The Doctor's Corner

I can always tell when there is media attention to a gynecologic issue, because we get phone calls and related appointments in the wake of celebrity focus and headlines! The latest “It” subject, according to Oprah, is menopausal Hormone Replacement Therapy, or HRT.  In a way, it’s good that such an important subject gets some popular attention; on the other hand, what’s right for one person (famous or not) may not be right for another. I will focus on some of the terms and issues surrounding HRT in this column.  By no means is this information exhaustive; entire books are written about this subject.  Also, the state of the science on HRT remains somewhat dynamic, so nothing written here is necessarily the “last word”. That said, we do have much more data on HRT than we did a few years ago, and it remains a “hot” (no pun intended!) topic.

HRT implies the replacement of ovarian hormones, which decrease with menopause. The ovaries produce two main hormones, estrogen and progesterone, in addition to smaller amounts of others, including testosterone, commonly thought of as the “male” hormone.  Most menopause symptoms are thought to result from estrogen deficiency, and replacement of this hormone generally gives quick relief of hot flashes and night sweats.  There is a long list of other potential menopause symptoms, including but not limited to sleep disturbance, mood changes, joint aches, vaginal dryness and “fuzzy brain”.  While these other symptoms may also respond nicely to HRT, the risks of HRT generally make us  limit its use to relief of hot flashes and night sweats, the so-called vasomotor symptoms, since the other symptoms might be well-managed using other things. Women who have an intact uterus (in other words, haven’t had a hysterectomy) need both estrogen for symptom relief, and its “sister” hormone, progesterone to prevent overgrowth of the uterine lining.  If the uterine lining becomes too thick, it can even develop pre-cancerous changes.  So, most women who are candidates for HRT will need two hormones, either taken separately or together in one product.

ERT means “estrogen replacement therapy” and implies the replacement of estrogen alone, not in combination with progesterone.  This is possible in women who have had a hysterectomy.  Progesterone is not needed in this case.  ERT is usually more straightforward than HRT, because the irregular bleeding issues common with HRT don’t exist in women who have had a hysterectomy.  Also, ERT carries less risk, because women on estrogen alone instead of the estrogen/progesterone combination don’t have an increased risk of breast cancer.  While the increase in breast cancer risk with HRT isn’t huge for any one individual, it has to be considered in the context of the big picture for that individual.  Generally, it is believed that short-term therapy, perhaps 5 years or less, is the way to go with HRT, while with ERT we can generally be less strict about duration of treatment.  It should be noted that both HRT and ERT are associated with a slightly increased risk of stroke/blood clotting problems, and this fact has to be considered for each individual. Quality of life and the other benefits of HRT/ERT (such as reducing the risk of colon cancer and protecting against osteoporosis) have to be balanced with potential risk.

There is a lot of confusion about the different products available for HRT and ERT.  There are several FDA approved products that are commonly used.  These may be animal-derived, plant-based or synthetic.  There is not thought to be any significant difference in safety or effectiveness of a product based on its source.  The term bioidentical is a term that is recently in vogue.  Bioidentical simply goes back to organic chemistry class…it means structurally just like what is produced by the body.  Bioidentical does not mean safer or more effective, so there is no particular advantage to bioidentical, even though it sounds “cool”.   Compounded is different from bioidentical.  It means mixed in the pharmacy according to a doctor’s specific formula or recipe instead of being a standardized, FDA-approved product.  There is no reason to think that compounded products are safer or more effective than commercial products; in fact, they can vary from dose to dose and are unregulated, so they might just be less safe and effective than other products.  Natural is a marketing term and has no place in the discussion of medications.  Arsenic and hemlock are “natural”; so are heart attacks and kidney stones, but they are not good for you.  Enough said about “natural” as far as it applies to HRT/ERT.  As far as non-medication sources of symptom relief, both soy and black cohosh are used in alone or in combination with other ingredients in various over-the-counter products.  Research studies on these substances give mixed results as far as effectiveness for menopause symptom relief, but at least soy is nutritious.

There is some controversy about the replacement of testosterone as part of HRT.  While the ovaries do produce testosterone, it is not present in large amounts in women, even before menopause.  Most of the talk about testosterone for women is related to “sex drive” issues.  Keep in mind that women are not wired for “drive” (that would be men); rather, women are wired for “responsiveness” or “receptiveness”.  Men wish we were “driven” like they are, but Mother Nature didn’t design us the same way.  Testosterone doses for women that are high enough to increase sex drive usually have un-sexy side effects such as unwanted hair growth.  It seems like the Holy Grail in the pharmaceutical industry would be a medication that would make women have a higher sex drive, but then again, it’s really not a female trait. Lowered interest in sex is usually part of menopause and can be a source of distress for women and their partners.  Understanding that this decreased interest makes sense for mammals that are no longer in the child-bearing business doesn’t necessarily make it any easier! Women live longer than ever before, and we expect to have fulfilling sex lives beyond menopause.  Fortunately, there are products that can make sex more comfortable and ways to keep a woman interested or receptive, even if she isn’t “driven”. For example, vaginal estrogen creams can improve the suppleness and responsiveness of tissues without being absorbed systemically.

I’ll stop there and look forward to seeing you in the office.  If you have any menopause/HRT/ERT issues, make an appointment to focus on the problem.  Hopefully you will feel more informed about the subject, whether or not you watch Oprah!