Menopause & HRT (Hormone Replacement Therapy Information

What is menopause? — Menopause is the time in a woman's life when she stops having monthly periods. At this time, her ovaries stop releasing eggs and stop making the hormones estrogen and progesterone. Menopause usually occurs between the ages of 45 and 55. The average age is 51.

How do I know if I am going through menopause? — Most women start to wonder about menopause when their periods start to change. If you are going through menopause, you might:

• Have periods more or less often than usual (for example, every 5 to 6 weeks instead of every 4)
• Have bleeding that lasts for fewer days than before
• Skip one or more periods
• Have symptoms of menopause, such as hot flashes or depression (described below)

If your uterus has been removed, but you still have your ovaries, it might be tough to tell when you are going through menopause. Still, women who do not have a uterus can have menopause symptoms. If your ovaries were removed before the usual age of menopause, you had what doctors call "surgical menopause." That just means that you went through it early, because your ovaries were removed.

What are the symptoms of menopause? — Some women go through menopause without symptoms. But most have 1 or more of these symptoms:

• Hot flashes – Hot flashes feel like a wave of heat that starts in your chest and face and then moves through your body. Hot flashes usually start happening before you stop having periods.
• Night sweats – When hot flashes happen during sleep, they are called "night sweats." They can make it hard to get a good night's sleep.
• Sleep problems – During the transition to menopause, some women have trouble falling or staying asleep. This can happen even if night sweats are not a problem.
• Vaginal dryness – Menopause can cause the vagina and tissues near the vagina to become dry and thin. This can be uncomfortable or make sex painful.
• Depression – During the transition to menopause, many women start having symptoms of depression or anxiety. That's especially true for women who have been depressed before. Depression symptoms include:
  • Sadness
  • Losing interest in doing things
  • Sleeping too much or too little
• Trouble concentrating or remembering things – This might be caused by lack of sleep that often happens at menopause, or by the lack of estrogen. Some experts suspect that estrogen is important for good brain function.

Should I see a doctor or nurse? — If your periods start changing and you are 45 or older, you do not need to see your doctor or nurse. But you should see your doctor or nurse if you have symptoms that really bother you. For instance, you should see your doctor if you cannot sleep because of night sweats, if it is hard to work because of your hot flashes, or if you feel sad or blue and don't seem to enjoy things anymore.

You should also see your doctor or nurse if you:

• Have your period more often than every 3 weeks
• Have very heavy bleeding during your period
• Have spotting between your periods
• Have been through menopause (have gone 12 months without a period) and start bleeding again, even if it's just a spot of blood

Is there a test for menopause? — There is a test that can point to menopause. But doctors usually use that test only in women who are too young to be in menopause or who have special circumstances.

Can I still get pregnant? — As long as you are still having periods, even if they do not happen often, you could get pregnant. If you have sex and do not want to get pregnant, use some form of birth control. If you have not had a period for a full year, it is probably safe to say you have been through menopause and can no longer get pregnant.

How are the symptoms of menopause treated? — Treatments include:

• Hormones (estrogen) – The hormone estrogen is the most effective treatment for menopause symptoms. Women who no longer have a uterus can take estrogen by itself. Women with a uterus must take estrogen with another hormone, called progesterone. Experts think these hormones are effective and safe for many women in their 40s and 50s with symptoms of menopause. If you want to take hormones, ask your doctor or nurse if it is an option. You should not take hormones if you have had breast cancer, a heart attack, a stroke, or a blood clot.
• Women who have vaginal dryness without other symptoms of menopause can try "vaginal estrogen." Vaginal estrogen is any form of estrogen that goes directly into the vagina. It comes in creams, tablets, or a flexible ring. Vaginal estrogen comes in small doses that don't increase the levels of estrogen in other parts of the body very much.
• Ospemifene (brand name: Osphena) – This medicine is similar to estrogen, but is not estrogen. It comes as a pill you take once a day. It helps relieve vaginal dryness caused by menopause, but it can also cause hot flashes. It is for women who have trouble using vaginal estrogen or prefer not to use a vaginal medicine.
• Antidepressants – Some types of antidepressants can ease hot flashes and depression. Even women who are not depressed can take them to help with hot flashes.
• Anti-seizure medicine – One of the medicines used to prevent seizures seems to help some women with hot flashes – even if they do not have seizures.

Can I do anything on my own to reduce the symptoms of menopause? — Yes. There are some steps you can try (table 1). But ask your doctor before you take any "natural remedies." Some natural remedies might not be safe, especially for women who have a history of breast cancer.

What can I do to protect my bones? — You can:

• Take calcium and vitamin D supplements
• Be active (exercise helps keep bones strong)
• Ask your doctor when you should start having bone density tests

If needed, your doctor can prescribe medicines to help keep your bones strong.

Menopause Hormone Therapy

WHAT IS MENOPAUSAL HORMONE THERAPY? — Menopausal hormone therapy is the term used to describe the two hormones, estrogen and progestin, that are given to relieve bothersome symptoms of menopause. Estrogen is the hormone that relieves the symptoms. Women with a uterus must also take progestin (a progesterone-like hormone) to prevent uterine cancer. This is because estrogen alone can cause the lining of the uterus to overgrow (potentially leading to uterine cancer).

Women who have had a hysterectomy do not have a uterus and cannot develop uterine cancer. These women are treated with estrogen alone.

Types of estrogen — Estrogen is available in many different forms. For hot flashes, it can be taken as a transdermal patch (worn on the skin), an oral pill, or a "ring" or tablet that is inserted into the vagina. There are also creams and sprays that can be put on the skin.

The "standard" dose of oral (by mouth) conjugated estrogen used to be 0.625 mg, but the current approach is to start with a lower dose of 0.3 to 0.45 mg and then increase the dose as needed, if symptoms are not relieved. Lower doses seem to have fewer side effects and probably help to minimize risks.

Many women now prefer taking "estradiol" rather than conjugated estrogens. Estradiol is the estrogen that is identical to the one the ovary makes throughout reproductive life. Estradiol can be given by mouth, skin patch, or vaginal ring.

Estrogen patch — Many experts now prefer treating women with the estradiol patch rather than estrogen pills (because it may be associated with a lower risk of blood clots than estrogen pills). A combination estrogen and progestin patch is also available. Some patches need to be replaced every few days, while others are only replaced once a week.

Estrogen patches work as well as estrogen pills to increase bone density and treat menopausal symptoms. Women with a uterus who use an estrogen patch must also take a progestin to decrease the risk of uterine cancer. (See 'Types of progestin' below.)

Estrogen pill — There are many types of estrogen pills. One of the most commonly used brands, called Premarin (conjugated estrogen), is made from the urine of pregnant horses (mares). Other preparations, including estradiol, are derived from plant sources. As noted above, estradiol is the same estrogen that the ovary makes before menopause. All types of estrogen can help to relieve menopausal symptoms.

Combination pills that include both estrogen and progestin are available. (See 'Types of progestin' below.)

Low-dose birth control pill — Very low-dose birth control pills are a good option for women in their 40s who have bothersome hot flashes, irregular bleeding, and who still need a reliable form of birth control. Extreme caution should be used for women over 40 years who are also obese because of the higher risk of blood clots. Birth control pills are generally not recommended for postmenopausal women, because the dose of estrogen is higher than needed to relieve hot flashes. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)" and "Patient education: Menopause (Beyond the Basics)", section on 'Menopause and birth control'.)

Vaginal estrogen — Women with vaginal dryness can also be treated with very low doses of estrogen that treat the dryness but not hot flashes (because the dose is too low to get into the bloodstream). Vaginal estrogen comes in a cream, vaginal ring, or vaginal estrogen tablets. The low-dose vaginal estrogens do not usually require the use of a progestin pill. Vaginal estrogen used to treat dryness is discussed in a separate article. (See "Patient education: Vaginal dryness (Beyond the Basics)".)

Types of progestin — Postmenopausal women with a uterus who are treated with estrogen alone have an increased risk of developing uterine cancer and hyperplasia (a precursor to uterine cancer). Taking a second hormone, progestin, minimizes this risk. (See "Patient education: Endometrial cancer diagnosis and staging (Beyond the Basics)".)

• Oral progestins – One commonly prescribed progestin pill is medroxyprogesterone acetate. Other types of synthetic progestin pills (norethindrone, norgestrel) are also available.
• Many experts now treat the majority of their menopausal patients with natural progesterone rather than synthetic progestins. Natural progesterone has no negative effect on lipids and is a good choice for women with high cholesterol levels. In addition, natural progesterone might have other advantages when compared with medroxyprogesterone acetate.
• Intrauterine progestin – An intrauterine device (IUD) is a form of birth control; one type, the levonorgestrel IUD (sample brand names: Mirena, Liletta, Kyleena, Skyla), releases progestin to prevent pregnancy. In some countries, these types of IUDs (using a lower dose of levonorgestrel) are used in menopausal women taking estrogen to minimize the risk of developing uterine cancer. The IUD is not currently approved in the United States for use in menopausal women; however, if you already have one when you enter perimenopause, your doctor may suggest that you keep it in until after menopause is complete.

"Natural" or "bioidentical" products — Many women are turning to "natural" or "bioidentical" hormone therapy as an alternative to conventional hormones for treating symptoms of menopause. The "bioidentical" approach uses an individualized dose of hormones that is made by a pharmacy as pills, creams, or vaginal suppositories.

The hormones most commonly included in bioidentical products are estradiol, estrone, estriol, progesterone, testosterone, and dehydroepiandrosterone (DHEA). You may be asked to provide a saliva or blood sample to measure your baseline hormone levels. Based upon the results, the prescriber selects the individual hormones and doses, which are then made by a compounding pharmacy.

The quality of these products is not regulated by the US Food and Drug Administration (FDA). The dose of hormones can vary from batch to batch. We agree with expert groups who recommend that women not adopt this approach, because the hormone products do not have adequate quality control. Supporters of this approach claim that bioidentical hormones are safer and have fewer side effects than commercially available preparations. However, there is no scientific proof that this is true.

RISKS AND BENEFITS OF HORMONE THERAPY — The Women's Health Initiative (WHI) was a large study designed to find out if hormone therapy would reduce the risk of heart attacks (coronary heart disease [CHD]) after menopause. The study found that taking estrogen-progestin in combination actually increases the risk of heart attacks, breast cancer, blood clots, and strokes in older postmenopausal women but not in younger postmenopausal women. (See "Menopausal hormone therapy: Benefits and risks".)

The results of the estrogen-only study were different. Women who took estrogen alone had a small increase in the risk of stroke and blood clots, but there was no increased risk of heart attacks or breast cancer.

Heart attacks — The risk of having a heart attack related to use of hormone therapy appears to depend on your age. There is noincreased risk of heart attacks related to hormone therapy in women who:

• Became menopausal less than 10 years before starting hormones or
• Were age 50 to 59 years when they took hormone therapy

Other studies since the WHI also report that hormone therapy does not increase heart attack risk in younger women; some suggest it might even lower the risk slightly. In the WHI, women who become menopausal more than 10 years ago or over age 60 years were at increased risk of having a heart attack related to hormone therapy.

Breast cancer — There is a small increased risk of breast cancer in women who took combined estrogen-progestin therapy but not in women who took estrogen alone. Experts think that it takes approximately 10 years or more of estrogen use (alone) before the risk goes up but only five to six years if you take both hormones. After that, the risk will continue to go higher if you keep taking estrogen. This is discussed in detail separately. (See "Menopausal hormone therapy and the risk of breast cancer".)

Osteoporotic fracture — The risk of breaking a bone at the hip or spine because of osteoporosis is lower in women who take estrogen-progestin or estrogen alone. However, hormone therapy is not recommended to prevent or treat osteoporosis, because there are bone medicines (called bisphosphonates) that have fewer serious risks. (See "Patient education: Osteoporosis prevention and treatment (Beyond the Basics)".)

Dementia — In women who took combined estrogen-progestin or estrogen alone, there was no significant improvement in memory or thinking, but there was an increase in the risk of developing dementia. However, some experts think that estrogen treatment might be helpful for preventing dementia if you take it in the early years after menopause (although this is not proven); taking it many years after menopause seems to be harmful.

Depression — Many women experience anxiety and/or depression during the transition to the menopause. Some studies show that estrogen treatment helps improve mood and decrease depression. However, some women need to be treated with both estrogen and an antidepressant to feel completely better. Once women reach their postmenopausal years and their hormones are stable, they usually begin to feel better. (See "Patient education: Depression in adults (Beyond the Basics)".)

Sleep problems — Many perimenopausal and postmenopausal women have sleep problems. Sometimes this is because they have hot flashes at night that interfere with sleep (night sweats). However, women can have trouble sleeping even if they don’t have hot flashes. This can be due to disorders like restless leg syndrome and sleep apnea. Estrogen treatment is very effective for improving sleep in women with night sweats.

WHO SHOULD TAKE HORMONE THERAPY? — The most common reason for taking hormone therapy is to treat bothersome menopausal symptoms, such as hot flashes or vaginal dryness. Most experts agree that hormone therapy is safe for healthy women who have menopausal symptoms.

Most experts recommend that you taper and stop your hormone therapy after four or five years to avoid any increased risk of breast cancer. However, this can be a challenge for many women because the average duration of hot flashes is approximately seven to eight years.

If you are using a patch, your doctor or nurse can give you a lower-dose patch to help you taper the dose. If you are taking pills, one way to do this is to skip one pill per week at first, then continue to gradually decrease the number of pills per week until you are no longer taking any.

If menopausal symptoms return as you lower your dose of hormones, you can try hormone therapy alternatives. Some women have to go back on hormone therapy for a while.

Who should avoid hormones? — Hormone therapy is not recommended for women with the following:

• Current or past history of breast cancer
• Coronary heart disease
• A previous blood clot, heart attack, or stroke
• Women at high risk for these complications

Women with breast cancer — Women with breast cancer often experience early menopause due to breast cancer treatments. In these women, estrogen or hormone therapy (by mouth or patch) is not recommended. The hormones could increase the chance of the cancer coming back.