Risk Management & Treatment

Managing menopause with hormones

Women in surgical menopause are encouraged to discuss the risks and benefits of hormone replacement therapy with their health care provider. 

Hormone replacement may be categorized in different ways:

A woman’s body makes various types of estrogen, as well as progesterone, testosterone, and other hormones. Several hormone replacement options for women with surgical menopause contain varying amounts and combinations of these hormones, depending on a woman’s situation or symptoms. 

Estrogen progesterone & testosterone

A woman’s body makes different hormones throughout her life. The three major sex hormones made by the ovaries are the so-called “female” sex hormones estrogen and progesterone, and the so-called “male” sex hormone testosterone.  During reproductive years, these hormones prepare the body for pregnancy, but they also affect other aspects of the body, health and well-being. After natural menopause or when the ovaries are surgically removed, these hormone levels decrease, leading to menopausal symptoms.  

Most hormone replacement therapy (HRT) preparations used to treat menopausal symptoms contain one or both of the female sex hormones. Estrogen replacement therapy (ERT) usually refers to hormone replacement therapy containing estrogen alone. ERT tablets, skin patches, gels, sprays, lotions and a vaginal ring (Femring) are available.  Combination estrogen-progesterone preparations are available as tablets and patches. Progesterone-only preparations are available as a pill, injections, vaginal gel, or an intrauterine device (IUD). Testosterone therapy is currently not approved for women in the United States.

Using estrogen alone increases the risk for uterine cancer. Adding progesterone to hormone replacement protects the uterus from cancer. For this reason, estrogen-only preparations are usually only used in postmenopausal women who have had hysterectomies. Because they have no uterus, these women have no risk of uterine cancer and therefore don’t require progesterone.

Progesterone therapy is usually added to estrogen therapy in women who still have a uterus.

Bio-identical hormones

Much attention has been focused on whether certain hormone preparations are safer or more effective than others.  “Bio-identical” hormones are hormone preparations that are chemically identical to the hormones produced in the body—whether they originate in animals, plants, or are manufactured synthetics, they cannot be distinguished from the body’s own hormones. No evidence conclusively shows that bio-identical hormones are safer than other preparations.

Some physicians prescribe compounded bio-identical hormones that are prepared by pharmacists. Compounded hormone replacement is described in more detail below. 

FDA-approved vs. compounded hormone preparations

Certain hormone preparations (including estradiol and progesterone), have been tested by the FDA and are available commercially by prescription. Other "compounded" hormone preparations contain combinations of different hormones that are individually prepared by pharmacists. There is no evidence that compounded hormones are any safer than commercial hormones. Because compounded hormones are not tested or approved by the FDA, compounded hormones may vary from one pharmacy to another. Some custom-compounded preparations are not covered by insurance plans. Occasionally, custom-compounded hormones may provide certain benefits, allowing doses and mixtures of different hormones that are not available in commercial products. 

Some health care providers periodically use saliva tests to measure the overall level of hormones in patients who use compounded hormones. Many menopause experts believe this type of testing unnecessary and unreliable.

The North American Menopause Society (NAMS), a professional organization devoted to promoting women's health and quality of life through an understanding of menopause, published a position statement on compounded hormone replacement. For most women, NAMS does not recommend custom-compounded products over well-tested, government-approved products. Nor does the Society recommend saliva testing to determine hormone levels.

Systemic, vaginal and intrauterine hormones

Systemic hormones are given by skin patch, cream or pills. They enter the bloodstream and deliver hormones throughout the body. Systemic hormones are the most effective way to treat menopause symptoms, but they can come with side effects. 

For women who have not removed their uterus, Intrauterine Devices (IUDs) may be used to deliver progesterone directly to the uterus to protect against endometrial cancer. Intrauterine progesterone has fewer side effects than systemic progesterone. 

For women who experience vaginal symptoms and cannot take or do not need systemic hormones, vaginal hormone replacement medications such as EstringVagifem tablets, or Estrace or Premarin creamIntrarosa, or Imvexxy vaginal inserts may be options. These work by delivering hormones to the vaginal walls with very little absorption into the body; leading to fewer side effects and improved safety for cancer survivors and other women who cannot safely take systemic hormones. 

Selective Estrogen Receptor Modulators (SERMs)

SERMs are a type of oral medication that acts like estrogen in some parts of the body, while blocking estrogen in other parts of the body. SERMS can block the effects of estrogen in breast tissue. Tamoxifen and raloxifene are two SERMS that are used to treat breast cancer or prevent breast cancer in high risk women. SERMS can also treat some of the side effects of menopause. Ospemifene (Osphena) is a SERM with FDA approval to treat vaginal dryness and pain during intercourse caused by menopause. Raloxifene can be used to prevent or treat osteoporosis. 

Benefits and risks of hormone replacement therapy

Systemic hormones improve most of the side effects and long-term consequences of surgical menopause, including

  • hot flashes
  • osteopenia and osteoporosis
  • vaginal side effects
  • sexual side effects

Oral estrogen therapy  has been linked to an increased risk for blood clots and stroke.  Estrogen skin patches, in contrast do not appear to increase risk of these conditions.

When estrogen therapy is combined with systemic progesterone therapy (oral or by patch) in women with a uterus, an increased risk of breast cancer is noted after several years of use. When estrogen  therapy is used without progesterone in women with a uterus, there is an increased risk of uterine  cancer.  

Much of the research has looked at older women who took hormone replacement after natural menopause. For healthy, high risk previvors (women who never had a cancer diagnosis) who remove their ovaries before age 45, most experts believe the benefits or hormone replacement therapy outweigh the risks, even in women with intact breasts. Experts do not recommend systemic hormone replacement therapy for women who have been diagnosed with breast cancer.

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Last updated September 28, 2020