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Those raging hormones
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Estrogen and progesterone play important roles in women’s health long after their reproductive years have passed. The benefits of hormone replacement therapy during perimenopause and menopause may outweigh the risks of not replacing them
By Kate Cottrell
Canadian women are living longer than ever. In fact, many of us will survive well into our eighties — almost 40 years longer than many of our grandmothers. Indeed, women today can look forward to spending almost as much time out of their reproductive years as they did in them.
With such impressive longevity before us, the opportunity has never been better to ensure that as much of that time as possible is spent in vibrant health and spirit. That’s because today, women have choices — choices never before available which will help maintain our current and future health. We can decide, for example, to take the time we need to renew our bodies and refresh our minds.
We can pay heed to our diet and fortify ourselves against diseases that otherwise might harm us. With Hormone Replacement Therapy (HRT), we can choose to replenish our protective female hormones as we go through menopause, protecting our bones, our heart and our emotions against the long-term consequences of hormone loss. These choices are ours to make. But before we make them, we need to know what’s in it for us.
According to an Angus Reid survey released in September 2000, 73 per cent of Canadian women age 45 to 64 believe HRT can improve their quality of life during menopause. Yet only 24 per cent of these women were taking HRT. The reasons for the discrepancy range from fear of increasing risk of breast cancer, to getting fed up with the side effects of HRT, which can include unpredictable bleeding and headaches. But there are those in the medical community who maintain that, for most women, HRT is the best protection they can have against heart disease and osteoporosis, and does not significantly elevate cancer risks.
Dr. Christine Derzko, an obstetrician/gynecologist at St. Michael’s Hospital in Toronto and a member of our advisory board, tells us the latest thinking on hormone replacement therapy and the implications for this time and beyond.
THJ: How do I know I’m ready for hormone replacement therapy?
CD: Officially, a woman is menopausal once she has no periods for 12 consecutive months. However, ovaries don’t stop functioning overnight. Rather, during the transition phase, often called the perimenopause, the ovaries produce estrogen in fits and starts — producing a lot one month and very little the next. This stop-and-go hormone production helps explain why some women can have menopausal symptoms some months but not others. Hot flashes, of course, are probably the best recognized sign that our ovaries are shutting down estrogen production.
But other symptoms of failing estrogen levels include the need to urinate more frequently, an inability to lubricate adequately during sex, poor sleep patterns and often, irregularities in menstrual bleeding with either an increase or a decrease in flow and often unpredictable periods.
Depending on your symptoms and your needs at this time in your life, your doctor may recommend hormone replacement therapy (HRT). This consists of giving you back both an estrogen and a progesterone (unless you have no uterus, in which case it is only estrogen).
Replacing these two female hormones resolves menopausal symptoms in most women. Alternatively, women who experience menopausal symptoms such as hot flashes, vaginal dryness, urinary frequency and insomnia — particularly while they are having irregular periods — are best treated with a low-dose birth control pill (except women who are smokers). This is an ideal choice for women who need birth control as well as cycle control.
During this time of life, the higher hormone doses found in birth control pills are often needed to control symptoms, especially irregular bleeding. Even low dose birth control pills are four to six times higher in dose than post menopausal HRT. The post menopausal doses are appropriate for menopause.
The important thing to remember is that hormone therapy can be tailored to suit each woman’s needs, and it can be initiated either before or after official menopause, depending on your symptoms and your long-term needs.
THJ: Will I feel any differently if I take hormone therapy?
CD: Hormone-related effects depend on what hormones you’re taking. Women who still have their uterus, in other words those who have not undergone a hysterectomy, should be taking two different hormones: estrogen for symptom control and long-term benefits and progestin to protect the uterine lining from cancer, the risk of which is increased if estrogen treatment is used alone. When you first start on hormone therapy, you may notice some breast tenderness as well as an increase in normal vaginal discharge, both of which are related to estrogen use. Some women get headaches when they stop estrogen and such headaches are easily treated by changing to a non-stop estrogen routine.
Progestin is like the progesterone your body produces after ovulation. Like progesterone, progestin can cause premenstrual-like symptoms including bloating, fluid retention, irritability and a depressed mood. Hormone-related symptoms tend to diminish once your body adjusts to the new regimen. However, if you are still troubled by nuisance effects after being on hormone replacement therapy for a number of months, ask your doctor or your pharmacist about changing your regimen to one which might suit you better. A continuous regimen, where you take lower doses of both hormones every day, tends to produce fewer nuisance effects than a cyclic regimen, where you stop estrogen and progestin at the end of every month to allow for withdrawal bleeding.
Women without their uterus do not need progestin, and are usually advised to take estrogen nonstop on a daily basis.
THJ: Won’t I gain weight on hormones?
CD: Once women reach their forties and fifties, it’s a fact that many tend to put on weight. If weight gain corresponds to the time when you start taking hormones, it’s tempting to blame it on that. But a more likely explanation is that thanks to the hormone therapy, you may simply feel and sleep better, your moods have improved, you’re enjoying yourself and living more fully — and sometimes, eating more and exercising less.
A brisk 45-minute walk, four to five times a week, does wonders for physical health and overall morale. And you do have time. Remember, this is the rest of your life and you’re choosing to live it well.
THJ: Am I going to have a period for as long as I stay on hormones?
CD: Again, it depends to some extent on the regimen your doctor prescribes. Taken alone, estrogen leads to a build-up of the lining of the uterus, known as the endometrium, and this endometrial build-up is known to be associated with an increased risk of endometrial cancer. The addition of a progestin eliminates this increased risk on the uterine lining. But it does so by giving you an artificial period at the end of each month which gets rid of any excess endometrium. To get around the monthly bleeding, but still protect the uterus, doctors might suggest you take both estrogen and progestin daily.
With continuous hormone replacement, withdrawal bleeding is much less common. However, the continuous plan doesn’t work for all women, and it causes spotting in up to 40 per cent of women for the first three to six months.
Another option is to take progestin for 10 to 12 days, three to four times a year, after which you will have a period. Under special circumstance and close supervision, some doctors will allow women who still have their uterus to take estrogen alone.
Although you won’t have periods with estrogen alone, you will have to go back at least once a year to have your uterus checked. This commonly requires a biopsy of the uterine lining. Pelvic ultrasound is also sometimes used to measure the thickness of the uterine lining.
If you want a 100 per cent guarantee that taking hormones will provide you with everything hormone replacement promises, the traditional cyclic estrogen and progestin regimen complete with a monthly period is the way to go.
THJ: Does taking hormones increase my chances of developing breast cancer?
CD: Study after study has shown that breast cancer risk is not elevated with short-term use of HRT. Hot flashes normally subside within five years anyway, so many women will not need to use this therapy any longer. While the breast cancer risk is elevated somewhat, probably about three per cent overall in long-term users of HRT, the type of cancer these women typically acquire is a less serious form of the disease. Newer research suggests even less of a risk.
One study found that estrogen replacement does not elevate the breast cancer risk of women with a history of benign breast disease any more than having had cancer does. Women who are concerned about breast cancer should remember that in general, their risk for heart disease is far greater than their risk for breast cancer. Nevertheless, guidelines developed by health professionals still recommend that HRT not be used in women with a history of breast cancer and used only cautiously in women with a family history.
In years past, when HRT consisted only of estrogen, there was a significant risk of cancer of the endometrium (the lining of the uterus) in patients with an intact uterus. However, the newer therapies that combine estrogen with progestin dramatically reduce the risk of uterine cancer. The down side is that adding progestin may decrease some of the estrogen’s beneficial effects on cholesterol levels. Other evidence appears to support the belief that HRT decreases the risk of colon cancer, the second most common type of cancer among non-smoking Canadian women.
THJ: Aren’t hormones harmful for women who smoke?
CD: Hormones can be harmful for women who smoke, but not the hormones given to older women for replacement therapy. Remember, the doses of hormones used for replacement therapy are about one-third to one-sixth as high as those used in birth control pills. But because smoking contributes to heart disease and other problems such as arteriosclerosis, women who smoke benefit even more from hormone therapy than women who do not smoke. But it’s not too late to quit.
THJ: What about heart protection?
CD: The risk of heart disease increases significantly after menopause, coinciding with the dwindling production of female hormones. HRT may decrease risk of heart disease because it lowers LDL (bad cholesterol) and raises HDL (good cholesterol). Estrogen also relaxes the blood vessels to improve blood flow to the heart. More than 30 observational studies conducted over the last two decades have reported up to a 50 per cent reduction in heart disease among women taking HRT.
THJ: Nobody in my family ever had
heart disease, so why do I need hormone replacement therapy?
CD: Even though more women die of heart disease than any other cause, bone disease also robs many women of a long and healthy life. Osteoporosis, a common problem in older women, is a condition of excess bone loss resulting in fractures which occur with minimal or no trauma. Simply rolling over in bed, bending over to pick something up or receiving a hug from a loved one can cause an osteoporotic fracture to occur. The same number of women die of complications from fractures, especially of the hip, as die of breast cancer.
Female hormones increase bone mass in all areas of the skeleton, and reduce wrist and hip fractures by 50 to 60 per cent, provided hormone therapy is continued for at least six years. Especially in older women, bones cannot absorb as much calcium as they need to prevent osteoporosis if estrogen levels are inadequate. Unfortunately, as we age the body’s ability to absorb calcium is reduced, while, at the same time calcium needs increase. Estrogen is important in preventing excess calcium loss from the bones.
To protect bones from the debilitating disease of osteoporosis, women need a calcium-rich diet, adequate vitamin D, regular weight-bearing exercise and hormone therapy after menopause. Again, because smokers are more likely to develop osteoporosis, hormone replacement is particularly important in women who smoke.
THJ: Do I have to take hormones for the rest of my life to benefit from them?
CD: Bones start to lose calcium once hormone therapy is discontinued. To protect bones against osteoporotic bone disease, HRT should be continued for a minimum of 10 years.
This probably holds true for the heart-protecting effects of hormone therapy as well, with studies showing that a woman’s chances of having a heart attack or any other important circulatory event are cut in half as long as a woman is taking hormone replacement therapy and has done so for a number of years.
THJ: What lifestyle changes can a menopausal woman make to maintain good health?
CD: At midlife, there is no substitute for a good lifestyle. Diet and exercise are key. We all know to eat a sensible diet, which includes lots of vegetables and grains, and keep animal products, such as beef and butter, to a minimum. After 50, women also need more than of 1,200 mg of elemental calcium a day, yet the average Canadian woman’s diet does not provide this amount. Calcium supplements, plus 400 international units of vitamin D, should be taken. As well, women can choose low-fat milk, soy products that contain calcium, broccoli, almonds, canned salmon and the like.
Exercise helps the heart and maintains bone, as long as it is weight-bearing, such as walking and biking, or puts lateral stress on the bones, such as swimming. Lifting weights also helps. Menopausal symptoms are also lessened with exercise. Women tend to have fewer hot flashes and sleep better after regular brisk walking.
Should I take HRT?
Estrogens are prescribed orally, transdermally (patch) or vaginally. The pill and patch are equally effective in treating menopausal symptoms such as hot flashes and sleep disturbances, and they should provide the same protection to the bones. The liver metabolizes the pill, the “grandmother” of HRT treatments, in a process that stimulates the positive effects on blood cholesterol. Patches avoid the liver, so the cholesterol changes are lessened but they generally deliver estrogen (the patches contain progestin) in a consistent and predictable manner.
Women with gallbladder disease or uncontrolled hypertension, or who are taking drugs that affect the liver, may want to consider this option. Those with digestion problems, who have difficulty swallowing or who simply have an aversion to taking pills, may also want to opt for the patch. The patch’s superior absorption could also make it a good choice for women with a history of hormonal difficulties such as headaches. However, skin irritations are a side effect in 10 to 20 per cent of patch users. Vaginal estrogen in the form of creams or a vaginal ring also avoids the liver, but releases less of the hormone into the body. These may be the preferred mode of delivery for women experiencing severe vaginal dryness. A new hormonal gel applied directly to the inner arms or thighs is effective in alleviating menopausal symptoms too. It does not affect the liver and causes relatively few skin irritations.
Kate Cottrell is an Ottawa-based health writer.
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