Hormone replacement therapy in menopause

Hormone replacement therapy, or hormone therapy, is a standard treatment for menopause. The use of drugs with estrogen and progestin is intended to alleviate symptoms such as hot flashes, sleep disorders, or sleep disorders. At the same time, hormone replacement therapy is repeatedly criticized because of possible side effects. What side effects can hormone replacement therapy bring with it during menopause? Are there herbal alternatives, and what should you consider if you want to stop taking hormones?

Hormone therapy: definition and effect

With hormone replacement therapy, also known as hormone replacement therapy (HRT), the name says it all: artificially produced estrogens or progestins are added to the body to compensate for the lack of these hormones that occur during menopause. Severe menopausal symptoms can be alleviated in this way. Hormone replacement therapy is now only used to prevent osteoporosis if there is an increased risk of fractures and if there are intolerances or contraindications to other medications suitable for preventing osteoporosis.

Positive effects have been found in scientific studies, especially with the occurrence of hot flashes, but also with sleep disorders, depressive moods and pain during sexual intercourse. In addition, some side effects are also possible, which are explained below. 

 

What forms of therapy are there?

There are two types of hormone replacement therapy:

• Monotherapy: In monotherapy, only drugs with artificial estrogens are used.
• Combination therapy: In most cases, a combination of drugs with estrogens and progestins is used for menopausal symptoms.

The combination therapy can be carried out continuously, which means that both hormones are constantly used simultaneously. On the other hand, sequential therapy is also possible. In this case, estrogens are used continuously, and progestins are used for a particular month (usually ten to twelve days). Examples of synthetic hormone preparations include LAFAMME® and Ladivella® (synthetic progestins) or Velbienne® (estrogen and progestin preparation).

Treatment with hormones during menopause can be systemic, for example, by taking tablets or capsules or using sprays, gels or hormone patches, or locally, i.e. in the form of vaginal suppositories or ointments.

There are also remedies with so-called bioidentical hormones. These are semi-synthetic, as some required substances are derived from plants, such as yams or soybeans. They are put together individually in the pharmacy. They have side effects similar to those used in “classic” hormone therapy.

Phytoestrogens: herbal hormone replacement therapy?

For mild menopausal symptoms, remedies based on plant estrogens, so-called phytoestrogens, are often recommended. These plant compounds are chemically similar to the hormone estrogen.

Most preparations are made from soy, black cohosh or red clover. Smaller studies have shown an improvement in hot flashes and vaginal dryness for soy preparations. There are no precise results for remedies with black cohosh or red clover. 

In the case of mild depressive moods, the doctor should be asked whether a therapy attempt with St. John’s wort could bring relief. 

Generally, it is essential to know that when using herbal preparations, positive effects can only be felt after taking them for about four to six weeks.

 

Possible side effects of hormone replacement therapy

Hormone therapy can have a variety of side effects. In the beginning, the hormonal changes can lead to spotting, a feeling of tension in the breasts and nausea. These symptoms should improve after a few months. If this is not the case, the wrong hormone dosage could trigger the symptoms. A doctor should then clarify these.

Long-term side effects

In addition, hormone replacement therapy can have more severe side effects in the long term. A study published in 2002 called the “Woman’s Health Initiative” attracted particular attention. Sixteen thousand women between the ages of 50 and 79 took part. The study showed that the risk of breast cancer, as well as the risk of thrombosis and the risk of heart attack, increased in the participants taking combination preparations with estrogen and progestin. However, the average age of the study participants was 63 years. The significance of the study for the use of hormone therapy in younger women is, therefore, limited.

The following figures are given in the current guideline of the German Society for Gynecology and Obstetrics (DG):

• Sequential combination therapy: 14 additional cases of breast cancer per 1,000 women
• Continuous combination therapy: 20 extra cases of breast cancer per 1,000 women
• Estrogen monotherapy: five extra cases of breast cancer per 1,000 women

These figures apply to an application period of five years or more for women over 50. The probability refers to the period of the next 20 years.

With monotherapy, the risk of breast cancer is, therefore, least increased. However, the likelihood of developing growth in the uterus increases after two to three years. Monotherapy is, therefore, usually only used in women who have had a hysterectomy.

With all forms of therapy, there is also a slightly increased risk of thrombosis. When it comes to the risk of a heart attack, very different effects seem possible: in women under 60 years of age, it is even assumed that the use of HRT slightly reduces the risk, while it increases in women over 60 years of age.

Consider personal risk factors.

With a view to possible side effects, age seems to be an essential factor. In addition, personal risk factors, such as a family history or being overweight, should be taken into account when deciding for or against hormone replacement therapy. Contraindications for hormone replacement therapy, therefore, include a history of coronary heart disease, breast cancer, thrombosis or stroke.

 

Menopause: stopping hormones

First of all, it must be noted that stopping the hormones can have an individual effect on each woman – that is, the menopausal symptoms can return after stopping but also stay away permanently. If symptoms recur, therapy can be started again. A lower dosage then makes it possible to keep a better eye on the development of the symptoms.

With hormone replacement therapy, the hormones should not be discontinued from one day to the next. Instead, the dosage should be slowly reduced (“tapered off”) over several months. Hormones should only be discontinued after consulting a doctor.

Hormone replacement therapy: beneficial or not?

There is no general answer to the question of whether hormone replacement therapy makes sense during menopause. The individual benefits and risks should be weighed with the doctor. With the necessary health conditions, HRT can help to alleviate menopausal symptoms. Nevertheless, hormone therapy should consistently be dosed as low as possible and used for as short a time as possible. The treatment should be checked regularly by a doctor.