Estrogen Hormone Therapy
Estrogens (Estradiol, Estriol, and Estrone) are essential hormones in women, and the main drivers of female fertility (along with progesterone). They are also responsible for many other physiological functions in the body, including maintaining libido and sex drive, and preserving bone density to prevent fractures. Before menopause, estrogens (mainly Estradiol) are primarily made in the ovaries. Estrogen levels start to decline as early as 35 years of age and by the age of 50 most women begin to experience symptoms of menopause, which is the medical term used to describe the time when the ovaries stop producing estrogen. Some common symptoms of menopause are:
- Irregular periods
- Viginal dryness, which can lead to pain during sex
- Hot flashes
- Sleep problems
- Mood changes
- Weight gain and slowed metabolism
- Loss of breast fullness
If you have symptoms of menopause, the treatment team will check the levels of sex hormones in your blood. You may be prescribed supplemental estrogen either as a standalone treatment or with the addition to supplemental progesterone and testosterone. Estrogen replacement therapy (with or without progesterone replacement) can help combat the symptoms of menopause and improve health and wellbeing. Estrogen is typically administered as a daily cream or pill.
Should I Be On Supplemental Progesterone While On Estrogen Therapy?
“Unopposed estrogen therapy” is the administration of estrogen without progesterone, and it can result in abnormal growth of tissue in the uterus (endometrial hyperplasia) and increased risk of endometrial cancer. To prevent this, all women with an intact uterus should receive progesterone along with estrogen. Post-menopausal women who have undergone hysterectomy (removal of the uterus) should not receive progesterone, because combined estrogen and progesterone therapy has been shown to increase risk of breast cancer (see below).
Should I Be On Supplemental Testosterone While On Estrogen Therapy?
Adding testosterone to hormone therapy has a positive effect on sexual function in postmenopausal women, although it may be accompanied by hair growth, acne and a reduction in HDL (“good”) cholesterol. Your doctor will review whether this is appropriate based on your treatment goals.
Does Estrogen Replacement Increase My Risk Of Developing Blood Clots And Stroke?
Studies of the use of estrogen (either alone or in combination with progesterone) to treat post-menopausal women have shown increased risk of blood clot and stroke. As such, estrogen replacement therapy is not recommended for women with increased risk of blood clots for other reasons – these will be reviewed by your doctor. However, these studies included primarily older women (60 years or older); the risk of adverse effects in women in their 40’s and 50’s is relatively low by comparison. Subsequent research has shown that use of transdermal creams rather than pills may further reduce this risk. It is also worth noting that hormone replacement therapy was not associated with increased risk of death from any cause. If you are still concerned about this increased risk and if your symptoms are limited to vaginal dryness and/or pain with sexual intercourse, a vaginal estrogen cream may be a safer option to consider.
Does Estrogen Replacement Increase My Risk Of Breast Cancer?
The impact of hormone replacement therapy with either estrogen alone or combined estrogen and progesterone on breast cancer risk has been studied extensively. Current data suggest that treatment with estrogen alone may actually decrease risk of developing breast cancer, but it is not recommended in women with an intact uterus as it may increase the risk of endometrial cancer. Use of combined estrogen and progesterone has been shown to increase risk of breast cancer – this is discussed further in our section on progesterone.
Should Estrogen Be Prescribed As A Transdermal Cream Or As A Pill?
The risks of oral estrogens include elevated blood pressure, blood clot formation, high triglycerides, and an increase in estrone, which may increases the risk of breast and endometrial cancer. It can also elevate liver enzymes, decrease growth hormone, and increase sex hormone binding globulin that can reduce testosterone levels, resulting in weight gain. As noted above, using a transdermal cream instead of a pill is considered much safer and is less likely to have these adverse effects.