Hormone Replacement Therapy
In a society where youth and health at are at the top of many peoples personal life priorities there is a gender specific form of hormone treatment that remains under discussion. Hormone replacement therapy or (HRT) is a controversial topic. There are experts who support the use of HRT and there are experts who oppose it. For the purposes of this research paper, I will discuss the definition and symptoms of menopause, history of HRT, benefits and risks of using HRT, types of HRT, the need for consultation and physical examination before starting HRT, and why I support the use of HRT.
According to Dr. Elmer Van Dyke, MD “There are two types of menopause, natural menopause and surgically induced menopause. Natural menopause is when a woman’s body slowly stops producing estrogen and progesterone and menstruation ceases. Surgical menopause is when a woman’s ovaries are surgically removed before natural menopause occurs.” The U.S. Food and Drug Administration (FDA) defined menopause as “When a woman has not had a period for twelve months in a row” (“Menopause and Hormones”). Menstruation ceases when the ovaries don’t make enough estrogen to keep the lining of the uterus (endometrium) thick enough to produce menstrual periods. According to the American College of Obstetricians and Gynecologists (ACOG), “The average age for women to stop having menstrual periods is around 51 years, but the normal range is from 45 years to 55 years” (“Questions”). The symptoms of menopause vary among women.
Symptoms can include (1) “Changes in your period, time between periods or flow may be different (2) hot flashes (‘hot flushes”) getting warm in the face, neck and chest, (3) Night sweats and sleeping problems that may lead to feeling tired, stressed, or tense, (4) Vaginal changes-the vagina many become dry and thin, and sex may become painful, and (5) Thinning of your bones, which may lead to loss of height and bone breaks (osteoporosis)” (U.S. Department of Health & Human Services). Women who are candidates for HRT may be prescribed hormones to help relieve their menopausal symptoms.
Due to hormone therapy not being approved by the FDA until the 1940s and that in the past women did not live long enough to experience the symptoms of menopause unless they had good family genetics and a practiced a healthy lifestyle, the history content for HRT is limited. Even with this limited history, Susan Lark, MD reported “Scientists first isolated estrogen and progesterone in the laboratory in their purified state during the 1920’s” (Facts About Hormonal Replacement Therapy). The somewhat primitive approach of crushing animal ovaries and liquefying them to give to women with surgically induced menopause limited the use of HRT for several decades. During the 1950s and 1960s the need for estrogen to treat menopausal symptoms became better understood. This development lead to the increased use of estrogen for things such as hot flashes, night sweats, vaginal dryness, mood swings, and even staying young. Unfortunately, the new concept of estrogen alone for therapy was not clearly understood, and thus women were not informed of its risk factors.
It wasn’t until the 1970s that research studies showed menopausal women with uteruses taking estrogen alone had an increased risk for endometrial cancer. The results of these studies scared women and providers, so estrogen therapy for postmenopausal symptoms came to a screeching halt. Several years later, research showed that the “combination of estrogen and progesterone offered protection against the development of cancer of the lining of the uterus” (Lark). This new data allowed providers to use combination therapy for menopausal symptoms with less risk for patient safety.
The type of therapy initiated depends on whether she has or does not have a uterus. For those patients with a uterus, a combination of estrogen and progesterone is indicated. For those without a uterus only estrogen therapy is needed. Hormone replacement therapy, if given under the supervision of a qualified health care provider and for the right medical reasons, poses little risk to the patient. Lack of estrogen can lead to “problems with urination, such as burning, frequency, urgency, loss of urine, and pain, vulvar itching and/or burning, bleeding and/or spotting, and pain with intercourse” (University of Iowa). Estrogen also plays an important role in the quality of life for many women, including bone health. Mayo Clinic staff reported “women who take estrogen for short-term relief of menopausal symptoms many gain some protection against osteoporosis and colorectal cancer” (“Hormone Therapy”).
Those seeking HRT should be screened carefully and meet the medial requirements for this therapy. Women who are experiencing the following are not candidates for HRT “(1) Current, past, or suspected breast cancer, (2) Vaginal bleeding of unknown cause, (3) Current or past history of blood clots, (4) High blood pressure that is untreated or poorly managed, (5) Angina that is currently symptomatic or a heart attack that has been recent, and (6) Active liver problems” (University of Maryland Medical Center) The dosage and route of administration of HRT depends on the patient’s medical condition. HRT can be administered by mouth, skin patches, gels, spray, vaginal ring, and a vaginal tablet or cream.” However, the latest trend is “to use “transdermals” such as a patch, spray, or gel that by passes the liver and go directly into the bloodstream” (E Van Dyke). Oral hormones are synthesized and broken down by the liver, and avoiding this process with the use of transdermals, there is less chance of blood clot formation. According to P Van Dyke, “both the provider and the patient must have realistic goals for HRT and follow the American College of Obstetricians and Gynecology (ACOG) recommended guidelines for therapy.” Peggy Van Dyke has ten years of experience in women’s health care and uses HRT herself. She is an advocate for HRT and believes women should be informed on the pros and cons of HRT so they can make an educated decision on whether or not HRT is right for them. For women who want to consider and or use HRT a health care evaluation is necessary. While the medical evaluation may vary among practitioners, most will do the following “(1) A complete physical examination, including a pelvic exam and a breast exam, (2) A PAP smear to determine a cancerous or precancerous lesion of the cervix, (3) Blood tests to check liver function, blood sugar, cholesterol, triglyceride, calcium and phosphorous levels, as well as tests of thyroid function, (4) Complete blood count to check for anemia, as well as an urinalysis, (5) Mammography and professional breast examination for breast cancer.
(6) Bone density studies to help determine the level of bone loss. (7) and a comprehensive family history to obtain data about the risk factors for heart disease, osteoporosis, and breast and other forms of cancer” (Lark). I have worked for Dr. Van Dyke for over a year, as his personal medical assistant. He is board certified in gynecology and has over 45 years of experience in women’s health care. I have seen firsthand the benefits of HRT. After being placed on HRT for about six months, most patient’s menopausal symptoms were eliminated. I have also witnessed women who were not on HRT become frequent visitors to our office with a variety of menopausal complaints, especially painful intercourse, hot flashes, night sweats, mood changes, and urinary complaints. One patient of ours was in her late 30’s and had not had a period for 17 years. She was obese and thought not having periods was great. No one had ever told her this was abnormal. Three other patients were having post-menopausal bleeding which they thought was a return of their menstrual period. They did not know that once a woman has not had a period for a year and bleeding returns it is not a menstrual period but is in fact, post-menopausal bleeding. According to these patients, no one had discussed or offered them HRT. Unfortunately, three of the patients died from endometrial cancer, and the patient in here late 30’ almost died on the operating table. I felt horrible for these patients, because this could have been prevented with proper HRT management. One of my roles as medical assistant is to do bone density scans on women at high risk for osteoporosis.
I’ve noticed that women who were not on HRT consistently have lower T scores than those who are on HRT. Even when our patients take HRT in small doses, along with lifestyle modifications such as not smoking, eating a well-balanced diet, following an exercise plan, increasing calcium and vitamin D 3, their chances of developing osteoporosis decreased. Because of HRT, women can now experience relief from hot flashes, night sweats, mood swings, difficulty concentrating, vaginal dryness, atrophic vaginitis, yeast and bacterial infections in the vagina, vaginal spotting, difficulty with urination, and painful intercourse. In addition, women using systemic and vaginal estrogen also show improvement with urinary urgency and frequency.(P Van Dyke). When looking at all the benefits of safely administered low dose HRT, overall these benefits outweigh the risk factors for women with menopausal symptoms and those at risk for osteoporosis. Hormone replacement therapy has both benefits and risks associated with its use. Since HRT is a personal choice, women should discuss the risks and benefits with their health care provider. I know when it is my time to decide I will chose HRT and I feel comfortable educating others so that they may also make an educated, healthy decision for themselves. Works Cited
1.) American College of Obstetricians and Gynecologists. “Frequently Asked
Questions.” Aug. 2011. Web. 16 April. 2012.
2.) Josefson, Deborah. “FDA issues advice to women taking hormone replacement therapy.” British Medical Journal. 20 Sept. 2003. Web. 16 April. 2012. 3.) Lark, Susan M. MD. “Facts About Hormonal Replacement Therapy.” n.d. Web. . 16 April 2102. 4.) Mayo Clinic. “Hormone Therapy: Is it right for you?” 2010. Web. 7 Feb. 2012. 5.) National Library of Medicine, National Institutes of Health. “PubMed Health.” 7 Nov. 2011. Web. 16 April. 2012.
6.) National Osteoporosis Foundation (NOF). “Clinician’s guide to prevention and treatment of osteoporosis.” Bone Source. Jan 2008. Web. 16 April. 2012 7.) Siris, E.S. “Preventing & treating osteoporosis: A focused update.” PhysWeekly. March 2009. Web. 16 April. 2012 8.) United States Food & Drug Administration. “Menopause and Hormones.” 2009. Web. 16 April. 2012. 9.) United States Food & Drug Administration. “Pharmacy Compounding/Compounding of Bio- identical Hormone Replacement Therapies.” 19 April 2007. Web. 16 April. 2012. 10.) University of Iowa. “Atrophic Vaginitis.” 2004. Web. 16 April. 2012. 11.) University of Maryland Medical Center. “Menopause-Medications.” 25 Aug. 2009. Web. 16 April. 2012. 12.) Van Dyke, Elmer H. MD. Personal Interview. 17 April. 2012. 13.) Van Dyke, Peggy DNP, FNP-BC. Personal Interview. 18 April. 2012.