Starting and Stopping Hormone Replacement Therapy
Hormone replacement therapy (HRT) can help ease the discomfort many women experience with menopause by replacing the estrogen that is lost once the ovaries stop producing it. For women who enter menopause abruptly, such as after ovary removal, symptoms may be more uncomfortable than with typical menopause. Estrogen also has protective health effects. Researchers say that HRT, either estrogen alone or combined with progesterone, can help reduce menopause symptoms like hot flashes by up to 75%.
However, HRT is not an exact science. Along with its benefits, doctors also study the long-term health risks of HRT, which influence when a woman might start HRT, the type she takes, and how long she takes it. Here’s what women’s care experts recommend for starting and stopping HRT, including after hysterectomy, and what to expect with side effects when stopping HRT.
The American College of Obstetricians and Gynecologists, the North American Menopause Society (NAMS), and the Endocrine Society publish HRT guidelines based on scientific evidence.
Women who may be good candidates for HRT, starting with the lowest dose appropriate for each individual, include those who:
Are younger than 60 years old
Have not been menopausal for more than 10 years
Have no history of heart disease
Have no history of breast cancer
Women who have a risk of heart disease and/or blood clots may have another option though. Rather than the traditional oral HRT in pill form, they may be candidates for a patch. Studies have shown patches don’t have as strong an effect on blood pressure or cholesterol, both of which are risk factors for heart disease.
For women experiencing vaginal symptoms or those related to urination, it’s possible neither pills nor patches are necessary. Many women do well with vaginal estrogen in the form of creams, suppositories and rings.
Some women stay on HRT for years, others for a few months, to stabilize their menopause symptoms. In general, the shorter the duration of HRT the better in order to reduce the risk of complications related to the medication. The usual recommendation is not to stay on HRT for longer than five years and not after you turn 60.
Longer therapy is possible, depending on the type and severity of your menopause symptoms and why you started therapy in the first place. Younger women who had a hysterectomy with ovary removal may be on estrogen-only HRT much longer than a woman taking combination HRT who underwent natural menopause, for example. (Women without a uterus do not need to take progesterone.) HRT experts recommend continuing with estrogen-only hormone therapy until the natural menopause age of 52.
Studies show about half of women who take HRT stop treatment within a year, and up to 75% within two years. Most don’t have any problems while they stop, however, stopping suddenly does increase the risk of menopausal symptoms returning, so you should not stop taking your HRT without consulting your doctor.
Doctors may differ in how they taper their patients off HRT. Some gradually decrease estrogen and progesterone doses over time. Others decrease the number of times a week patients take the HRT, along with lower doses. Depending on what type of HRT you are taking and how high the dose, it can take from 3 to 6 months to completely taper off. It can be as long as a year, particularly if your menopause symptoms reappear during the process.
If you stop taking HRT and your symptoms, like hot flashes return, your doctor may first recommend you try nonhormonal treatments before putting you back on HRT. For women with vaginal symptoms, keep in mind that low-dose estrogen in the vagina does not increase the risk of breast cancer, heart attack or stroke. Continuing vaginal estrogen (rather than estrogen pills or patches) does not pose a health risk according to studies.
Side effects of stopping hormone replacement therapy include the return of menopause symptoms, especially hot flashes. If there are symptoms, they may be more manageable than before HRT. Some women experience uncomfortable symptoms after stopping HRT with little relief. Unfortunately, it’s impossible to tell ahead of time who will be affected the most.
Stopping HRT may affect your bone health. The estrogen in HRT helps protect your bones by preventing bone loss, which can lead to osteoporosis. Once you stop taking estrogen, you may develop brittle bones. However, lifestyle, dietary and nonhormonal medications can be very effective in preventing bone loss and osteoporosis.
Women who stop taking HRT may have a lower risk of developing breast cancer. The effect of stopping HRT on the risk of heart disease is not clear, but the risk of developing blood clots is lower.
If you need help deciding on when to start or stop HRT, ask your gynecologist about the most up-to-date guidelines for HRT and how they relate to your personal and family health history.