Hormone Replacement Therapy (HRT): Advantages and Disadvantages

by Savvas Ioannides N.D.

Hormone Replacement Therapy (HRT) sometimes called Estrogen Replacement Therapy (ERT) and also known as Menopausal Hormone Therapy (MHT) (1) is medication containing hormones such as estrogen alone (usually in the cases where women have had their uterus removed) or estrogen with progestin (synthetic progesterone). HRT is used to treat the deficiencies in the female hormones caused by menopause or otherwise. (2), (3) However, the question that needs to be answered is that, is natural biological processes, like menopause, pathologic, or is this the trend of the 21st century?

Medication is available in the form of a pill, a patch, or a vaginal cream. HRT is most often used to treat women who are going through menopause and who had already gone through it (post-menopausal). Symptoms associated with menopause include:

  • hot flashes,
  • vaginal dryness causing itching and pain during sexual intercourse,
  • mood swings,
  • sleep disorders and
  • decreased libido.(2)

Many concerns have been raised about the risk and benefits of HRT, especially after the July 2002 release of “Risks and Benefits of Estrogen plus Progestin in Healthy Postmenopausal Women” by the Writing Group for the Women’s Health Initiative Investigators (WHI) and its predecessor, the Estrogen/Progestin/ Replacement Study (HERS) for the HERS Research Group in the same year. This essay will look into publications on HRT particularly discussing the benefits and risks of HRT. HRT is the medication for the treatment of hot flashes, vaginal dryness, mood swings, sleep disorders, decreased sexual desire and for women who have an increased risk of developing cardiovascular disease &/or osteoporosis. (4) The risks and benefits of HRT discussed in this essay are associated with healthy menopausal and post-menopausal women. The risks differ depending on the health status of the person and on the type of HRT.

The WHI study, which was started in 1993, is one of the most important and long-term research that examined among other the health benefits and the risks of HRT including the risk of developing breast cancer, myocardial infraction, strokes and blood clots. (5) The WHI component that studied the use of estrogen and progestin in women who had a uterus in July 2002 was stopped early because the health risks exceeded the health benefits specifically due to a 26% increase in breast cancer. In addition, another component of WHI, which studied the use of estrogen-alone therapy in women who had hysterectomy was also stopped early because of a 41% increase in the risk for strokes. Moreover, the researchers of the WHI study found that post-menopausal women on HRT were at a 29% higher risk of cardiovascular heart disease (CHD) and had 2-fold greater rates of venous thromboembolism (VTE), as well as deep vein thrombosis (DVT) and pulmonary embolism (PE). Total cardiovascular disease, including other events requiring hospitalization, was increased by 22% in the estrogen plus progestin group. However there was a reduction of 37% in levels of colorectal cancer and a 39% reduction in hip fractures. The reductions in other osteoporotic fractures (23%) and total fractures (24%) were statistically significant. (2), (5)

Other outcomes from the WHI study suggest that the farther a woman was from the onset of menopause when she began hormone therapy, the greater her risk of CHD. Overall, hormone therapy did not reduce the risk of CHD. Furthermore, the WHI study analyses firstly confirmed that hormone therapy increases the risk of stroke and this risk does not appear to be influenced by age or time since menopause, secondly, there is an increased risk of breast cancer in women taking estrogen with a progestin even in women within 10 years of menopause, and thirdly, there was a trend towards reduced risk for death associated with hormone use in younger compared to older women. (5), (6)

In August 2003, The Million Women Study from the United Kingdom confirmed the initial WHI study. This study recruited 716,738 women during 1996-2001. These women did not have a previous hysterectomy or previous cancers, and were followed up for an average of 3.4 years, during which 1320 endometrial cancers were detected. The risks were different depending on the type of medication used. Women who used the continuous combined therapy (progesterone added daily to estrogen) had a reduced risk of endometrial cancer whereas women who had used the cyclic combined preparations (estrogen with progesterone added every 10-14 days per month) had no difference in risk. Those who had previously used tibolone or estrogen-only HRT had an increased risk of endometrial cancer. (7)

Other side effects include nausea, bloating, breast tenderness or headaches caused primarily by the hormone estrogen in HRT. Moreover, water retention, bloating, irritability, mood swings and anxiety are cause by the progestin. Although the side effects of HRT may vary from woman to woman withdrawal bleeding is the most frequent reason women cease HRT. Withdrawal bleeding may occur if progestin is taken cyclically for 10 to 14 days every month and the bleeding resembles a light menstrual period occurring at the end of each progestin cycle. (8)

Other side effects depending on the type of HRT usage are skin irritations with itchiness and redness due to the transdermal skin patches, allergic skin reactions in some women who use vaginal creams and some hormones can cause acne-like skin problems. (8)
An increase in skin dryness, a decrease in skin elasticity and an increase in looseness are other symptoms that many women notice during menopause. A recent study showed that the effects of a combination of glycolic acid cream and 17 -oestradiol cream resulted in the increase in skin thickness. Also another study showed that topical 0.03% oestrol and 17 -oestradiol made a significant improvement on wrinkle depth and skin hydration. (9)

Another important part of menopause that many women experience but that these studies did not address, are the symptoms of menopause (i.e., hot flashes, night sweats, vaginal dryness and irritation, and painful intercourse). These symptoms usually occur during the first few years after the menopause, but may last longer for some women. For these symptoms, nothing is more effective than estrogen. (10)

The Women’s Health Initiative Memory Study (WHIMS), a randomized, double-blind, placebo-controlled clinical trial demonstrated that “61 women were diagnosed with probable dementia, 40 (66%) in the estrogen plus progestin group compared with 21 (34%) in the placebo group.” “This increased risk would result in an additional 23 cases of dementia per 10,000 women per year”. Alzheimer’s disease was the principal form of dementia. (11)

Sexual problems and a worsening of various aspects of libido is another symptom that accompanies menopause. A study which enrolled 184 women receiving HRT with tibolone showed that the effect of 2.5 mg daily for at least 4 months with tibolone (Liviel) had a significant increase in women’s satisfaction with their sexual lives and a significant improvement in different aspects of libido. However, these effects may be due to both an increase in genital blood flow and the central estrogenic/androgenic activity. (12)

In conclusion, postmenopausal hormone therapy use increased dramatically during the past twenty years because of a prevailing belief in its health benefits. Recent evidence (discussed in this essay) demonstrated adverse cardiovascular disease events, breast cancer and other risks with hormone therapy in the form of oral estrogen combined with progestin. (13)

I believe that information about the risks and benefits of HRT should be incorporated through educational and/or governmental organizations much before menopause begins, so that prevention of osteoporosis may be attained. I would not advise a woman to take HRT because the risks weigh much more than the benefits, however the decision is solely up to the individual. Most importantly, whether HRT should be administered depends upon one’s quality of life particularly in the case of osteoporosis. A different point of view of menopause will assist a woman to accept the changes that naturally occur during menopause. Such view is that it is a natural and physiological phase of a woman’s life and that changes in the lifestyle including mental, emotional and physical are necessary. Furthermore, alternatives to HRT such as herbal medicine, homeopathy, nutrition, exercise and other modalities are of great help to alleviate most of the symptoms of menopause and guide a woman to health.

Works Cited

  1. National Centre for Complimentary and Alternative Medicine. NCCAM Publication. Do CAM Therapies Help Menopausal Symptoms. [Online] November 2005. [Cited: June 09, 2007.] http://nccam.nih.gov/health/menopauseandcam/. D297.
  2. National Institute of Child Health & Human Developement. National Institute of Child Health & Human Developement. Hormone Replacement Therapy. [Online] May 24, 2007. [Cited: June 09, 2007.]http://www.nichd.nih.gov/health/topics/Hormone_Replacement_Therapy.cfm.
  3. Medline Plus. Meldline Plus. MedlinePlus Medical Encyclopedia Hormone replacement therapy. [Online] February 09, 2006. [Cited: June 09, 2007.]http://www.nlm.nih.gov/medlineplus/ency/article/007111.htm.
  4. Trickey, Ruth. Women, Hormones & The Menstrual Cycle. Sydney : Allen & Unwin, 2000.
  5. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. Writing Group for the Women’s Health Initiative Investigators. 3, July 17, 2002, JAMA, Vol. 288, pp. 321 – 333.
  6. National Institutes of Health (NIH). National Institutes of Health (NIH). Effect of Hormone Therapy on Risk of Heart Disease May Vary by Age and Years Since Menopause. [Online] April 03, 2007. [Cited: June 09, 2007.]http://www.nih.gov/news/pr/apr2007/nhlbi-03.htm.
  7. Endometrial cancer and hormone-replacement therapy in the Million Women Study. Million Women Study Collaborators. April 30, 2005, Lancet, Vol. 365, pp. 1543-1551.
  8. Slupik, Ramona I. American Medical Association (AMA). Medem Medical Library Hormone Replacement Therapy: Risks vs. Benefits. [Online] March 2005. [Cited: June 09, 2007.] http://www.medem.com/medlb/article_detaillb.cfmarticle_ID=ZZZ596TUCKC&sub_cat=0.
  9. Skin aging and sex hormones in women – clinical perspectives for intervention by hormone replacement therapy. Sator, G Paul, et al. s4, December 2004, Experimental Dermatology, Vol. 13, p. 36.
  10. Jaffe, Robert B. and Santen, Richard. Medem Medical Library, Hormone Therapy for Menopausal Symptoms: The First Few Years. [Online] March 2006. [Cited: June 09, 3007.] http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZFSCKZGLD&sub_cat=2002.
  11. Estrogen Plus Progestin and the Incidence of Dementia and Mild Cognitive Impairment in Postmenopausal Women. WHIMS Investigators. 20, 28 May, 2003, JAMA, Vol. 289, pp. 2651-2662.
  12. Hormone replacement therapy with tibolone: effects on sexual functioning in postmenopausal women. Egarter, Christian, et al. 7, July 2002 , Acta Obstetricia et Gynecologica Scandinavica, Vol. 81, pp. 649-653.
  13. National Use of Postmenopausal Hormone Therapy: Annual Trends and Response to Recent Evidence. Hersh, Adam L, Stefanick, Marcia L and Stafford, Randall S. 1, January 7, 2004, Jama, Vol. 291, pp. 47-53
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About Naturopathy by Savvas Ioannides
Savvas Ioannides is a Naturopathic, Herbal and GAPS Diet practitioner who studied at Nature Care College in Sydney. Savvas uses holistic and natural therapies including Herbal remedies and Nutrition to boost your vitality and help you achieve optimum levels of health.

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