Hormone Replacement Therapy (HRT) is a treatment used to reduce the disorders (symptoms) that can occur in menopause.
The available evidence and the main international agencies, including the European Medicines Agency, recommend hormone replacement therapy for women who have disorders attributable to menopause, such as hot flashes, sweating and consequent sleep problems, perceived as important, lasting and responsible for a worsening of the quality of life.
In light of the available evidence, postmenopausal HRT is not recommended for the prevention of health problems that may develop later in life, such as cardiovascular disease or osteoporosis.
Considering the benefits and harms, HRT should generally be reserved:
- to women who have entered menopause at the age of less than 45, i.e. in early menopause
- to women who suffer from hot flashes, sweats and nocturnal awakenings in menopause, perceived as important and lasting
- to women who experience menopause in a negative way, and wish to take therapy after receiving information from their doctor about the benefits and harms of treatment
Before starting HRT, you should talk to your family doctor or gynecologist to get information about disorders attributable to menopause, the benefits and harms of hormone therapy, and that once treatment is stopped, the disorders can recur.
Contraindications to the use of HRT include:
- previous breast, ovarian or uterus cancer
- blood clotting problems
- high blood pressure (hypertension)
- liver disease
Types of Therapy
Hormone Replacement Therapy (HRT), as the word itself implies, replaces the hormones a woman's body no longer produces during menopause. The two main hormones used in HRT are estrogen and i progestogens laboratory products and analogues to natural hormones produced by the ovaries during reproductive life. Hormone replacement therapy may involve taking both of these hormones (combined HRT) or estrogen alone. Most women take combined HRT because taking estrogen alone increases the risk of developing uterine cancer. L Taking the progestogen together with estrogen reduces this risk, which is why estrogen-only HRT is only recommended for women who have had their uterus removed (hysterectomy).
HRT can be used in a way cyclical taking an appropriate dosage of estrogen each day and progestogen only during the last 14 days of the month or so keep it going taking both estrogen and progestogen every day without any interruption.
It may take a few weeks to feel the positive effects of the therapy and some undesirable effects may occur at the beginning which, generally, tend to subside spontaneously after the first weeks of treatment.
The main side effects associated with taking estrogen and / or progestogen include:
- increased sensitivity in the breast
- leg cramps
- headaches or migraines
- mood swings
- difficulty in digestion
- vaginal bleeding
Taking medications with meals can help reduce nausea and digestive difficulties, and regular exercise can help reduce swelling and leg cramps.
HRT can be taken in the form of pills, patches or gels, and each woman should decide with her doctor what is most convenient for her by weighing the pros and cons of each option.
Tablets, which are usually taken once a day, are one of the most common ways to take HRT. Tablets are available that contain only estrogen or estrogen and progestogen. It is important to know that the risk of venous thrombosis (formation of blood clots) slightly increases with taking the drugs by mouth compared to other modalities.
They are the most used modality, and must be replaced periodically according to the different dosages. Patches are available that release either estrogen only or both estrogen and progestogen. Some women find the patches more practical than taking the tablets daily and they are associated with a slightly lower risk of venous thrombosis (blood clots) than with oral therapy.
The gel containing estrogen is applied to the skin once a day and allows immediate absorption of the drug. It offers the same benefits as the patch and is especially recommended for women who have had their uterus removed.
Creams, pessaries or vaginal gels
Creams, pessaries or vaginal gels containing only estrogen are an effective and safe solution for genital discomfort such as itching, vaginal dryness, pain during sexual intercourse or recurrent urinary tract infections.
This local therapy does not involve the risks described for general replacement therapy because the absorption of hormones via the vagina is minimal. For this reason, all women must be informed about this safe and effective treatment opportunity for the control of disorders (symptoms) related to vaginal dryness that usually appear a few years after the onset of menopause.
The optimal duration of HRT treatment is uncertain but guidelines recommend prescribing the lowest active dose for as short a treatment period as possible with periodic assessment of the disorders and the woman's willingness to continue therapy.Risks
As with all drug therapies, the benefits of HRT must be balanced against the risks. They understand:
- increased risk of stroke
- increased risk of venous thrombosis (blood clots)
- increased risk of breast cancer, in relation to the duration of therapy
The increased risk of these diseases at an individual level is low and the decision to undertake, or not, hormone treatment must be based on the assessment of the individual risk, also considering the possible presence of other risk factors for the same diseases. More recent studies and new guidelines from the US National Institute of Health (NIH) and the UK National Institute for Health and Care Excellence (NICE) state that the overall risk for young women starting HRT early for the treatment of the disorders of menopause is, in general, very low.
Studies looking at whether HRT may increase the risk of breast cancer have estimated an increase of 1 in every 1,000 women taking it every year. The risk is lower for women using estrogen-only therapy than for those taking estrogen and progestogen together. After 5 years from the suspension of therapy, the risk seems to return to that of the general population. It is therefore very important that women taking HRT participate regularly in breast cancer screening.
Tumor of the ovary
Studies on the role of HRT in increasing the risk of ovarian cancer have so far yielded mixed results. A recent study found that for every 1000 postmenopausal women who take HRT, one more case of this cancer occurs for five years. As with breast cancer, the risk decreases once HRT is stopped.
Cancer of the uterus
Studies that have examined whether HRT may increase the risk of endometrial cancer (the mucous membrane that lines the inside of the uterus) have shown an increased likelihood in women who take only estrogen. For this reason, estrogen-only therapy should only be used by women who no longer have a uterus (following a hysterectomy). With combined hormone replacement therapy (estrogen and progestin), this risk is almost completely reduced.
Venous thrombosis (blood clots)
Studies that have investigated whether HRT may increase the risk of venous thrombosis have estimated an increase of 2 in 1000 postmenopausal women for each year. The use of patches or gels decreases the risk of thrombosis compared to administering HRT by mouth.
Stroke and heart disease
Studies on the role of HRT in increasing the risk of stroke have estimated an increase of 1 in 1000 women every year. New studies suggest that starting treatment before age 60 reduces the risk of heart disease.Alternative Methods or Therapies
Alternative Methods or Therapies
To control the symptoms (symptoms) of menopause, alternative therapies are available and are recommended especially for those who are unable or unwilling to take hormone-based HRT.
The tibolone is a drug that acts like combined HRT (estrogen and progestogen). It must be prescribed by the doctor and is usually taken as one tablet per day.
It can help relieve ailments such as hot flashes, mood swings and reduced sex drive, although some studies have suggested that it may not be as effective as combined HRT. It is indicated for women who have had their last menstrual period for more than a year (post-menopause).
The risks of tibolone are similar to those of HRT and include a small increased risk of developing breast cancer and stroke. Also for this drug it is necessary to consult a doctor both for its prescription and to decide how to take it and continue the therapy.
The bioidentical or natural hormones are hormonal preparations extracted from plant sources (phytoestrogens). They are similar to human hormones. Many claim that these hormones are a "natural and safer alternative to the preparations used in HRT. However, robust scientific evidence for their efficacy and safety is not available for these preparations.
The complementary therapies include several products for the treatment of menopausal disorders (symptoms). You can buy them in herbalists and parapharmacies. They include herbal remedies such as primrose oil, black cohosh (root of a South American plant), angelica, ginseng and St. John's wort.
There is evidence to suggest that some of these remedies, including black cohosh and St. John's wort, may help reduce hot flashes but, in general, most complementary therapies are not supported by scientific evidence. purity and ingredients cannot always be guaranteed and can cause unwanted effects (side effects). It is advisable to ask your family doctor, gynecologist or pharmacist for advice if you are considering using complementary therapy.
Lifestyle changes can help reduce some menopausal ailments without posing any health risk. An appropriate diet is recommended that includes a variety of fruits, vegetables and cereals, limiting the intake of saturated fats, oils and sugars.
It is good to carry out regular physical activity that helps reduce hot flashes, sweats and urinary incontinence and improves mood and sleep quality as well as being useful in the prevention and treatment of high blood pressure (hypertension) and excess fat in the blood.
Smoking increases the risk of heart disease, stroke, osteoporosis, cancer and a host of other health problems as well as increasing hot flashes. In menopause, therefore, it is advisable to stop smoking or, in any case, to try to reduce the number of cigarettes as much as possible.
Against hot flashes it is advisable to dress in layers to be able to lighten up if necessary, drink a glass of cold water, move quickly to a cooler environment; try to identify and avoid the things that trigger hot flashes such as hot drinks, caffeine, spicy foods, alcohol and stress.
Local therapy with estrogen-based creams, pessaries or gels and / or over-the-counter drugs such as water-based vaginal lubricants or moisturizers can be used against vaginal discomfort. Avoid products that contain glycerin as they can cause burning or irritation in women sensitive to these substances. Staying sexually active helps by increasing blood flow to the vagina.
Against insomnia it is important to avoid caffeine, which can make it difficult to sleep, and not to drink too much alcohol. It is a good idea to be careful not to exercise before bedtime. If your sleep is disturbed by hot flashes, it could be useful to lighten the blankets or take a shower before going to sleep.
Against urinary incontinence, the pelvic floor muscles can be strengthened with simple and effective physical exercises that must always be performed under competent guidance (such as a physiotherapist or a professional nurse) and tend to strengthen the pelvic floor.In-depth link
Mayo Clinic. Hormone therapy: is it right for you? (English)
EpiCentro (ISS). Hormones in menopause