I am on hormone replacement therapy (HRT) but it doesn't seem to be working?
Dear Dr. Redmond: I recently turned 51 and a few months ago started on hormone replacement therapy. I am still having hot flashes and I do not lubricate as well as I used to but my doctor says the dose I am on is correct. Why am I still having these problems?
IT IS NOT UNUSUAL for women on hormone replacement therapy (HRT) to be somewhat dissatisfied with the effects. Indeed, the majority of women who start HRT discontinue it after less than a year. Sometimes this is due to side effects, but more often women are worried about adverse effects or do not see hormone replacement as benefiting them. In part this is due to different understandings on the part of doctors and patients as to the purpose of hormone replacement. Lets review the reasons for taking HRT and then consider why misunderstandings about it are so common.
There are two kinds of benefits from HRT — immediate, and long term. The long term benefits are: decreases in the risk of heart disease, osteoporosis, and Alzheimer’s disease. HRT also has short term benefits in maintenance of well-being. Symptoms of estrogen deficiency include hot flashes, night sweats, insomnia, vaginal dryness and more subtle changes such as skin discomfort and mood swings. These are established effects of lack of estrogen (although they not always taken seriously by health professionals).
One of the problems is that the doses required for different benefits of estrogen are different. A quite small dose will help prevent osteoporosis and heart disease. The doses needed to relieve symptoms are often higher.
Miscommunication is common because doctors often have in mind the long term preventive effects of HRT, while women are expecting relief of symptoms and may think that they are not benefitting from the medication if symptoms do not go away. They quite naturally expect immediate benefit — the restoration of well being. Both ideas are reasonable, but because the different purposes for which estrogen is taken are not recognized, communication is not successful.
Medical education programs for doctors stress the long term benefits of HRT. Doctors see the effects of osteoporosis and heart disease in their practices, and so are concerned to prevent them. Since the risk of these diseases extends far into the future, many women don’t see them as a real danger.
Who is wrong? I think both are wrong. Women need to continue to increase their understanding of how to best maintain their own health. Breast cancer is the disease women fear most, yet heart disease causes 10 times as many female deaths. Osteoporosis can result in hip fractures with a high death rate from complications. More often, compression fractures in the spine cause permanent curvature and considerable pain and disability. This can greatly impair quality of life (though it does not generate the fear that breast cancer does).
Some women believe that by exercising and having an adequate intake of calcium and vitamin D, they can prevent osteoporosis. Studies clearly show, however, that while osteoporosis is worse without adequate calcium and vitamin D, good nutrition and exercise are not sufficient to prevent the loss of bone which occurs with estrogen deficiency. Women need to take these risks seriously and take measures to reduce them.
This is not to minimize the importance of breast cancer but rather to underline the fact that there are other important health problems women need to consider in a prevention program. The effect of HRT on risk of breast cancer is still not clear, though it is clear that the overall effect of HRT on a woman’s health is positive. Of course, some women should not use HRT, but we don’t have the space to discuss the reasons here and now.
Not all doctors understand the discomfort that menopausal symptoms can produce and how much they can interfere with normal activity. Women’s complaints, especially vague ones such as “overall achiness” or “mood swings” are still not always taken seriously and women, knowing this, sometimes feel that they are not being listened to. In past generations, women in their 50s often did not work and their children were grown. A woman of that age now may have adolescents still at home, need to contribute to paying for their college, and have a job which is quite demanding because she has reached a responsible position. She cannot sleep because of night sweats, is irritable because of mood swings, or has embarrassing flushing and sweating in the middle of a business presentation. The difficulties are considerable. A generation ago she might have felt just as uncomfortable but had relatively few demands on her.
Because “baby boomers” have been stereotyped by the press as being self-centered, their concerns are sometimes dismissed. If women are more vocal about menopause problems now than in the past it is because current life-styles are often more demanding at this point in a woman’s life and because women are less afraid to ask for help when they need it.
I mentioned earlier that the doses required for relief of symptoms are usually higher than the minimum needed for prevention of osteoporosis and heart disease. Briefly, typical daily preventive doses are 0.625 mg of conjugated estrogens (Premarin®), 1.0 mg of micronized estradiol (Estrace®), or a patch between 0.025 and 0.05 (Climara®), Vivelle®, Fempatch®, Alora® and others). Usual maximum doses are conjugated estrogens 1.25 mg, micronized estradiol 2.0 and patches 0.1. Occasionally these doses can be exceeded. Often a dose above the minimum but still not at the maximum will relieve symptoms. The vaginal tissues need a lot of estrogen for normal resiliency and moistness. Oral or patch estrogen can be supplemented with estrogen cream placed in the vagina.
For women who have a uterus, it is necessary to take a form of progesterone such as medroxyprogesterone acetate (Provera® and Cycrin®) or natural micronized progesterone (Prometrium®) to prevent excessive stimulation of the lining of the uterus which can lead to cancer.
There are many considerations which determine if a woman can safely use HRT and what doses are best for her. I have tried to outline the issues here but decisions about HRT must be made with a physician.
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