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FAQ (Health)

Menopause and HRT


Benefits of Hormone Replacement Therapy

The use of hormone replacement therapy (HRT), is highly effective for improving the quality of life of women suffering from acute symptoms of menopause, such as hot flashes, night sweats, insomnia, increased fatigue and irritability, depression, skin changes, vaginal dryness and incontinence. HRT also provides some long-term protection against cardiovascular disease, osteoporosis and colon cancer. To get a summary of these benefits you may skip to the bottom and read the Summary.

Improved Quality of Life

The major benefit of HRT cited by women who use it is the improved quality of life and relief of symptoms. They appreciate the freedom it provides. Quality of life cannot be quantified. Your mood, your feeling of well-being, and your satisfaction with yourself and your surroundings is perceived differently by you than it will be by other women. It is a very individual matter. Your societal and domestic status can also play a role in how you feel and react to menopause.

The typical menopausal woman today holds optimistic beliefs about maintaining her femininity and sexuality. Unfortunately, she may be confused about how to do that and what to expect. There is no doubt that taking hormones after menopause does have direct beneficial effects on mood and behavior, and therefore on the quality of life.

Relief of Hot Flashes

The relief of hot flashes is the most significant benefit you will perceive soon after starting HRT. Estrogens are remarkably effective in eliminating this annoying symptom. Hot flashes can occur during the day or at night, as "night sweats," and can cause sleeping disturbance up to and including the need to shower, change night clothing, and change bedding. HRT brings relief from hot flashes and an improvement in sleep.

Improved Mental Outlook

Studies have shown conclusively that estrogen improves the mood of women who had lost ovarian function.

The actual reasons for the mood-elevating effects are not fully understood, but it is known that estrogens have many effects within the brain and the nervous system. This mental tonic effect of estrogens, which is perceived as a feeling of overall well-being, goes beyond the fact that the hot flashes have been relieved. Women often describe a feeling of revitalization and of being reborn, which translates into better performance of daily duties and greater enjoyment of daily pleasures. These women feel more alert and better able to function.

Reduce Minor Depression

Estrogen reduces the minor depression that some women experience after menopause. Major, continuing depression, however, requires a different therapy.

Enhanced Quality of Sleep: Enhanced Quality of Sleep:

Studies at Harvard confirmed that estrogens enhanced the quality of sleep. We know that stopping the night sweats for women suffering hot flashes improve their sleep. Women without night sweats experienced an improvement in REM sleep (rapid eye movement-the good sleep). This improvement occurred for all the women on HRT. There was a deterioration of REM sleep in women deprived of HRT.

Improved Short-Term Memory

Improved short-term memory is a distinct advantage of HRT. A study performed at King's College Hospital, London, England found a distinct difference in short-term memory between women who had active ovaries or were on postmenopausal HRT as compared to menopausal women without ovaries or HRT. Other studies have confirmed these findings, and continue to provide evidence that when women take estrogen their short-term memory improves.

Disease Prevention

Combats Osteoporosis

Estrogen therapy is the most successful method of combating osteoporosis. However, there is some question whether estrogen is really that effective when women has already reached menopause for combating the effects of osteoporosis. Estrogen does increase bone mass by inhibiting the function of osteoclasts, the cells that eat old bone so that new bone can be laid down. Our bones remodel throughout life in accord with how we bear weight and how we exercise.

The action of osteoclasts and osteoblasts in rebuilding bone mass can be illustrated by what happens when an orthodontist applies braces to straighten teeth. The braces put pressure on the bone that holds the teeth in place. Osteoclasts respond to this pressure by eating away the bone on the far side of the tooth, giving it room to move. Osteoblasts lay down new bone on the near side of the tooth to hold it in place. To have a healthy bone, we need to have control on both - osteoclats that eat away bones and osteoblasts that rebuild new bones.

Long-term estrogen use (10 or more years) may be required to prevent postmenopausal bone loss. Estrogen helps bones absorb the calcium they need to stay strong. It also helps conserve the calcium stored in the bones by encouraging other cells to use dietary calcium more efficiently. While estrogen decreases osteoclast activity, thus increasing bone mass, it has no effect on osteoblast activity. In other words, it doesn't build new bone. In contrast to this, exercise does increase osteoblast activity, as does progesterone. We do not know for sure whether estrogen-and-progesterone combinations or progesterone alone are best for the prevention and treatment of osteoporosis. Clinical tests are being carried out now that will shed some light into this in the near future.

Most bone is lost before menopause even begins. A low-fat, low-protein diet rich in fiber and green leafy vegetables, regular exercise, and the avoidance of smoking, alcohol, and carbonated beverages (high phosphate level in the carbonated drinks displaces calcium from bones) is the best strategy for maintaining healthy bones throughout the life cycle.

Reduces the Risk of Cardiovascular Diseases (CVD)

Since heart disease develops about ten years later in women than in men, and risk begins to increase postmenopausally, low estrogen levels have long been considered a risk factor. Premenopausally, women have higher levels of HDLs (good cholesterol), and lower levels of LDLs (bad cholesterol) than do men. After menopause, a woman's total cholesterol level increases, HDLs drop and LDLs rise. Since estrogen plays an important role in lipid metabolism, it seems to follow that it might prevent cardiovascular disease postmenopausally. Scientists are not certain whether the beneficial effects observed from HRT is due to progestins or the estrogen or both.

It was suggested that women who take estrogen substantially reduce their risk of developing and dying from heart disease. One study showed that after 15 years of estrogen replacement, risk of death by CVD was reduced by almost 50 percent and overall deaths were reduced by 40 percent. Estrogen maintains HDL and LDL at their healthier, premenopausal levels through its interaction with proteins in the liver. Estrogen also directly affect the blood vessels themselves.

Thus, estrogen is beneficial for women who are at high risk for heart disease such as:
bulletWomen with a strong family history of CVD
bulletThose with high blood pressure
bulletObese women.

One study observed fewer cardiovascular deaths among estrogen users compared to nonusers. (See below under survival rates.) Women whose ovaries had been surgically removed had the greatest reduction of risk. As in everything else, there is some serious questions as to the effectiveness of HRT especially for older women in reducing CVD.

One of the most famous studies of cardiovascular disease is the Framingham Study. This well-regarded study showed no reduction in coronary artery disease as a result of estrogen replacement. Furthermore, postmenopausal women taking estrogen had a 50 percent increase in the risk for stroke.

Another study that is often quoted to show a significant effect of estrogen on the prevention of cardiovascular disease is the Nurses' Questionnaire Study, based on statistics gathered from over 48,000 nurses. An article published in the New England Journal of Medicine in 1991 indicated that risk of death from heart disease was 39 percent less in nurses currently using hormones and 17 percent less for former hormones users compared to nonusers. Critics of the study suggested that since the hormone users were also less likely to have diabetes, less likely to smoke, and more likely to exercise, they may have had a lower general risk for heart disease. Furthermore, the sample was too small to prove statistically that estrogen prevented heart disease. As in the Framingham Study, there was a significant increase in strokes among hormone users.

A recent study, however, raises serious questions into the benefits of HRT in reducing disease progression in older women with established heart disease. The study was presented on March 13, 2000, at the American College of Cardiology's annual meeting.

"Based on this study, we can't rule out a small benefit of estrogen, but a dramatic effect, as seen with lipid-lowering therapy in patients with high cholesterol, is unlikely," said David Herrington, a cardiologist at Wake Forest University Baptist Medical Center and the study's principal investigator.

The research is still pending on HRT's role in the heart disease prevention in younger women. The current research focused exclusively on post-menopausal women with documented heart disease.

The study, called the Estrogen Replacement and Atherosclerosis (ERA) trial, examined 309 subjects randomly assigned to take estrogen, estrogen combined with progestin (synthetic progesterone), or a placebo containing no hormones. The average age of the subjects was about 66 years.

About one-half of the women had suffered a heart attack prior to the study. "Overall, there were no differences between the groups in how quickly the disease progressed. HRT did lower cholesterol, but these changes didn't translate into a measurable benefit in the arteries of the heart," Herrington said.

The ERA results supported the findings of the 1998 Heart and Estrogen/Progestin Replacement Study, or HERS. This trial followed 2,763 women with established cardiac disease over the course of four years. It determined that hearts attacks occurred as frequently in women who took HRT as in those who did not.

These findings have puzzled scientists. The conventional wisdom suggests that the cholesterol-lowering effects of HRT should have slowed the progression of heart disease.

Ongoing studies will clarify these issues in the future. One such study is the Women's Health Initiative. It will examine the effects of HRT in younger women, specifically the role played by HRT in the prevention of heart disease and osteoporosis in a large, randomized clinical trial. Results should be available in 2006.

Reduces Colon Cancer Risk

A study published in the Journal of the National Cancer Institute supports one of estrogen's possible benefits: a reduced risk of colon cancer.

In a study of more than 2,300 postmenopausal women, researchers found that women who had used estrogen alone or with progestin within the previous ten years had a significantly lower risk of developing colon cancer than those who had never taken hormones. Although this study alone doesn't prove a connection, it lends credence to research suggesting that estrogen and HRT plays a protective role against one of the most common forms of cancer.

Enhances Sexuality

Estrogen is an important hormone for maintaining female sexuality. The absence of it reduces sexuality whereas its presence enhances it. There are many ways in which estrogen can produce increased awareness, sensuality, desire, and enjoyment of sexual activity.

Slows Down the Aging Process

Estrogens cannot prevent aging. Aging is a natural process of evolution. However, estrogen unquestionably slows the aging processes of your body. As an example, we will take a look at how estrogen affects the skin.

The skin is the largest organ of the body. It undergoes many changes related to menopause and has many responses to HRT. After menopause, women notice that their skin is thinner, dryer, and that their body hair begins to fall out. These changes are often reversible once you begin HRT. Within six months, your skin can appear thicker and softer because of increased oil secretions from the sebaceous glands. As the skin plumps up, your wrinkles diminish, giving you a somewhat younger appearance.

Bladder/Pelvic Floor

Sex hormones also maintain the firm tone of the pelvic muscles. When estrogen dwindles, muscle tone diminishes and the uterus, bladder, and vagina can drop to varying degrees. This condition is called prolapse.

Symptoms of prolapse are usually described as a "feeling of something coming down" or as "a sense of heaviness." If the bladder is involved, coughing, sneezing, or laughing may cause a little urine to leak out despite your best intentions not to permit it. There are four successful treatments available for these problems:

  1. Pelvic exercises help mild cases only, but should be tried. They simply involve contracting or tightening the pelvic muscles as often as you can, but no fewer than ten times a day. You can learn more about this in our exercise section under Kegel exercises.
  2. Estrogens improves the muscle tone of the pelvic floor and are of value in mild cases.
  3. Pessaries and rings are plastic devices inserted by the gynecologist to lift up the organs. They are used to delay surgery, or if the patient cannot for some reason undergo an operation.
  4. Surgical repair. Because prolapse is not a disease, surgery should be considered only if you have troublesome symptoms.

Remember that the most important function of the vagina is to enable you to enjoy an active and fulfilling sex life. Women who think that their vaginas are stretched and no longer permit them favorable sexual sensation can consider vaginal repair operations. These will tighten the pelvic muscles and narrow the vagina. Don't be embarrassed to discuss this problem and its repair with your doctor. Sexual pleasure represents a vital aspect of life.

Before thinking of vaginal repair surgery, you should know that bladder symptoms frequently regress when you start to take HRT. Urge incontinence, a disruptive symptom that causes a severe urge to empty the bladder even when it contains very little urine, is frequently eliminated by HRT.

Restores Breast Firmness

Many women feel changes in their breasts during their normal monthly cycle. These changes are a result of the changing levels of their sex hormones. Loss of hormones can result in smaller breasts in slim women. Estrogen treatment may be of value in restoring firmness to breasts. All patients and especially those with fibrocystic breast disease should have regular breast checkups and mammography, when indicated. However, estrogen should not be used as a treatment to develop the breasts.

Estrogen and HRT Increases Survival Rates

In the midst of the continuing debate as to the benefits of HRT such as reduction in osteoporosis, heart disease, colorectal cancer etc. and the risks posed by increased breast cancer, women are torn between the risks and benefits of HRT.

A study published in the January Obstetrics and Gynecology looked at just one outcome—death instead of looking at the effect of hormone-replacement therapy on individual health benefits or risks. The scientists concluded that women who use estrogen long term "can substantially reduce their risk of dying prematurely."

The investigators identified 232 women, all born before 1915, who began taking daily estrogen tablets between 1969 and 1973 to lessen the side effects of menopause and who continued this therapy for at least five years. In 1993, the researchers reviewed the women's medical charts. They also looked at the medical records of 222 similarly aged women who had never taken estrogen or had tried it for less than a year.

A larger percentage of estrogen-taking women were still alive in 1993 than non-estrogen-taking women—77 percent vs. 61 percent. This survival advantage can be chalked up primarily to fewer deaths from heart attacks and other diseases of the heart and arteries—more than twice as many women who didn't take estrogen died from these causes. That's in line with the protective effect ascribed to estrogen found in other studies over the last few years. The benefit from estrogen continued for several years after long-term use was stopped.

Cancer accounted for an identical 11 percent of deaths in both groups. The researchers did see a slight increase in the risk of dying from breast cancer among the women who took estrogen, but this was offset by a reduced risk of dying from lung cancer.

This was one of the first carefully conducted studies to look at estrogen use over an extended period. The women used estrogen for an average of 17 years after natural or surgically induced menopause. Previous studies have been limited because they looked at the effect of taking estrogen over a relatively short period, often an average of five years and rarely as long as 10 years. While the results from these earlier studies have been promising, the long term implications were not known.

Given the strengths of this study, its main finding—a 46 percent reduction in the risk of death, mostly from cardiovascular causes, seen over a two-decade period among long-term users of estrogen supplements—should have a strong impact on physicians who may prescribe hormone-replacement therapy or on women who must decide whether or not to begin it.

Another important observation of this study was that women taking lower doses of estrogen (0.625milligrams/day) had the lowest risk of death, and as the dose went up, the benefit declined. Thus, when it comes to estrogen, more is not necessarily better; more may simply increase the possibility of experiencing the negative side effects of hormone-replacement therapy without doing anything more to decrease the risk of killer diseases.

It is possible that the women who took the ERT were more health-savvy than the average woman who was in the control group. They may have been healthier to begin with, or more conscious about eating a healthy diet or exercising, two habits known to reduce the risk of dying early from heart disease. But given all the other studies to date, which also suggest that estrogen extends life, it is more likely that the survival difference is due to the hormone-replacement therapy.

HRT Protects Teeth

A study showed that taking estrogen supplements within five years of menopause can slow down periodontal disease.

The study, found in the Journal of Periodontology, says estrogen supplements can lower gingival inflammation in menopausal women who have osteoporosis, or low bone density, a growing problem for older women. Dr. Richard Reinhardt, of the University of Nebraska College of Dentistry, says for women at risk for osteoporosis -- which makes them more vulnerable to rapid periodontal bone loss -- "this may be yet one more reason to be on estrogen."

Studies show that 25 million women have osteoporosis and at least half of Americans 55 and older have advanced periodontal disease. Reinhardt says menopause is also a great time to quit smoking because that can speed up the progression of periodontal disease even faster than not having enough estrogen.

Reduces the Risk of Smoking

Those who smoke are much more likely to develop heart disease or have a stroke than those who do not smoke. But after menopause, a smoker's risk climbs dramatically. Low estrogen levels and smoking are separate risk factors for CVD. When the two are combined, the risk is much higher than either one alone.


Here is a summary of the suggested benefits of HRT:

Enhance quality of life
bullet    Mental tonic effect
bullet    Improved sleep
bullet    Improved short term memory

Prevent osteoporosis and fractures

Prevent heart attack

Eliminate hot flashes

Enhance sexuality
bullet    Enhanced sensation
bullet    Increased build-up of vaginal epithelium
bullet    Improved pelvic floor muscles

Slower overall body deterioration
bullet    Smoother skin
bullet    Tauter bladder/pelvic floor muscle tone
bullet    Firmer breasts
bullet    Improved muscle tone

Increased longevity

Compare and contrast these benefits with the risks of HRT. This may give you a good perspective from which to determine if this therapy should be for you.

Next Topic: Risks/Dangers of HRT

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