How to Take Estrogen and Hormone Replacement Therapy

Background

Estrogens are the class of hormones responsible for many female characteristics such as breast growth, body fat distribution, vaginal lubrication and lining thickness and uterine tissue growth. There are three human estrogens:

• estradiol - the most common and most potent estrogen manufactured by the ovary in ovulating women
• estrone - a weaker estrogen manufactured mostly in the fat cells
• estriol - the weakest estrogen found only in any significant quantities during pregnancy.

Estradiol levels begin declining about 5 years prior to menopause, on the average and precipitately drop at the time ovulation stops completely at the time of menopause. Most of the signs and symptoms of menopause result from the decrease in estrogen production, mainly estradiol. Hormone replacement therapy with estrogen and progesterone (HRT) is given if a woman has not had a hysterectomy (to avoid estrogenic endometrial stimulation and possible endometrial cancer in later life) or just estrogen replacement therapy (ERT) is used to diminish menopausal signs and symptoms and help prevent other medical problems.

Any one or combination of the natural estrogens can be used as replacement therapy as well as synthetic, manufactured and even plant (herbal) estrogens.

Medication

• HRT usually consists of an estrogen hormone plus a progesterone (progestin) hormone. The two hormones combined protect against endometrial cancer, a risk with estrogen taken alone. Estrogen therapy alone may be used for women who have had a hysterectomy.
• The dose and form and regimen for the medications are determined depending on the individual woman's background, current symptoms number of years post menopause, family history, medical history, and goals for the replacement therapy. Frequently, women are prescribed both medications daily continuously. This regimen eventually leads to the complete absence of any vaginal bleeding after several months of therapy. Other women may be prescribed hormones on a cyclic schedule during the month to avoid irregular bleeding by inducing a regular light menses each month.
• Doses or schedules may need to be adjusted to completely resolve menopausal symptoms or side effects of the HRT or ERT. The medications can be supplied in oral form or skin patch form (transdermal), skin cream form, injections, skin implants (pellets), and oral or vaginal pellets that absorb through the skin lining of the cheek or vagina. Also, estrogen cream is and slow hormone release silicone rings are available that can be prescribed to relieve vaginal symptoms.
• For long-term protection from osteoporosis, tooth loss, the new occurrence of cardiovascular disease, a lowered incidence of Alzheimer's disease, colon cancer, cataracts and acute macular degeneration of the eye leading to blindness, HRT or ERT must be taken for a decade or more. Also it needs to be started as close to the menopause as possible. Starting HRT or ERT 10 or more years after the menopause loses most of the long term benefits while still maintaining the risks.

Taking the Medications

• many "natural" hormone pills are absorbed better when taken with a meal.
• if you take the oral pills in the morning but still have difficulty sleeping at night, try taking your dose in the evening or cutting your dose in half and taking it morning and evening.
• If you miss a pill, take it as soon as possible. If it is almost time for the next dose, skip the missed one. You do not need to double up on a missed dose like you do with birth control pills. Also, you do not need to wear more than one transdermal patch at a time.
• if nausea is a problem, take the pill(s) with food or right after eating. Nausea usually goes away with continued use.

Effects of Therapy

Short term

• Relieves hot flashes (sweating episodes)
• Improves sleep difficulties
• Improves vaginal lubrication and lessens vaginal dryness that can cause pain and discomfort during sexual intercourse.
• May improve mood, feeling of well being, lessen depression and irritability

Long term

• Prevention of osteoporosis and improvement of bone density by 1-2% a year.
• Helps prevent the new occurrence of heart disease (30%)
• Is associated with a significantly reduced incidence of colon cancer (35-50%)
• Is associated with a significantly reduced incidence of Alzheimer's disease
• Is associated with a significantly reduced incidence of macular degeneration of the eye leading to blindness
• Is associated with a slightly HIGHER incidence of a well differentiated, early stage breast cancer
• Is associated with an increased incidence of gall bladder disease

Relative Contraindications

• Breast cancer (depending on when the diagnosis was made).
• Past or current history of a blood-clotting disorder such as thrombophlebitis) is generally not a contraindication, but should always be discussed with the doctor.
• Known or suspected pregnancy.
• Uterine (endometrial cancer) (depending on when the diagnosis was made).
• Undiagnosed vaginal bleeding - usually needs to be evaluated before HRT, ERT is started.

Side effects

HRT, ERT is generally well tolerated. If a woman has not had a hysterectomy, the most common side effect is irregular uterine bleeding, which usually diminishes in time. If you are on HRT and continue to have irregular bleeding after the third month, notify the doctor to see if any work-up or change in dose is needed.

• Swollen feet or legs
• Mood changes
• Breast tenderness or pain
• Pelvic cramping
• Fatigue
• Depression
• Headaches

Adverse reaction

Notify the doctor immediately if there any signs or symptoms of a vascular or heart problem

• sudden or severe headache
• sudden loss of coordination
• sudden loss or change in vision
• sudden slurring of speech
• weakness or numbness in arm or leg
• prolonged thigh or calf pain (not muscle cramps)
• pains in the chest or going down the left arm
• sudden unexplained shortness of breath

Follow-up Examinations

• Women taking hormones should have an annual pelvic examination and a mammogram.
• The doctor may want to see you at 2-3 months after starting ERT, HRT to make sure you are at the best dose and not having problems
• If after taking the HRT, ERT for a month or more and the symptoms of hot flashes, sleep difficulties or vaginal dryness are only partially decreased, schedule a visit to see if your dose needs to be changed.