®TheFemale Patient

M ariel, age 50, is having hotflashes. Every hour or two,day and night, she feelsintense heat spreading from

her chest to her face. She has not had anormal night’s sleep for weeks. Hercoworkers laugh when they see her fanning herself. Mariel tries to go alongwith the joke, but her symptoms are no longer funny. She wants help. Couldhormone therapy (HT) be the answer?

This Is MenopauseYou are “in menopause,” or “postmenopausal,” onceyou have had no periods for 1 year, unless there isanother reason for not having periods (ie, using thebirth control shot or other forms of hormones). At thistime, your ovaries have stopped producing the hor-mones estrogen and progesterone, and you can nolonger become pregnant. The average age at meno-pause in the United States is about 51. Menopause canalso occur when a woman’s ovaries are removed bysurgery. However, the ovaries may rarely stop workingeven if just the uterus is removed, especially if awoman is close to the age of menopause.

Some women experience menopause without anyparticularly bothersome symptoms, but many, likeMariel, have frequent, intense, or persistent problemsthat interfere with their lives, such as hot flashes.These are usually most frequent and intense duringthe years just before and after your last period, butmany women have symptoms that last for years.Other symptoms of estrogen loss include vaginal dry-ness, pain with intercourse, mood swings, and sleepdisturbances. Of course, changes that can develop inconjunction with menopausal symptoms—such asdepression or decreased interest in sex—may also berelated to other things happening in your life.

There are many approaches you can try to dealwith hot flashes and other menopausal symptoms.Lifestyle changes discussed in this handout can help.Some herbal therapies can decrease the frequency of

hot flashes. Black cohash is an herb womenoften try. There are prescription drugs withouthormones that clinicians can offer to reducethe frequency and intensity of hot flashes. Amedication called clonidine, which is used forhigh blood pressure, as well as some drugsthat were developed to treat depression, canreduce hot flashes and help mood swings. Othermedications, such as those used to treat nerve irrita-tion, have shown promise in treating hot flashes. How-ever, HT is the most effective treatment for reducingmenopausal symptoms.

Hormone Therapy: Risks and Benefits Menopause itself is not a disease and does not needtreatment. However, when severe hormone-loss symp-toms interfere with your quality of life, postmenopausalHT can be very beneficial. Estrogen relieves hot flashesand vaginal dryness, but does not reliably revive sexualinterest or treat depression. Mood swings that are causedby hot flashes at night can be treated with HT. However,if you have symptoms of significant depression—changein appetite and sleep, decreased pleasure in formerly en-joyable activities, and thoughts of self-harm or suicide—get help. Hormone therapy is not the answer, but thereare other effective treatments.

If Mariel had entered menopause 10 years ago, herhealth care provider might have encouraged her to takeestrogen/progestin tablets for the rest of her life to“replace” what her ovar-ies no longer produced.Estrogen was formerlythought to prevent heartdisease, the leadingkiller of women, andpossibly Alzheimer’s disease as well. Proges-tins were used alongwith estrogen to pro-tect against cancer ofthe uterine lining.

Enthusiasm for HTslowed, however, when a large study,the Women’s HealthInitiative, found that

4/06 The Female Patient grants permission to reproduce this handout for the purposes of patient education.

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What You Should Know AboutHormone Therapy

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when hormones were given to older women, they didnot prevent heart disease or mental decline. In fact,the study showed that long-term use of estrogen andprogestin made women somewhat more likely todevelop heart disease, strokes, blood clots, and breastcancer. While estrogen by itself did not increase therisk of heart attacks (in fact, new findings have shownit may even lower the risk of coronary heart diseasein women aged 50 to 59 years), it was reported toincrease the risk of strokes and blood clots. So, whileestrogen helps prevent bone fractures from osteo-porosis, women who do not have hot flashes maywant to use other effective treatments.

How does Mariel know if HT is appropriate forher? Because her symptoms are interfering with herlife, she and her health care provider discuss therisks and benefits of HT. Mariel’s weight, blood pres-sure, and cholesterol are all normal. She eats sensi-bly and exercises regularly, and no one in her familyhas heart disease, so her risk of a heart attack is low.Her yearly mammograms have been fine.

She and her health care provider discuss othertreatments that can help reduce hot flashes, butdecide that HT is worth trying. She understandsthat she should use the lowest dose of HT that con-trols her symptoms, for the shortest amount of timepossible. She also learns that when she stops theHT, the hot flashes may return. If that happens, shemay decide to continue HT until the hot flashesstop on their own, or until the risks of using HT aregreater than the benefits she receives.

Many HT preparations are available. Estrogen/pro-gesterone combinations come as prescription tablets orskin patches. For women who have had a hysterectomy,estrogen alone can be prescribed as a pill, a skin patch,or a skin cream.

For vaginal dryness not relieved by over-the-counterlubricants (ie, Astroglide, KY Jelly, Surgilube, Replens),estrogen can be delivered directly to the vaginal area.There are creams, suppositories, and a vaginal ring that

can all provide estrogen. Vaginal treatments do not causeas high a level of hormones in a woman’s circulation.

Like all medications, HT may have side effects. Somewomen have breast tenderness, vaginal bleeding orspotting, bloating, nausea, or mood swings when theystart HT. It is important for HT users to get regularmedical follow-up, but they do not need any extra vis-its or tests if they use hormones successfully.

You may also have heard about “bioidentical hor-mones,” which are compounded (made by hand) bycertain pharmacies. Although hormones made “espe-cially for you” may sound appealing, there is noresearch to tell if these preparations are effective or safeand no agency to warn women if problems do arise.

What Else You Can DoThere are ways to live with hot flashes. You can dressin removable layers, turn a small bedside or desk fanon and off as needed, and avoid flash-inducing foodsand drinks like caffeine, alcohol, and hot spices. Sleepproblems may improve with daily exercise (not tooclose to bedtime), regular bedtime, caffeine avoid-ance, and cooler bedroom temperature. Relaxationexercises, stress management, talking with friends andfamily, regular exercise, and a healthy diet can helpwith mood swings and minor depression. Manymenopausal symptoms, other than vaginal dryness,get better with time.

Complementary and alternative remedies areanother choice, although most have not been studiedenough to ensure if they are safe and effective. Informa-tion about alternative and complementary remedies isavailable at the National Women’s Health InformationCenter listed in the Resources box.

In ConclusionMenopause is another phase of a woman’s life. Whenmenopausal symptoms such as hot flashes interferewith quality of life, HT used in the lowest possibledose for the shortest amount of time is the mosteffective therapy. If you are considering HT, workwith your health care provider and get all the infor-mation you need about all of your choices. Make aninformed decision and commit to taking good care ofyourself for the rest of your life.

This Patient Handout was prepared by Diane E. Judge, APN/CNP,

using materials from The National Women’s Health Information Cen-

ter Web site; and Judge, DE. Hormone Therapy in the Menopausal and

Postmenopausal Years: What Should You Do? Journal Watch

Women’s Health. Sept 5, 2005.

The Female Patient grants permission to reproduce this handout for the purposes of patient education. 4/06

• The National Women’s Health Information Centerhttp://www.womenshealth.gov/faq/menopaus.htm

• National Institutes of Health National Heart Lung and Blood Institutehttp://www.nhlbi.nih.gov/health/women/index.htm

Resources

Hormone Therapy

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