US Pharm. 2012;37(9):17-18.
Menopausal Hormone Treatment
In menopause, levels of estrogen and progesterone are reduced,
leading to the development of serious symptoms (e.g., hot flashes and
vaginal dryness) and physical changes (e.g., osteoporosis) in some
women. Menopause occurs naturally as part of the aging process, usually
over a period of years, but it can be artificially induced by
hysterectomy and treatment of certain diseases, such as cancer.
Hormone replacement therapy (HRT), also sometimes referred to as
menopausal hormone therapy, is the therapeutic replacement of estrogen
with or without progestin. Estrogen and progestin act to ease the
symptoms and physical changes associated with menopause. Historically,
HRT was standard practice for relieving menopausal symptoms and
preventing heart disease and osteoporosis. This modality was re-examined
after the Women’s Health Initiative (WHI) studies revealed that HRT was
linked to serious health problems, not only in naturally menopausal
women who were receiving estrogen and progestin, but also in women in
hysterectomy-induced menopause who were receiving estrogen alone.
A recent comprehensive review of the studies that were conducted
during the 10 years since the WHI studies were discontinued provides the
information necessary to update recommendations for the use of HRT. The
updated guidelines will likely confirm the current FDA recommendations
suggesting that HRT is safe for short-term use at the lowest dose
possible to relieve serious symptoms of menopause. HRT is not
recommended for long-term use or to prevent chronic diseases such as
osteoporosis in menopausal women.
No Longer Routinely Prescribed for All Menopausal Women
Menopause is the stage of a woman’s life during which estrogen and
progesterone levels decline. In some women, this reduced production of
female hormones causes symptoms such as hot flashes and vaginal dryness,
along with physical changes such as bone weakening (osteoporosis).
Menopause is a natural part of aging, usually developing over a number
of years. An artificial state of menopause can result after a woman
To Treat or Not to Treat? Hormone replacement therapy (HRT) is
the therapeutic replenishment of estrogen with or without progestin (a
progesterone-like drug). These hormones work to relieve the symptoms and
physical changes that occur with menopause. For many years, HRT was
used routinely to ease the symptoms of menopause, as well as to prevent
osteoporosis and heart disease. This practice was reconsidered after
studies discovered that HRT was linked to serious health problems, such
as stroke, heart disease, and certain types of cancer. It has since been
determined that, in some women, HRT can provide health benefits with
less risk than was previously thought. For women who experience natural
menopause after age 45 years and do not have significant symptoms, HRT
is not necessary for preventing osteoporosis or heart disease. Lifestyle
changes and nonhormonal medications to maintain bone strength are
recommended, if appropriate.
Forms of Therapy The treatment of menopause-related symptoms
should be specific to the patient. Each woman has a unique medical
history, family history, and set of symptoms for which she is seeking
relief, so the best drug regimen is tailored to the woman’s risk factors
and symptoms. Risk factors that may prevent a woman from being a
candidate for HRT are a history of breast, endometrial, or ovarian
cancer, blood clots or stroke, smoking, and liver disease.
Estrogen with or without progestin is the most effective treatment
for hot flashes and is available in both oral and patch dosage forms.
Symptoms of natural menopause are treated with an estrogen-progestin
combination; the progestin balances the estrogen and reduces the risk of
uterine cancer. Since women who have undergone hysterectomy no longer
have a uterus, they can take estrogen alone to ease the symptoms of
artificial menopause. Women who experience early menopause for any
reason should take HRT until at least age 45 years to prevent diseases
such as osteoporosis, heart disease, and dementia.
HRT should be used at the lowest effective dose for the shortest time
needed. If vaginal dryness or urinary symptoms are the primary problem,
estrogen in the form of vaginal cream, gel, ring, or suppository may be
used. These forms of estrogen do not relieve other symptoms, such as
hot flashes, but they have the advantage of little absorption into the
Bioidentical hormones, which are custom prescribed and compounded,
are an alternative to standard HRT medications. Although they have been
in use for many years, there is some controversy regarding their safety.
Chemically, bioidentical and standard HRT drugs are the same as those
produced in the body. Phytotherapy—the use of herbs such as black
cohosh, red clover, and passionflower—is another option for women
seeking relief from menopausal symptoms; however, these remedies have
not been proven effective, and they may not be standardized or
manufactured in approved facilities.
Nonhormonal drugs that have been successfully used to treat hot
flashes and other menopausal symptoms include selective serotonin
reuptake inhibitors, clonidine, and gabapentin. To prevent osteoporosis,
drugs that increase bone strength, such as bisphosphonates and
selective estrogen receptor modulators, are used instead of hormone
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