Estrogen replacement therapy (ERT) is a form of hormone replacement therapy (HRT). Women use ERT to help control the symptoms of menopause. Menopause is the stage in a woman’s life when sex hormone levels fall and her menstrual period stops. Symptoms of menopause include hot flashes, night sweats, sleep problems, vaginal dryness, mood swings, anxiety, decreased sexual desire, fatigue, and headaches. Menopause can also cause thinning bones (osteoporosis). The two main sex hormones that a woman’s body makes are estrogen and progesterone. Progesterone is primarily produced by the ovaries and, in pregnant women, the placenta. The ovaries produce estrogen. Estrogen is responsible for the female sexual characteristics. It is also important for many body processes, such as maintaining a healthy heart and bones. A woman who has had her uterus removed by hysterectomy may receive estrogen alone for HRT. A menopausal woman who wants to minimize symptoms of menopause with HRT and still has her uterus must receive progesterone in addition to estrogen. Progesterone signals the uterus to shed its lining similar to a menstrual period. This decreases the risk of developing uterine cancer. ERT is only one method to treat the symptoms of menopause. Discuss all of your treatment options with your doctor or healthcare provider to understand which options are right for you. Types of ERT Estrogen is given in different forms, depending your individual symptoms and circumstances. The types of ERT approved by the U.S. Food and Drug Administration (FDA) include: Oral tablets taken by mouth. Examples include conjugated estrogens (Premarin), esterified estrogens (Estratab, Menest), estropipate (Ogen), and estradiol (Estrace). Skin creams and gels applied to clean, dry, unbroken skin on your arms or legs. Never apply estrogen skin preparations to your breasts because breast tissue can change in response to estrogen. Estradiol (Estrasorb, Estrogel) is available in this form. Skin patches, or transdermal patches, applied to clean, dry, unbroken skin on your stomach, lower back, or buttocks. Estradiol is available as a skin patch under a variety of brand names, including Climara, Estraderm and Vivelle. Skin spray, or transdermal spray, applied to clean, dry, unbroken skin on your forearm. Estradiol (Evamist) is available as a spray. Vaginal creams applied directly into your vagina. Examples include conjugated estrogens (Premarin cream), estradiol (Estrace cream), and estropipate (Ogen cream). Vaginal rings inserted into the uppermost part of your vagina. They remain in place for 90 days at a time. Estradiol (Estring, Femring) is available as a vaginal ring. Vaginal tablets inserted into your vagina. Estradiol (Vagifem) is available in this form. Other products A variety of alternative products are available to treat menopause symptoms. It is important to know how these products differ from FDA-approved ERT and HRT. Bioidentical hormones. The term, bioidentical, means that they have exactly the same chemical structure as hormones made by your body. Bioidentical hormones are synthetic, or made in a laboratory. They look exactly like your body’s hormones, but they are man-made. Your body cannot tell the difference between a bioidentical hormone product and its own hormones. Proponents of bioidentical hormones believe this makes them safer and more superior than other forms of synthetic estrogen. However, there is not enough scientific evidence to support these claims. Herbal products. Some herbal products claim to be useful for treating the symptoms of menopause. However, the FDA does not regulate herbal products in the same way that it controls over-the-counter and prescription medications. The FDA regulates herbal products as foods, not drugs. Manufacturers do not have to prove that herbal products work or that they are safe. Their purity is not regulated, and some products have been contaminated with toxic substances. Always consult your doctor and pharmacist before using herbal products. Your doctor may recommend estrogen replacement therapy (ERT) to treat menopause symptoms. Menopause symptoms most likely to respond to ERT include: Anxiety and mood swings, which can interfere with your daily life and become debilitating Hot flashes, which are often described as a sudden sensation of warmth, flushing and sweating Night sweats, which are the nighttime version of hot flashes Osteoporosis, or thinning bones, which is a complication of menopause. You may not know you have thinning bones unless your doctor finds it on a screening test. Sleep problems, including insomnia or sleeplessness Vaginal dryness, which cause burning, irritation, and painful sexual intercourse The following specialists prescribe estrogen replacement therapy: Family practitioners (family medicine doctors) provide comprehensive healthcare to adults and children. Internists provide comprehensive healthcare to adults. Midwives, including certified nurse-midwives (CNMs) and certified midwives (CMs). These types of midwives are healthcare professionals who provide prenatal, labor, and delivery care, and some gynecologic care, including menopause treatments. The ability of a midwife to prescribe estrogen replacement therapy varies by state. Obstetricians-gynecologists (Ob/Gyns) specialize in women's health, including pregnancy and labor and delivery. You will take estrogen continuously for estrogen replacement therapy (ERT) after a hysterectomy. This means that you take it every day without any breaks. This differs from estrogen combined with progesterone, which you take cyclically to mimic your menstrual cycle. This is typical for women who still have their uterus and are having menopause symptoms. Estrogen replacement therapy (ERT) is effective for treating many of the symptoms of menopause. However, it is not right for every woman because there are risks. Some risks are serious and even life threatening. Your healthcare provider is the best person to guide your treatment decisions based on your specific circumstances. The Women’s Health Initiative (WHI) is a major study supported by the National Institutes of Health (NIH). WHI looked at the risks and benefits of hormone replacement therapy (HRT). In general, the results from this study showed that women should use HRT in the lowest possible dose for the shortest amount of time. Long-term use of HRT was associated with significant risks. Risks of estrogen-alone replacement therapy include: Blood clots, in the form of a deep vein thrombosis. A blood clot can travel to the lungs and cause a pulmonary embolism (PE). Stroke Reducing your risk of complications You can reduce your risks by: Avoiding ERT if you have a personal or family history of blood clots or stroke Exercising regularly Maintaining a healthy weight Not drinking alcohol or limiting alcohol intake to one drink per day for women Quitting smoking Treating high blood pressure, high cholesterol levels, and diabetes as recommended by your healthcare provider Questions to ask your doctor It is common for patients to forget to ask about some of their concerns during a doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor or healthcare provider with concerns and questions before starting ERT and between appointments. It is also a good idea to bring a list of questions to your appointments. Questions can include: What form of ERT is best for me? How long should I take ERT? When should I stop ERT? What’s the best way to stop? Will my symptoms come back after stopping therapy? What are the other options for treating my symptoms? What are my risks of heart disease, breast cancer, colorectal cancer, stroke, and osteoporosis? What other options can help me prevent osteoporosis and other risks or menopause? When should I follow up with you? How should I contact you? Ask for numbers to call during and after regular hours. When should I call my doctor? It is important to keep your follow-up appointments when taking estrogen. Contact your doctor for questions and concerns between appointments. Call your doctor right away if you have: Any unusual symptoms Vaginal bleeding The Women’s Health Initiative (WHI) studied women on specific oral hormone replacement therapies. It is not known if other forms, such as vaginal creams or skin patches, carry the same risks. Depending on your symptoms and medical history, other medications and techniques may be an alternative to estrogen replacement. Other alternatives include: Anti-anxiety medications to help ease anxiety symptoms Antidepressant medications, such as paroxetine (Paxil) or venlafaxine (Effexor), may be effective in treating hot flashes and mood swings. Good sleep habits to promote sleep. These include keeping your room cool and dark, taking a relaxing bath before bed, avoiding caffeine and alcohol before bed, and completing physical activity earlier in the day. Lifestyle changes that may help a variety of menopausal symptoms. Lifestyle changes include dressing in layers, avoiding foods and beverages that trigger symptoms, and stress management techniques. Medications for osteoporosis, such as alendronate (Fosamax), raloxifene (Evista), or calcitonin (Miacalcin) Physical activity to help maintain bone strength and promote sleep Sleep aids to help insomnia. You should only take sleep aids on a temporary basis. Vaginal lubricants and moisturizers, such as Replens, may ease vaginal dryness and make sexual intercourse more enjoyable.