Menopause and Perimenopause
Medications
Recent studies have changed how health professionals use hormone therapy after menopause. For a long time, hormone replacement therapy (HRT) was thought to protect against heart disease and dementia. However, studies now show that HRT use can cause serious health problems. One large study done by the Women's Health Initiative (WHI) has shown that HRT does not protect against heart disease. In fact, in a small number of women who are 10 or more years past menopause, it causes heart disease, including heart attacks.11 In the WHI study, short-term use of HRT was also linked to an increase in the numbers of strokes and blood clots. Using HRT for several years was linked to increased cases of breast cancer and dementia. Overall, most women using HRT in the WHI study had no serious side effects, but they also had no long-term benefits.
ERT may also cause breast cancer in a small number of women.9
Experts do not yet know whether hormone therapy risks are the same for older and younger postmenopausal women. Researchers are now exploring HRT use by women who use short-term, low-dose hormone therapy starting at menopause.
Average HRT- and ERT-related risks are low among the general population of women. Your personal risks that hormone therapy may stimulate breast cancer, cardiovascular problems, blood clots, or neurological changes may be lower or higher, depending on your risk factors.
Many health professionals now suggest trying nonhormonal treatment for bothersome menopause symptoms before considering hormone therapy (birth control pills, estrogen alone [ERT], or estrogen-progestin [HRT]). There are several nonhormonal prescription treatments that can relieve or reduce hot flashes and other menopause symptoms. You can also try using black cohosh or dietary soy.
Medication Choices
Prescription medication without hormones
- Selective serotonin reuptake inhibitors (SSRIs), which are a type of antidepressant medicine such as Paxil or Prozac, can reduce the number and severity of hot flashes. Some women have side effects.12 The safety of very long-term use has yet to be studied.
- Clonidine, a high blood pressure medication, can reduce the number and severity of hot flashes.13 Some women have side effects related to low blood pressure.
- Gabapentin (Neurontin), an antiseizure medication, can reduce the number and severity of hot flashes.28 Possible side effects include sleepiness, dizziness, and swelling.
Prescription medication with hormones
- Birth control pills (estrogen and progestin) regulate menstrual bleeding and can relieve symptoms until menopause. Birth control pills are not used after menopause. You should not use birth control pills if you smoke or have diabetes, untreated high blood pressure, cardiovascular disease, or a history of breast cancer. Low-dose formulations are recommended for women older than 35. Some women have side effects.
- Progestin pills or the levonorgestrel IUD, which releases a form of progesterone into the uterus, reduce heavy, irregular menstrual periods during perimenopause. Some women have side effects.
- Low-dose vaginal estrogen (cream, tablet, or ring) reduces vaginal and urethral dryness and weakening without introducing high levels of estrogen into the body.
- Hormone replacement therapy (estrogen and progestin), in pill, patch, or vaginal ring form, can be used to treat menopause symptoms. Because recent studies have found that HRT increases some health risks for some women, health professionals have changed the way HRT is used. For menopause symptom relief, experts now recommend that HRT only be used at the lowest effective dose for the shortest possible period of time.1
- Bioidentical hormone replacement therapy is made from plants and is thought to be more similar to human-produced hormones than synthetic HRT. However, bioidentical HRT is not well-researched and may carry the same health risks that traditional HRT does.1 Any form of hormone therapy is best taken for as short a period as possible.
Estrogen replacement therapy (ERT) is used to prevent weakening bones and the severe symptoms that come with sudden, early menopause. Early menopause usually happens after surgery to remove the uterus and ovaries (hysterectomy and oophorectomy) or from ovary failure after cancer treatment. However, ERT is known to slightly increase the risks of stroke and blood clots during the first year of use.23 Long-term ERT may slightly increase breast and ovarian cancer risks.9, 21
Taking estrogen by itself (ERT) can lead to uterine (endometrial) cancer. Taking progestin with estrogen protects against uterine cancer. This is why ERT is only recommended if you have no uterus. If you have not had your uterus removed and want hormone therapy, you take progestin with the estrogen (HRT).
Short-term, low-dose HRT or ERT is hoped to offer a balance between HRT benefits and risks. It can be taken for up to 4 to 5 years, with regular checkups. This may work well for many women, who will find that their menopause symptoms have subsided within this period of time. As more women use low-dose hormones for shorter periods of time after menopause, researchers will be able to learn about the actual benefits and risks.
Progesterone creams. "Natural" progesterone creams (available in health food stores or through mail order) or prescription progestin creams, which are made by a compound pharmacist, are marketed to correct low progesterone levels. While some women report finding relief with progesterone cream, there is mixed evidence about whether these products increase the body's progesterone levels.29, 30, 31 This raises the following concerns about over-the-counter progesterone cream use.
- If it is absorbing well. Progesterone treatment has risks. It has been linked to breast cancer, headaches, and dangerous blood clots in a small number of women.31 This is why progesterone is usually a prescription hormone and is not safe for women with certain health risks.
- If it is not absorbing well. If you are taking estrogen (and have an intact uterus), you also need to have enough progesterone to prevent the estrogen from causing uterine (endometrial) cancer. Using a poorly absorbed progesterone cream while taking estrogen does not protect you from uterine cancer.30
Talk to your health professional before using an over-the-counter progesterone cream.
Testosterone.Testosterone-estrogen is sometimes used for menopausal symptoms that don't improve with estrogen therapy. But it is not FDA-approved because its risks are not yet fully known. Testosterone-estrogen carries the same risks as estrogen treatment (blood clots, stroke, breast cancer) as well as testosterone risks and side effects. Experts have not studied long-term risks of testosterone-estrogen use, but it is known that testosterone treatment can cause hair loss, acne, deepening of the voice, and facial hair growth.1
Testosterone is sometimes used to increase sexual desire in postmenopausal women who have low testosterone. But, no form of testosterone is approved for women. Studies have not shown a benefit for longer than 12 weeks of use, and long-term testosterone risks for women are not yet known.15 If you have a problem with decreased sexual desire, consider that most sexual troubles in women relate to such things as relationship problems, depression, or medicine side effects. For more information, see the topic Sexual Problems in Women.
What to Think About
HRT and osteoporosis. Researchers are studying the effects of low-dose estrogen therapy. A small early study has shown that a low estrogen dose—0.25 mg per day—may keep the bones as strong as the higher dose.32 However, the long-term risks of taking low-dose estrogen are not yet known.
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| Author: | Kathe Gallagher, MSW | Last Updated: May 26, 2006 |
| Medical Review: | Joy Melnikow, MD, MPH - Family Medicine Carla J. Herman, MD, MPH - Internal Medicine | |
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