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Menopause Through The Eyes of a Gynecologist- Hormone Replacement Therapy

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Almost everyday I am asked by a patient who has recently entered Menopause and feels bad “what can I take to feel better?”  The first question we have to answer

is what are your symptoms?  25% of women enter Menopause with no symptoms.  Of the 75% who do have symptoms most have a mixed bag including Hot Flushes, Vaginal Dryness,

Decreased Sex Drive, Irritability, and Not Sleeping Well.  You can either piecemeal all of these symptoms and end up taking 5 medications or start Hormone Replacement.  I experienced

all of these so I started on a very low dose estrogen patch- minivelle .0375.  I know you are probably thinking her Mom had breast cancer and she is taking estrogen?  I came to this decision

after careful review of the literature and a strong desire to feel like myself again.  The Women’s Health Initiative Postmenopausal Hormone Therapy Trials was started in 1991 and involved 161,808

healthy postmenopausal women.  The trials wanted to test the effects of HRT, diet, calcium supplements and vitamin D supplements on heart disease, bone fractures, breast cancer and colorectal cancer.

The HRT trial had two arms.  One involved Estrogen Plus a Progesterone in women with a uterus.  Progesterone has been shown to prevent endometrial cancer in women taking Estrogen with a uterus.

The second arm involved women taking only Estrogen without a uterus. The arms cannot be compared directly because the women in the estrogen-alone(no uterus) arm had a higher risk of cardiovascular

disease ( more women had hypertension, diabetes and obesity in the Estrogen only arm).   But the results were significant.  Compared with Placebo, Estrogen plus Progesterone resulted in 1. increased risk

of breast cancer 2. increased risk of heart attack 3. increased risk of Stroke 4. increased risk of blood clots 5. reduced risk of colorectal cancer 6. reduced bone fractures 7. and increased risk of dementia in

older women.  Now you know why I am so afraid of non FDA approved Bio-Identical Hormones that are so unregulated as to strength!  For the Estrogen alone arm the findings were different.  1. No difference

or slight decrease in breast cancer 2. no difference in heart attack 3. increased risk of stroke 4. increased risk of blood clots5. no difference in colorectal cancer 6. reduced bone fractures 7. and increased risk

of dementia in older women.  With these results in mind the recommendation is that we use the lowest dose for the shortest length of time. It’s a good thing that most symptoms of menopause except for

vaginal dryness usually improve on their own by age 60. Whether you take HRT and what you take is between you and your own doctor but this is what is available and the pro’s and con’s of the various treatments in my opinion.

 

When you have a Uterus –      Estrogen plus progesterone oral –  examples are prempro (premarin and provera), generic estradiol and northindrone, Con’s – Prempro is what was used in the WHI study, but the risks have been

found in most combination oral estrogen-progesterone treatments.  Oral estrogen passes through the liver increasing your Sex Hormone Binding Globulin which in turn does not help your sex drive

and also increases your clotting factors. Oral progesterone might be the more significant player in breast cancer because the increase in breast cancer was not seen in the estrogen only arm of the

WHI study. Pro’s- you just take one pill a day and it helps hot flushes, vaginal dryness, irritability and decreases your chances of bone loss and colon cancer.

 

Estrogen plus progesterone Patch- examples are Climarapro(which is generic and once a week) and Combi-patch( which is not generic and 2x per week)  Con’s- Hard to keep on.  They are big patches

and some women react to the adhesive.  Progesterone patches and creams have a low absorption rate so I see a lot of break through bleeding on these. Pro’s- there is no pass

through the liver so they help your sex drive and have less effect on your clotting factors.

 

Estrogen patch, gel or mist and an oral progesterone-  examples of Estrogen options- Minivelle, Climara, generic Estrogen Patch, Estrogel, Elestrin (gel) and Evamist with options of oral progesterone- provera,

aygestin and prometrium (all progesterones are available in generics)   Con’s-  This can be more expensive because it involves 2 prescriptions.  Oral progesterone might be the more significant player in breast cancer

because the increase in breast cancer was not seen in the estrogen only arm of the study.  Some patients feel that they get a happy spike after applying their gel or mist and then it goes down as the day goes on.

Estrogen Pellet with Progesterone Cream- Con’s- NOT FDA APPROVED, expensive,  progesterone cream has not been shown to protect the uterus as well as oral progesterone but we also don’t know what dose of estrogen in a Pellet you are receiving which makes counteracting endometrial growth with progesterone cream or pill difficult.  Pro’s  perceived as “natural”; no pass through the liver; relieves symptoms continuously for several months

 

Estrogen Only (No Uterus)

Pill- Premarin and generic Estradiol.  Con’s- passes through the liver so in some it doesn’t help your sex life and increases clotting.  Although some have painful intercourse from vaginal dryness so this would help in those women.  Pro’s-  It helps hot flashes, Irritability, inability to sleep and vaginal dryness and you only take a pill a day.

Patch-  Minivelle, Vivelle Dot generic, Climara and generic Climara    Con’s- keeping them on-  I do fine with the Minivelle but the generics are BIG and hard to keep on;  some patients are sensitive to the adhesive;  black ring when you replace it that you have to scrub off.   As long as a discount coupon is available for Minivelle then there is no significant difference in cost.  Climara non generic can be expensive.  Pro’s- no pass through the liver and steady release of Estrogen over days.

Gel or Mist-  Elestrin, Estrogel, and Evamist    Con’s no generics and can be pricey;  some patients are very sensitive to it; some patients are sensitive to how it wears off over a day.  Pro’s  no pass through the liver, no sticky residue like patch, no sensitivity to adhesive like patch.

Pellets- Con’s NOT FDA APPROVED;  unknown amount of hormone; expensive and insurance doesn’t cover; no control over manufacturing with possible mold contamination; and must be surgically placed. Pro’s no pass through the liver, relieves symptoms continuously for several months.