.

  • Stroke.

  • Blood clot in the lung (pulmonary embolism).

  • Breast cancer.

  • Blood clots in the legs.

Women who have gone through menopause should not be given HT to prevent heart disease and other chronic conditions.

Women who have gone through menopause and who have heart disease, may have a greater risk of another cardiac event (like heart attack) after starting HT, at least in the short-term. For women who have had strokes, their risk for having another stroke goes up when they start taking HT. Hormones are not recommended for women with heart disease or for women who have had a stroke. If you have gone through menopause, talk with your caregiver about whether hormones are right for you. You can check the National Women's Health Information Center website (www.womenshealth.gov) for updates on postmenopausal hormone therapy.

OTHER RISKS INCLUDE:

  • Developing high blood pressure.

  • Developing gallbladder disease.

  • Women with a fibroid non-cancerous tumor on the uterus may develop pain, bleeding or increase growth of the fibroid.

If you are taking HT, watch for signs of trouble. These include:

  • Abnormal bleeding.

  • Breast lumps, bloody discharge or red/painful breasts.

  • Shortness of breath.

  • Dizziness.

  • Abdominal pain.

  • Severe headaches.

  • Pain in your calves or chest.

Report these signs to your caregiver right away. Also, talk with your caregiver about how often you should have an exam.

DOES THE DURATION OF TAKING HT AFFECT BREAST CANCER RISK?

The relationship between a woman's risk of developing breast cancer and the length of time that she receives HT is not clear. Some women take HT for only a few years until the worst of their menopausal symptoms have passed. Others have taken it for 10 years or more. Some researchers believe that there is little or no increased risk of breast cancer associated with short-term use of either HT with estrogen alone or estrogen combined with progestin. But long-term use is linked to an increased risk. Women on HT should continue to do monthly self breast exams and get their mammograms as recommended by their caregiver.

WHY IS MENOPAUSAL HORMONE THERAPY USED IN SPITE OF THE CANCER RISK?

The known benefits of HT can improve the quality of life for many women, by reducing uncomfortable symptoms, as mentioned above. There also is evidence that HT helps prevent and treats osteoporosis. There is preliminary evidence that it can help prevent other problems associated with age, including colon cancer. The addition of progestin to the treatment has greatly reduced the risk of uterine cancer.

ARE THERE OTHER DRUG THERAPIES KNOWN TO TREAT CONDITIONS RELATED TO MENOPAUSE?

A class of antidepressant drugs called Selective Serotonin Reuptake Inhibitors (SSRIs) are effective in treating menopause-related symptoms of depression or mood changes. Vitamin E and Clonidine (drug typically used for high blood pressure) can help reduce hot flashes. To prevent osteoporosis, women who are at high risk for bone loss may be given drugs such as bisphosphonates, alendronate, raloxifene, calcium with vitamin D, calcitonin, and prescription medicines such as fasomax or boneva. Lastly, a class of cholesterol-lowering drugs called HMG-CoA-reductase inhibitors (statins) are proven to be effective for reducing risk of heart disease. They are also being explored to prevent osteoporosis. No alternatives to estrogen exist for prevention of colon cancer – a disease for which early evidence suggests HT may be beneficial.

WHO SHOULD NOT USE HT?

HT is often not recommended for women who have any of the following conditions:

  • Vaginal bleeding of an unknown cause.

  • Suspected breast cancer or history of breast cancer.

  • History of endometrial or uterine cancer.

  • Chronic disease of the liver.

  • History of heart disease.

  • History of blood clots in the veins or legs or in the lung (venous thrombosis). This includes women who have had thrombosis or blood clots during pregnancy or when taking birth control pills. Although the risk of blood clots in women is very low, HT increases the risk.

  • Severe or uncontrolled high blood pressure.

  • Anyone who may be pregnant.

HOW CAN I SORT THROUGH THE BENEFITS AND RISKS TO MAKE A GOOD DECISION ABOUT WHETHER OR NOT TO USE POSTMENOPAUSAL HORMONE THERAPY?

Here are several helpful points, summarizing the findings of the Women's Health Initiative (WHI) study:

First, it is important to know that because the study involved healthy women, only a small number of them had either a negative or positive effect from estrogen plus progestin therapy. The percentages describe what would happen to a whole population, not necessarily to any individual woman.

Second, remember that percentages are not fate. Whether expressing risks or benefits, a percentage does not mean you will develop a disease. Many factors affect that likelihood, including:

  • Your lifestyle.

  • Environmental factors.

  • Heredity.

  • Your personal medical history.

Realize that most treatments carry risks and benefits. No one can make a treatment choice for you. Talk with your caregiver and decide what is best for your health and quality of life. Begin by finding out your family history and your personal risk profile for:

  • Heart disease.

  • Stroke.

  • Breast cancer.

  • Osteoporosis.

  • Colorectal cancer.

  • Blood clots.

  • Other medical conditions.