As you approach menopause, your levels of estrogen and progesterone (the hormones that cause you to ovulate and menstruate each month) start to decline, often triggering a whole host of symptoms that can range from annoying to incapacitating. Replacing the lost estrogen with hormone supplements can alleviate these problems, which may include hot flashes )medically known as vasomotor symptoms), depression, mood swings, vaginal dryness, sleep disturbances, and clouded thinking.
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Is hormone replacement therapy safe?
Some women may be able to take hormone replacement therapy to treat hot flashes and other menopausal symptoms in the short term without any ill effects. However, some doctors believe that the risks are serious enough to outweigh the benefits of the therapy for many women.
In 2015, a study from Oxford University and published in the journal Cochrane Library found that if women start HRT more than 10 years after menopause, their risk of stroke increased slightly and their risk of blood clots rose as well. If women began the therapy within 10 years of menopause, however, the stroke risk disappeared and there was some small protection against heart disease. However, they still had an increased risk of blood clots.
Subsequent studies have been less alarming. A study published in the Journal of the American Medical Association in 2017 that tracked women for 18 years found no difference in the mortality rates from all causes between those who took HRT and the placebo group. The researchers said it reinforced the belief that short-term HRT for younger women was relatively safe but there was no evidence that the therapy was effective against heart disease or other conditions.
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The use of HRT is a decision between you and your doctor and should be made on a case-by-case basis, according to the Cochrane study authors. Many experts advise that HRT, if it's prescribed, should be used for the shortest therapeutic time possible due to the risks of cancer, stroke and other significant risks.
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If I do decide to take HRT for short-term use to control my hot flashes, what should I do?
See your doctor for a thorough exam and discuss whether the treatment is right for you. If you decide to go ahead, you'll need a prescription -- either for estrogen alone, in the form of a pill, patch, or cream, or for the regimen of pills that contain both hormones. The patch goes on your abdomen or thigh and needs to be changed every week or two. Estrogen cream can be rubbed into your vagina to lessen vaginal dryness.
As mentioned, doctors choose to prescribe progestin along with estrogen because estrogen taken alone can increase the risk of uterine cancer, unless you've had a hysterectomy. Progestin keeps uterine cells from dividing and causes the uterus to shed its lining each month. If you do use HRT, you'll need to have an annual checkup, including a blood pressure check, breast and pelvic exams, and a Pap test.
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You may notice breast tenderness, headaches, bloating, and mood changes while you're on hormone replacement therapy, especially if you're taking progestin. You might also find that you start having periods again or bleeding irregularly. Your doctor can help you experiment with the dosages to pinpoint those that relieve your symptoms without adding too many new ones, although the amounts may need to be adjusted over time as your own hormone levels taper off.
Getting HRT may be inadvisable if you have a personal or family history of breast cancer or if you've ever had uterine cancer, liver disease, a blood clot, heart disease, high blood pressure, a heart attack, or a stroke. It may also not be a good choice if you have uterine fibroids, since estrogen can make them grow bigger, and thus cause pain and bleeding.
How long should I stay on the therapy?
Discuss this concern with your doctor, who can help you weigh the risks. A Women's Health Initiative trial reported an increase in heart disease, invasive breast cancer, and blood clots associated with long-term use. In her JAMA editorial, in fact, Harvard physician Suzanne Fletcher urged clinicians to stop prescribing the combined estrogen/progestin pill for long-term use. The WHI study, she wrote, "demonstrates that risks from the drug add up over time."
What are my alternatives to HRT?
Many bothersome symptoms associated with menopause, including hot flashes and mood swings, frequently get better on their own. One of the best things women can do, according to the National Cancer Institute (NCI), is to adopt a healthy lifestyle -- including not smoking, getting regular exercise, and having a good, nutritious diet. This will help lower your risk of bone loss, which increases as you age. You may also want to take calcium and vitamin D supplements.
If you are at risk of heart disease or osteoporosis, and lifestyle changes don't seem to be working, there are many prescription drugs available to help ward off those conditions. And there are a variety of nonhormonal therapies to treat bladder problems and vaginal dryness associated with menopause.
Unfortunately, few effective alternative treatments exist for menopausal symptoms that are severe. But many women seek relief from hot flashes, mood swings, and other annoying symptoms of menopause through yoga, wearing layers of loose-fitting cotton clothing, and relaxation exercises. You may also try alternative remedies such as foods that contain plant estrogens (including soy products and whole-grain cereal), herbs such as black cohosh, and vitamin E and B complexes, according to the NCI. The safety and effectiveness of these remedies is still being studied, so be sure to discuss your decision with your physician.
