The following conclusion from 'A Critical Look at the Studies on Women's Hormone Therapy' by Janet Huang MD (ESSM Issue 21 ), clearly states the issues to be considered:
In the management of the menopause transition, it is imperative to evaluate each woman as an individual, with her unique set of symptoms, risk factors, concerns and philosophies. It is essential to have in in-depth and honest discussion about the potential risks and benefits so that each woman can make her own informed decision. While WHI (Women's Health Initiative) has raised a lot of concerns about potential harm of HT, the study validity has been a topic of heated debate. It is important to keep in mind that WHI does not really give us the answers regarding the use of HT in women who are in the menopausal transition and who need to make the decision whether to use HT or not. Moreover, WHI results should not be extrapolated to other forms of HT including bioidentical hormone therapy. HT is only a part of the whole menopause management. It alone cannot be expected to be the 'magic bullet' to maintain youth and optimise health. It is important that we use the 'whole-person approach' and address lifestyle issues, such as nutrition, exercise, stress reduction, as well as sleep adequacy and quality. I look at menopause as an opportunity to review a woman's health status (Huang, in press). Menopause is a good time to make a cohesive action plan to prevent disease and optimise quality of life.
Oestrogen Replacement Therapy (ERT) was first given to women at the menopause in the 1930s by intra-muscular injection. Implanted pellets of oestrogen were used from 1938. But by the 1970s it was becoming clear that increased rates of breast and uterine cancer were occurring from oestrogens taken on their own (‘unopposed’), and the popularity of ERT waned.
The term Hormone Replacement Therapy (HRT) was used after progesterone-like substances were successfully synthesised in the laboratory and marketed as ‘progestagens’. These progesterone-like substances enabled replacement therapy to follow more closely the pattern of hormone production in premenopausal women. When added to oestrogen therapy for the second half of the monthly cycle progestagens counteract the unopposed action of oestrogens on the uterus, thereby regularising the menstrual cycle and reducing the risk of uterine cancer. Because the risk of uterine cancer is the justification for using progestagens they are not considered necessary if a woman has had a hysterectomy.
A woman's decision to take or not to take HRT is often made on the basis of the balance of benefits and risks. These vary between individuals, and change over time. Hence the need for a woman and her doctor to review periodically whether the reasons for taking hormones remain valid. It is, most importantly, individual choice.
The risk of breast cancer is greater when there is a family history of the problem. The longer HRT is taken the greater the risk: used early in the menopause for up to one year it is not associated with an increased risk, and is the best way to treat menopausal symptoms such as hot flushes, night sweats and vaginal dryness.
It is a Doctor's 'duty of care' to give factual advice where patients may not have considered either the level of risk high or that treatment is justified by its benefits. Ultimately he must support his patient's decision and monitor the response to any hormones should these be prescribed.
Some women may continue to benefit from long-term HRT and be protected against heart attacks and osteoporosis. Some women undoubtedly feel more energetic on treatment and have a sense of wellbeing and greater libido.
There are various ways that traditional HRT is taken: tablets, implants, skin patches, creams, vaginal pessaries, and gels.
Tablet: Oestrogens and progestagens are commonly given in combination, either as Cyclical Sequential therapy or Continuous therapy:
Cyclical Sequential therapy: In this form of treatment Oestrogens are given from day 1 to 21 and progestagen from day 9 to 21. There are seven days per month without medication during which time light 'withdrawal' bleeding occurs.
Continuous therapy: Oestrogen is given continuously and progestagens are added from the 14th to 25th day of the cycle. A withdrawal bleed, very similar to a period, occurs within two days of the progestagen being stopped. For convenience progestagens may be taken only at the end of three months so that the frequency of withdrawal bleeding is reduced. Continuous therapy maybe given using Tibolone (Livial), once the lining of the uterus has become non-secretory (about a year after finishing periods).
Implants: Up to six month’s supply of oestrogen can be given as a sub-cutaneous implant, usually into the abdominal wall. Absorption occurs directly into the blood-stream avoiding the potential hazards of passing through the liver. The dose of oestrogen is smaller but progesterone is still needed to avoid the effects of unopposed oestrogens. However, the dose can’t be varied once the implant is inserted and removal is difficult. Increasing doses may be needed to limit menopausal symptoms for reasons that are not clear.
Skin Patches: Oestrogen is contained in a patch, which is placed on the lower trunk and changed every three or four days. Progestagens are taken from the 14th to the 25th day either as a pill, or by means of a patch combining oestrogen and progestagen. The skin may become red and sore following the use of a patch. With patches of this type the oestrogen is contained in a reservoir of alcohol, which looks like a small bubble, against the skin.
A Matrix-patch in which oestrogen is impregnated in a sponge-like medium is more comfortable, less bulky, and lies flat against the skin.
To take or
not to take?
Creams and Pessaries: Oestrogen cream is placed in the vagina with an applicator for the treatment of vaginal symptoms. Only limited absorption of oestrogen occurs making it unsuitable as a way of treating other menopausal symptoms.
Oestrogen gel provides an effective alternative to the patch. The gel is used on the inner aspect of the upper thigh and rubbed in daily. The dose is adjusted according to individual need on the basis of oestrogen levels measured in blood or saliva.