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 undergoes hysterectomy.

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 system.

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 supplements.

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