What is hormone replacement therapy (HRT)? Hormone replacement therapy (HRT) typically refers to the replacement of sex hormones in menopausal women. Women use HRT 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 also 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 woman who still has her uterus must receive progesterone in addition to estrogen for HRT. Progesterone signals the uterus to shed its lining—similar to a menstrual period. This decreases the risk of uterine cancer. HRT is only one method of controlling the symptoms of menopause. HRT involves some health risks. You may have other treatment options that involve less risk. Discuss all the treatment options with your doctor or healthcare provider to understand which options are right for you. Types of HRT Your doctor can prescribe HRT in different forms. The form your doctor or provider prescribes depends on your symptoms and circumstances. The forms of HRT approved by the United States Food and Drug Administration (FDA) include: Intrauterine devices (IUDs) placed inside your uterus by your doctor. A progesterone product, levonorgestrel (Mirena), is available in this form. Combination tablets taken by mouth. Examples include medications containing conjugated (mixed) estrogens and medroxyprogesterone acetate (Premphase, Prempro) and medications containing ethinylestradiol and norethindrone acetate (Femhrt). Estrogen tablets taken by mouth. Examples include conjugated (mixed) estrogens (Premarin), esterified estrogens (Estratab, Menest), estropipate (Ogen), and estradiol (Estrace). Progesterone tablets taken by mouth. Examples include medroxyprogesterone acetate (Cycrin, Provera), norethindrone acetate (Aygestin, Norlutate), and progesterone USP (Prometrium). Skin creams and gels applied to clean, dry, unbroken skin on your arms or legs. Never apply estrogen skin preparations to your breasts. 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. Combination products are also available as a skin patch. Examples include medications containing estradiol and norethindrone acetate (Combipatch) and medications containing estradiol and norgestimate (Ortho-Prefest). Skin spray, or transdermal spray, applied to clean, dry, unbroken skin on your forearm. Estradiol (Evamist) is available as a spray. Vaginal creams applied by placing the cream directly into your vagina. Estrogen examples include conjugated (mixed) estrogens (Premarin cream), estradiol (Estrace cream), and estropipate (Ogen cream). Progesterone (Crinone) is also available in this form. 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 Many alternative products are also available to treat menopause symptoms. It is important to know how these products differ from FDA-approved 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. Their chemical structure is 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 better than other forms of synthetic estrogen and natural occurring estrogens. 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. This means that manufacturers do not have to prove that they work or that they are safe. The FDA does not regulate their purity either. Some products have been contaminated with toxic substances. For your safety, always buy herbal products from a reliable source. Your pharmacist can help you choose a reliable manufacturer. You should also consult your doctor before using herbal products. Why is HRT prescribed? Your doctor may recommend hormone replacement therapy (HRT) to treat menopausal symptoms. Menopause symptoms most likely to respond to HRT 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. This can put you at increased risk for fractures. Sleep problems, which include insomnia or sleeplessness Vaginal dryness, which causes burning, irritation, and painful sexual intercourse Who prescribes HRT? The following specialists prescribe hormone replacement therapy for menopause: 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 hormone replacement therapy varies by state. Obstetricians/gynecologists (Ob/Gyns) specialize in women's health, pregnancy, and labor and delivery. Physician assistants (PAs) and nursing practitioners (NPs), who typically practice under supervision of a physician, but this varies by state. What are the risks and potential complications of HRT? Hormone replacement therapy (HRT) is effective for treating many of the symptoms of menopause. However, it is not right for every woman because there are risks, some of which are serious and even life threatening. The Women’s Health Initiative (WHI) was a major study published in 2002 that looked at the risks and benefits of HRT in women ages 50 to 79. Results from this study generally 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, including blood clots, stroke, and heart attack. The cardiovascular risks are greater for women 60 and older. There is also an increase in breast cancer for women taking combination HRT. However, a better understanding of the protective health effects of estrogen, long-term follow-up of women who took HRT, and more studies show the health benefits of HRT outweigh the risks for most postmenopausal women who start it within 10 years or earlier after the onset of menopause. The benefit-to-risk ratio is better for women who experienced early menopause (younger than age 40) and started HRT soon after. The most important thing to do is talk with your doctor, discuss your medical history, and make a joint decision with your medical provider on the safety of HRT for you. Reducing your risk of complications You can reduce the risk of complications by following your treatment plan and: Avoiding HRT if you have a personal or family history of blood clots, breast cancer, heart attack, or stroke Exercising regularly Maintaining a healthy weight Not drinking alcohol or limiting alcohol intake to one drink per day Quitting smoking Treating high blood pressure, high cholesterol levels, and diabetes as recommended by your healthcare provider How do I prepare for HRT? To reduce the risks associated with hormone replacement therapy, it is important to tell your doctor or provider about your entire medical history, allergies, and the all your medications. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times. If you smoke, this is the time to stop because it will significantly reduce your HRT risk profile. Questions to ask your doctor Deciding whether to take HRT can be stressful. 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 with concerns and questions before HRT and between appointments. It is a good idea to bring a list of questions to your appointments. Common questions include: Why do I need HRT? What form of therapy is best for me? How long should I take hormone replacement therapy? When can I stop HRT? What’s the best way to stop? Will my symptoms come back when I stop HRT? Are there any 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? 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 HRT. Contact your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have: Any unusual symptoms, such as swelling of the legs, shortness of breath, or chest pain Vaginal bleeding What are the alternatives to HRT? The 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 alternatives to HRT. HRT alternatives include: Anti-anxiety medications to help ease anxiety symptoms Antidepressant medications to treat hot flashes and mood swings. Examples include paroxetine (Paxil) and venlafaxine (Effexor). Good sleep habits to improve your 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 to help a variety of menopausal symptoms. Lifestyle changes include stress management techniques, avoiding foods and beverages that trigger symptoms, and dressing in layers that are easy to remove during hot flashes. Medications to treat osteoporosis. Examples include alendronate (Fosamax), raloxifene (Evista), or calcitonin (Miacalcin). Physical activity to help maintain bone strength, promote sleep, and help elevate mood Sleep aids to help insomnia. You should only take sleep aids on a temporary basis. Vaginal lubricants and moisturizers to ease vaginal dryness and make sexual intercourse more enjoyable. Examples include Replens and K-Y Jelly.