Female Sex Hormones
The ovaries produce two important sex hormones in a woman: oestrogen and progesterone. The levels of these hormones decline dramatically after the menopause. The normal menopause begins around the age of 50 years in most women. Although most women can tell when the menopause begins, some women require blood tests to measure their hormone levels and confirm the menopausal state.
The decline of female sex hormones increases the risk of osteoporosis (brittle bones), heart diseases such as heart attack, and stroke. The skin also ages more quickly in the absence of these hormones, becoming more wrinkled and thin.
The menopause is characterised by the ceasing of menstrual periods, hot flushes, and vaginal dryness and discomfort. These symptoms are fairly mild and tolerable in most women, but in others they can be very severe and unpleasant. Hormone replacement therapy (HRT) should be considered to alleviate the symptoms of the menopause and reduce the risk of osteoporosis. HRT contains the female sex hormones oestrogen and progesterone.
Which HRT Should I Use?
Before being considered for HRT, it is important to ask the following questions.
Have You Had a Hysterectomy in the Past?
Hysterectomy is the surgical removal of the uterus (womb). Oestrogen can increase the risk of womb cancer when given on its own. So women who still have their womb should be given HRT containing both oestrogen and progesterone to reduce the risk of womb cancer. HRT containing both sex hormones is called combined HRT, such as Prempak-C. The oestrogen tablets and progesterone tablets may have to be taken on different days over a one-month cycle.
Women who have had a hysterectomy do not require progesterone and can use an HRT containing only oestrogen, such as Premarin.
Have You Ever Had a Blood Clot in the Leg Veins or the Lungs? Or Has Anyone in Your Family Had Blood Clots?
Women with a personal or family history of blood clots in the leg veins or lungs have an increased risk of these conditions if they start taking HRT. Caution should be exercised when considering HRT in such individuals.
Do You Have High Blood Pressure?
Caution should be exercised when considering HRT in women with high blood pressure, as HRT can cause fluid retention that would make matters worse.
Do You Have a Medical History of Any of the Following Conditions?
|Heart disease||Kidney disease||Sickle cell disease|
Patients suffering from any of these conditions can take HRT with caution.
HRT and Breast Cancer Risk
As explained earlier in this book, oestrogen seems to promote breast cancer growth. However, the risk of breast cancer is increased by 30% in women who have taken HRT for more than 5 years.
Women taking HRT should still practise self-examination of the breasts and participate in breast cancer screening programmes (one mammogram every two years). It is also worth pointing out that breast cancers that develop in women taking HRT are usually early cancers and have a good prognosis.
The above advice also applies to women with a family history of breast cancer. Women who have had breast cancer will probably be taking tamoxifen (see Chapter 2). This drug has similar beneficial effects on the bones as HRT. If these women have severe menopausal symptoms, such as hot flushes and vaginal dryness, then HRT can still be considered. However, it is usually preferable to try alternative drugs to improve these symptoms.
Alternatives to HRT in the treatment of postmenopausal symptoms include progesterone tablets, oestrogen creams and Prozac-like drugs. Progesterone tablets can relieve hot flushes and oestrogen creams can be used in the vagina to improve dryness and discomfort. Remember that oestrogen creams applied in the vagina can still be absorbed into the blood stream, and only small amounts should be applied for short periods (maximum of three weeks) and repeated as necessary.
If you have had breast cancer, it is worth asking your breast specialist about the type of cancer you had. Some types of breast cancer are sensitive to oestrogen and the hormone stimulates tumour growth, while other types of breast cancer are not affected by oestrogen. If your cancer was of the non-oestrogen-sensitive type, HRT is less likely to increase the risk of the breast cancer returning.
It is the author’s opinion that women with breast cancer should avoid using HRT for at least two years after diagnosis. The development of new drugs to reduce the risk of bone loss or osteoporosis, such as bisphosphonates and raloxifene, is likely to reduce the need to use HRT among all women.
For women who require HRT for quality of life purposes, the use of transdermal estradoil in the form of gel or patch plus oral micronised progesterone (if the woman has a womb) is considered the safest.
For more information on HRT written by Prof. Kefah Mokbel