Archive for About HT (HRT)

Hormones

Hormonal communication systems augment the nervous communcation systems within the body. Hormones are chemical signaling molecules (peptides, proteins or steroids) produced in one site of the body that then travel to another site to have an effect. In this way one cell can effect other distantly located cells. The endocrine system displays an elegant system of checks and balances in the form of feedback loops to facilitate the normal funtioning of all bodily systems. Hormones may be made and have an action locally or may be made in one endocrine gland and have an effect at a distant site.  Glands are functional units of hormone secreting cells located in various regions of the body making up the endocrine system. Each gland has specific functions that help to maintain the normal internal environment and promote the survival of the organism.  Although there are some diffuse endocrine tissues, as in the gastrointestinal epithelium, there are several major glands or control centers within the endocrine system, including:

  • pituitary gland
  • anterior pituitary
  • intermediate lobe
  • posterior pituitary
  • hypothalamus
  • suprarenal (adrenal) gland
  • thyroid
  • parathyroid
  • pancreas
  • testes
  • ovary
  • pineal

“The Master Gland”
The pituitary gland, which lies is a small depression in the sphenoid bone of the skull called the sella turcica, has often been termed the ‘Master Gland’ because many of the hormones it releases effect the release of other hormones. However, the pituitary is really not the master. It is controlled by a brain region called the hypothalamus via the release of releasing factors into a special blood vessel network (hypothalamic-hypophyseal portal system) that feeds the pituicytes. These releasing factors then cause or inhibit the release of pituitary hormones which travel via the circulatory sytem to the target organ.  For example, as a woman’s menstrual cycle progresses toward ovulation, the hypothalamus releases LHRH (luteinizing hormone releasing hormone) that travels via the hypophyseal portal system to the pituitary where it stimulates the production and release of LH (luteinizing hormone). LH then travels to the ovaries where it causes ovulation and the subsequent development of a progesterone secreting corpus luteum.

Anatomically and functionally the pituitary can be divided into three portions:

1) anterior pituritary (adenohypophysis)
Six peptide hormones are secreted by the adenohypophysis: Growth hormone (somatotropin), corticotropin (ACTH), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), Luteinizing hormone (LH), and prolactin. All except growth hormone and prolactin regulate the activities of other glands.  Somatotropin, PRL and ACTH are polypeptide hormones and LH, FSH, and TSH are glycoproteins having very similar structures.

  • Growth hormone has no specific target tissue. All cells of the human body are affected by this hormone. It is very important in the growing child but it remains essential to many bodily functions throughout life. GH has effects on the growth of bone and cartilage, protein metabolism, RNA formation, electrolyte balance, fat and glucose metabolism.
  • ACTH    This trophic hormone stimulates the production and release of suprarenal steroids. Normally the amount of circulating ACTH is controlled by the levels of cortisol in the blood, individual biorhythms and stress.
  • TSH    This hormone stimulates the synthesis and secretion of thyroid homones. It is a glycoprotein hormone controlled by feedback from thyroid homones.
  • FSH    The target organs for FSH are the testes, in men, and the ovaries in women. The hormone stimulates the germinal epithelium in the testes to cause and facilitate the making of sperm. In women it stimulates the growth and development of the follicle. It stimulates the production of testosterone in men and estrogen and progesterone in women. Its release from the pituitary is governed by a negative feedback mechanism involving these steroids.
  • LH    The male target organ is the testes and the testosterone producing interstitial cells of Leydig in particular. In women the target of LH is the developing follicle within the ovary where it is necessary for ovulation to occur and a corpus luteum to develop.
  • Prolactin    This hormone is involved in breast development and lactation. In concert with estrogen, it prepares the mammary gland for lactation and then causes the synthesis of milk. Secretion is regulated by a release inhibiting factor and suckling may cause the release of prolactin from the pituitary.

2) intermediate lobe (pars intermedia)
In the adult human this lobe is diminished with poor vascular and neural connections such that secretion is not facilitated. Cells in the pars intermedia may secrete MSH (melanocyte stimulating hormone) which stimulates the activity of melanocytes in the skin.

3) posterior pituitary (neurohypophysis)
This portion of the pituitary is really an extension of the hypothalamus. Neurons with their cell bodies in the hypothalamus and their terminal protions in the neurohypophysis release two hormones. Antidiuretic hormone (ADH) and oxytocin are stored there within the terminal processes of neurons until the signal to release them is received.

  • ADH    In the presence of ADH, the kidneys reabsorb more water from the forming urine within the renal tubules. Without ADH the kidney tubules are almost completely impermeable to water such that a very dilute urine is excreted (diabetes insipidus). ADH has a direct effect on vascular smooth muscle causing vasoconstriction and an increase in blood pressure when present in large doses. The hypothalamus has osmoreceptors that sense the concentration of the blood. They are stimulated by a high blood osmolarity (increased concentration) causing the release of ADH. The hormone then causes the kidney tubules to reabsorb more water to return osmolarity to normal. Volume receptors also play a role when they sense a low blood pressure. Alcohol inhibits ADH secretion.
  • Oxytocin    A major role of this hormone is the stimulation of smooth muscle cells in the pregnant uterus. When labor begins, stretching of the cervix and vagina stimulates a reflex production and release of oxytocin. Oxytocin then travels in the blood to the uterus where it causes more forceful contraction of the smooth muscle. This hormone is also involved in lactation. It causes milk ejection by acting on the smooth muscle surrounding the milk producing cells. Again its production and release is mediated by a neural reflex, the suckling reflex. Emotion, anxiety and pain can inhibit oxytocin release.

Hypothalamus
Anterior pituitary functions are controlled by the region of the brain called the hypothalamus via the secretion of  releasing and inhibiting factors. Specialized neurons in the hypothalamus, controlled by feedback and other communication methods release factors that cause the release of hormones from the anterior pituitary. The pituitary trophic hormones then control the release of other hormones from a target gland. With the exception of prolactin, release promoting factors are more important to the release of pituitary hormones. Somatostatin (inhibits GH release),  prolactin inhibiting factor (PIF), LH releasing factor (LHRF), FSH releasing factor (FSHRF), prolactin releasing factor (PRF), corticotropin releasing factor (CRF), thyrotropin releasing hormone (TRH) are all hormones that control the release of anterior pituitary hormones. The release of these factors is controlled by feedback from the target organ hormone to maintain the proper hormonal balance.

Suprarenal (adrenal) Gland
The suprarenal glands are located on top of each of the kidneys. The adrenal cortex (outer portions) produce the corticosteroids: the mineralcorticoids and the glucocorticoids which are steroid hormones. The cortex also produces some male sex steroids. Cholesterol is the starting place for the biosynthesis of all these steroid hormones.

The adrenal medulla is actually an extension of the nervous system. The adrenal medulla produces norepinephrine and epinepherine (adrenaline) that are released in response to stress or a fright.

Mineralcorticoids
The major mineralcorticoid, which is secreted almost independently of ACTH from the pitutitary, is aldosterone. Aldosterone secretion is controlled mostly by the levels of potassium and sodium in serum and a blood pressure control system called the renin-angiotensin system. The principle action of aldosterone is the retention of sodium. Where sodium goes, so goes associated ions and water. Therefore, aldosterone profoundly effects fluid balance by effecting intracellular and extracellular fluid volume.
Aldosterone has the opposite effect on serum levels of potassium as it is lost in the urine in exchange for sodium in the renal tubules. Salivary and sweat glands are also influenced by aldosterone to save sodium and the intestine increases the absorption of sodium in response to aldosterone.

Aldosterone levels increase and cause fluid retention in diseases such as congestive heart failure and liver cirrhosis. Certain diruetics act by antagonizing aldosterone. In contrast to most diruretics that cause potassium loss, the aldosterone antagonists increase blood potassium and are sometimes used for this effect.

Glucocorticoids
The major glucocorticoid is cortisol. Cortisol has important actions in the control and metabolism of carbohydrates, lipids, and proteins and assists in the metabolic reaction to stress, especially chronic stress. It causes glucose to be liberated from the liver by  increasing glucose production from fatty acids (by-products of lipid breakdown) and amino acids. Cortisol causes the tissues to take up less glucose from the blood and mobilizes fat breakdown. The net effect is to increase serum glucose concentrations which is protective for the brain in that it cannot use any other fuel source than glucose. It also stimulates protein breakdown for glucose formation in all tissues except the liver where it stimulates protein synthesis.

At high concentrations (greater than physiologic) glucocorticoids (such as hydrocortisone or prednisone) are useful for the treatment of allergies and inflammation. Each step of the inflammatory process is blocked by glucocorticoids when given systemically (an IV injection or orally). Topical application of glucocorticoids have anti-inflammatory effects for the local area. The anti-inflammatory activity of glucocorticoids is thought to be due primarily to the stabilization of cell membranes. The immune response can also be suppressed by the use of glucocorticoids. Eosinophils and lymphocytes decrease in the circulation affecting both cellular and humoral immunity. The glucocorticoids are used for many other conditions including asthma, renal diseases, rheumatic disorders such as lupus and inflammatory bowel disease.

Thyroid
The thyroid is a large endocrine organ that functions mostly to control metabolism. It is located in the neck between the trachea and laynx and is bi-lobed with a connecting isthmus. The gland is composed of many tiny follicles, that are in effect, each a separately functioning gland with a single-layer epithelial lining. Each follicle accumulates a storage form of the circulating thyroid hormones, thyroglobin. Thyroglobin is a large protein molecule that contains multiple copies of the amino acid tyrosine. The thyroid hormones are very simple modifications of the amino acid tyrosine. Iodide is added to one or two spots on the amino acid and then two of the modified tyrosines are combined to form one of the two thyroid hormones, thyroxin (T4) or triiodothyronine (T3).  The thyroid hormones are then cut off the thyroglobin as needed and released into the circulation. The thyroid follicles accumulate iodine by extracting it from the blood and trapping it within the lumen of the follicle. This ability to store homone in a large molecule is unique to the thyroid.

Both T4 and T3 enter cells and bind to an intracellular receptors whereby they increase the metabolic capabilities of the cell. Mitochondria and mitochondrial enzymes are increased thereby influencing cellular metabolism. Thyroid hormones are necessary for normal growth and development. They have metabolic effects on protein synthesis, lipid metabolosm and carbohydrate metabolism.

Also produced by parafollicular cells within the thyroid is the polypeptide hormone calcitonin. It funtions in calcium maintainence to decrease the levels of calcium in the blood. When serum calcium levels are excessive, calcitonin is released. It inhibits bone resorption (by inhibiting osteoclast activity), allows the loss of calcium in the urine and therefore decreases calcium in the blood. It opposes the action of parathyroid hormone and has been used clinically for the treatment of osteoporosis.

Parathyroid
The four parathyroid glands lie on top of the thyroid gland in seperate nodes spread out to the four quandrants of the thyroid. Parathyroid homone is under direct feedback control of circulating levels of calcium. If calcium levels fall, then parathyroid hormone is released. As calcium levels rise, release of the hormone is reduced. Parathyroid homone acts on bones, the kidneys and the intestines to reabsorb calcium.

Pancreas
The pancreas is a mixed exocrine and endocrine gland. The exocrine portion makes many of the digestive enzymes necessary for gastrointestinal function. The endocrine portion is comprised of discrete islands of cells called the islets of Langerhans. Cells within the islets produce two hormones that regulate the concentration of glucose in the blood. Insulin is a polypeptide hormone produced by the beta cells that reduces the level of circulating glucose. It is the only hormone that reduces circulating glucose levels, is secreted in response to high glucose levels and is subject to negative feedback control. Insulin causes cells to take up glucose, stimulates the storage of glucose, and inhibits the making of glucose. Abnormalities in the secretion or response of cells to insulin cause the condition diabetes mellitus.

Glucagon is a small protein produced by alpha cells within the islets that causes the level of blood glucose to increase. Its release is controlled by blood levels of glucose. As levels fall, glucagon release is increased causing the release of stored glucose and the synthesis of glucose until levels are increased and glucagon release is then reduced via negative feeedback. Glucagon opposes the metabolic actions of insulin. This opposition plus the negative feedback control of glucose levels maintains very tight control on blood glucose levels.

Testes
Testosterone is the principle hormone of the testes and is synthesized from cholesterol by the Leydig cells. The secretion of testosterone is under the control of LH from the pituitary. LH secretion is decreased by increased levels of testosterone in the blood via negative feedback. Testosterone develops and maintains the male secondary sex characteristics, is anabolic and growth promoting and participates in the formation of sperm. It also causes aggressive behavior and increased libido. Body hair is increased by androgens while scalp hair is decreased.

Like other steroids, testosterone enters cells and binds to an intracellular receptor and then causes the production of mRNA coding for proteins that manifest the changes induced by testosterone. In some target tissues a form of testosterone, DHT, is produced that has greater stability in combination with the receptor and therefore produces a longer lasting effect. DHT is needed for the maturation of the accessory glands and external genitalia, while testosterone is more important in the growth of muscle mass, development of the internal genitalia and maintainence of the male libido and sex drive.

Another hormone produced by the testes is the polypeptide hormone, inhibin, produced by the Sertoli cells. It inhibits FSH secretion by a direct action on the pituitary.

Ovary
The ovaries produce the steroid hormones (estrogens and progesterone) that cause the development of secondary sexual characteristics and develop and maintain the reproductive function in the female. Specifically the estrogens are secreted by the theca interna cells and the granulosa cells of the ovarian follicle, the corpus luteum and the placenta. LH from the anterior pituitary binds to receptors on theca interna or granulosa cells to cause the production of estradiol from cholesterol or a downstream precursor androstenedione that is passed from the thecal cells to the granulosa cells. Progesterone is secreted mostly by the corpus luteum and the placenta but some is made by the developing follicle. Negative feedback from progesterone decreases LH secretion and large doses can prevent ovulation.

Estridiol is the most potent and major secreted estrogen although estrone and estriol can be found in circulation as well. Like other steroid hormones, estrogens enter target cells, combine with a nuclear receptor and cause the production of mRNAs that, when translated into proteins, modify cell function. Estrogens are metabolized by the liver and secreted in bile where some is reabsorbed back into the body. Metabolites of estridiol are excreted in the urine.

Estrogens in the blood stream inhibit the release of FSH and LH, in some circumstances, via negative feedback. At other times, as in the preovulatory LH surge, estrogens increase the release of LH, via positive feedback. Estrogen also increases the excitability of uterine smooth muscle, myometrial sensitivity to oxytocin and increases the libido in women by a direct action on hypothalamic neurons.

Estrogens lower plasma cholesterol, inhibit atherogenesis (plaque formation in blood vessels), and are protective against myocardial infarction as suggested by the lower incidence of heart attacks and atherosclerosis in premenopausal women.

Progesterone has the principal targets of the uterus, breasts and the brain. It promotes the development of breast tissue, causes changes in the endometrial lining during the luteal phase of the cycle, decreases the excitability of myometrial cells and decreases uterine sensitivity to oxytocin.

Cells of the developing follicle also produce the polypeptide hormone inhibin which inhibits FSH secretion by a direct action on the pituitary.

Pineal
The pineal gland can be found deep in the brain at the top of the third ventricle where it is is close communication with the cerebrospinal fluid. In the adult, the pineal gland can often be seen in x-rays of the brain because of the accumulation of radiopaque calcium phosphate and carbonate into small granules called pineal sand. The cells of the pineal gland secrete the hormone melatonin in a diurnal cycle (the amount changes throughout a 24 hr period) where the amount remains low during the daylight hours but increases during the dark hours. This diurnal variation is controlled by norepinephrine from sympathtic nevous input that is regulated by the light-dark cycle in the environment.

Although some people use melatonin supplements to treat insomnia, this effect has not been proven in scientific trials. There have been reports of increased insomnia and depression as well as other side effects associated with its use.

WISDOM: HT Beyond Menopause

Following confirmatory studies, women have again been advised not to start hormone therapy in their older age, many years beyond menopause. Another large study to report on hormone therapy use in older women, the WISDOM study published 12 July, 2007, has confirmed that combined oestrogen and progestin results in a small increase in the risk of heart attacks and blood clots.

This is now the 10th large study to confirm that if hormone therapy is started in older women aiming for prevention of disease, the risks outweigh the benefits.

This information is not relevant for the majority of women considering hormone therapy or taking hormone therapy at the time of menopause for symptom relief.

As based on extensive evidence, women at menopause can take low-dose hormone therapy short-term without a significant increase in risk and with substantial benefit in symptom relief and quality of life.

Note: Hormone therapy (HT) is also known as hormone replacement therapy (HRT)

Background

Results from the Women’s International Study of long Duration Oestrogen after Menopause (WISDOM) were published on 12 July, 2007 in the British Medical Journal. The study was a multi-centre randomised controlled trial of hormone replacement therapy (HT) in postmenopausal women conducted in Australia, New Zealand and the UK.

In 2002, the Women’s Health Initiative (WHI) trial found that postmenopausal women taking HT had more heart attacks and strokes than non-HT users. The trial was halted early and millions of women around the world stopped taking HT. But scientists now believe that these risks may only apply to older women who do not normally use HT.

In 1999, the WISDOM trial began to assess the long-term risks and benefits of HT after the menopause. This trial was also stopped after the first WHI results appeared, but the WISDOM findings, published on 12 July, 2007, make an important contribution to the body of knowledge about HT when it is initiated in older, postmenopausal women.

The WISDOM team identified 5,692 healthy women registered at general practices in the UK, Australia and New Zealand with an average age of 63 years and 15 years after menopause.

The women who had not had a hysterectomy were split at random into two groups. One group was given a daily dose of combined hormone therapy (oestrogen and progestogen) and the other group was given a placebo pill. Women who had had a hysterectomy were split between combined hormone treatment, oestrogen only and a placebo.

All women were monitored for an average of 12 months and main outcomes such as cardiovascular disease, osteoporotic fractures, breast cancer and deaths, were recorded.

The study confirms an early increase in thromboembolic and cardiovascular risk in older women starting hormone replacement therapy many years after menopause. The results are also consistent with the early findings of WHI and other trials, and support the conclusion that combined oestrogen and progestogen therapy should not be initiated to prevent cardiovascular disease in older, postmenopausal women.

However, the authors, including Professor Alastair MacLennan, Department of Obstetrics and Gynaecology, University of Adelaide, Women’s and Children’s Hospital, Adelaidestress that these results cannot necessarily be applied to younger menopausal women starting hormone replacement therapy to relieve symptoms such as hot flushes and night sweats. For these women, recent studies suggest there may be cardiovascular benefits of taking HT around the time of menopause. The authors say that more research is needed to assess conclusively the long-term benefits and risks among these women.

More information about the Women’s Health Initiative and Million Women Study

Find out about the Women’s Health Initiative (WHI) and Million Women Study (MWS) along with expert comment from the Jean Hailes Foundation for Women’s Health at:

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WHI, Oestrogen Only and Breast Cancer

Breast cancer not increased

The Women’s Health Secrets reports on new evidence showing the risk of breast cancer is not increased for women on oestrogen-alone hormone therapy.

The latest news from the American Women’s Health Initiative provides greater clarity on the risks and benefits of hormone therapy. It shows women who have had hysterectomies and who use oestrogen-alone for menopausal symptoms are not at greater risk of breast cancer.

In fact, they may be protected from some forms of breast cancer. The study found oestrogen-alone hormone therapy “does not increase breast cancer incidence in postmenopausal women with hysterectomy, and may decrease the risk of early stage disease and ductal carcinomas”.

The findings were announced in the April 12, 2006 issue of the Journal of the American Medical Association (JAMA).

This information is relevant to more than 30,000 Australian women who have a hysterectomy each year. Hysterectomy is the surgical removal of the uterus or womb.

The findings are a direct contrast to the combined hormone therapy findings from 2002, which revealed a small but significant increased incidence of breast cancer in women who had used hormone therapy prior to commencing in the study, though there was no significant increase in risk in those who had not used hormone therapy beforehand.

Professor Helena Teede, Director of Research at the Foundation:
“This is reassuring for both clinicians and for women who have had a hysterectomy, when considering or using hormone therapy. This information needs to be considered in combination with additional individualised advice from their doctors to explain their risks and benefits.

I must emphasise these results are directly relevant only to women who have had hysterectomies. For women with a uterus considering, or currently taking hormone therapy, progesterone is necessary to protect their uterus from cancer.”

Questions and answers

The Women’s Health Secrets answers some questions on hormone therapy

Note: hormone therapy (HT) may also be referred to as hormone replacement therapy (HRT).

Can hormone therapy increase the risk of breast cancer?

Women who take the combined oestrogen-progestin hormone therapy for up to five years are not at significantly increased risk of breast cancer. Beyond five years there is a small increase in risk. For example, if 1,000 women are followed from age 50 to 70, approximately 45 will develop breast cancer without hormone therapy. Use of hormone therapy for more than five years is thought to lead to two more cancers (for example, 47 women). Use for 10 years increases this to about 51, and for the whole 20 years to 57, an increase in risk of 1.2 per cent. Women who take oestrogen-only hormone therapy (only possible after a hysterectomy) do not have an increased risk from breast cancer after seven years.

What is a hysterectomy?

A hysterectomy is the surgical removal of a woman’s uterus (or womb). Women who have had a hysterectomy often take oestrogen-only hormone therapy. Women who have not had a hysterectomy must take combined oestrogen-progestin hormone therapy to treat menopausal symptoms.

Can I stop taking the progestin part of my combined hormone therapy?

No! Women who have a uterus and who are taking combined oestrogen-progestin hormone therapy should continue to take both to protect their uterus from cancer.

How does this help women who have not had a hysterectomy?

As doctors become better informed, they are making sure women’s breast tissue is exposed to as little progestin as possible – while still protecting the uterus from cancer. While some forms of hormone therapy are thought to offer this, their effects on breast cancer remain uncertain.

What is the Women’s Health Initiative?

The Women’s Health Initiative (WHI) was a large study with two arms focusing on hormone therapy (HT). It began in the US in 1997 and looked at the long-term use of oral hormone therapy in women aged 50-79 years for the prevention of heart disease. The combined oral oestrogen plus progestin therapy arm of the study was stopped in 2002 after women had been monitored for five years. It stopped when researchers found a slightly greater rate of breast cancer in the women taking oestrogen-progestin HT.

In 2004, the oestrogen-only arm of the WHI was stopped after seven years – a year ahead of schedule – because a beneficial effect of hormone therapy on heart disease risk was not found. They did, however, reveal a small increase in the incidence of strokes. Researchers also found no increase in breast cancer risk. The latest results confirm these findings and offer some good news for women taking oestrogen-only HT.

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Oestrogen and Breast Cancer

More from the Women’s Health Initiative

Oestrogen-alone hormone therapy, used in women who have had a hysterectomy, does not increase breast cancer risk if used for seven years or less, as revealed recently from the Women’s Health Initiative.

Experts from the Women’s Health Secrets explain the latest study results from both the Women’s Health Initiative and the Nurses Health Study on the use of oestrogen-alone therapy in relation to breast cancer.

Note: Hormone therapy (HT) may also be referred to as hormone replacement therapy (HRT).

This robust randomised controlled data from the Women’s Health Initiative is now supported by new data from the large observational Nurses Health study showing that there is no increased risk of breast cancer in women taking oestrogen-alone for less than 10 years. This observational study reported in the Archives of Internal Medicine, suggests a small increased risk among women taking oestrogen for more than 20 years.

Summary

The use of oestrogen-alone in perimenopausal and menopausal symptomatic women who have had a hysterectomy does not increase breast cancer risk if used for seven to ten years. It is important for each woman to regularly discuss her individual risks and benefits of hormone therapy with her health practitioner.

More information

See also Oestrogen-only hormone therapy may protect against breast cancer

Background

The Women’s Health Initiative (WHI) was a large study with two arms focusing on hormone therapy (HT). It began in the US in 1997 and looked at the long-term use of oral hormone therapy in women aged 50-79 years for the prevention of heart disease. The combined oral oestrogen plus progestin therapy arm of the study was stopped in 2002 after women had been monitored for five years. It stopped when researchers found a slightly greater rate of breast cancer in the women taking oestrogen-progestin HT, although the increase was seen only in women who had been prior users of hormone therapy before starting in the study.

In 2004, the oestrogen-only arm of the WHI was stopped after seven years – a year ahead of schedule – because a beneficial effect of hormone therapy on heart disease risk was not found. They did, however, reveal a small increase in the incidence of strokes, primarily in those participants who were over 60 years of age at commencement. Researchers also found no increase in breast cancer risk. The latest results confirm these findings and offer some good news for women taking oestrogen-only HT.

The Nurses Health Study is a large, observational follow-up study of female nurses who have been followed since 1976. By the end of enrolment 28,835 menopausal women who’d had a hysterectomy were included. Women were asked every two years by questionnaire if they used hormones and whether they had developed breast cancer. Whilst this is a large trial, it is observational and the results need to be interpreted with caution and supported by randomised controlled trials, like the Women’s Health Initiative mentioned above.

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Heart Disease and HT

Does hormone therapy (HT) have effects on cardiovascular disease?

Women taking HT (also known as hormone replacement therapy – HRT) appear to have a lower risk of heart disease, but there may be many reasons for this. HT, in tablet form, reduces cholesterol as well as having favourable effects on the blood-vessel wall. However, it also increases the risk of blood clots forming when blood-vessel plaques rupture. Currently HT should be avoided in women with established heart disease.

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WHI – USA

Women’s Health Initiative – USA

The USA National Institutes of Health established the Women’s Health Initiative (WHI) to address the most common causes of death, disability and impaired quality of life in postmenopausal women.

The overall goal of WHI is to reduce coronary heart disease, breast and colorectal cancer, and osteoporotic-fractures among postmenopausal women via prevention strategies and risk factor identification.

WHI – Hormone therapy research

The hormone therapy (also known as hormone replacement therapy ) component of the WHI trial looked at the long-term use of oral hormone therapy (HT) in older women in the USA for the prevention of disease. It was not a study of menopausal HT in symptomatic women around age 50.

There were 16,608 women (who were postmenopausal and had a uterus) who randomly received either Prempro (0.625mg of conjugated equine oestrogen + provera 2.5mg) or a placebo (dummy pill).  The trial was stopped in 2002 after an average of 5.2 years participation and more than two years early because the incidence of invasive breast cancer exceeded the safety level set by the WHI.

The oestrogen only arm (for women without a uterus) of the study was closed one year early in March 2004, as the beneficial effect of hormone therapy on heart disease risk was not observed in this part of the ongoing study. However more recent analysis has suggested cardiovascular benefit in women less than 60 years of age, particularly those given oestrogen only. A small increase in strokes was noted, hip fractures were reduced and, importantly, breast cancer was not increased.

For more information go to: Women’s Health Initiative Participant Web Site (www.whi.org)

Expert comment on WHI results

Around the world debate continues in regard to hormone therapy (HT) – also known as hormone replacement therapy (HRT) – since the results of the benchmark (WHI) trial in the US, which was prematurely halted in 2002.

The studies published in the Journal of the American Medical Association give detailed information about the outcomes of the WHI research into the effects of combined oral oestrogen progestin therapy in postmenopausal women on average 13 years past menopause.

As the WHI results are published, experts from The Jean Hailes Foundation for Women’s Health will comment from the Australian perspective.

Hormone therapy in Australia

The WHI trial used only one form of combined oestrogen plus progestin tablet not commonly prescribed in Australia.

There are different ways of taking hormone therapy (HT) and different combinations of the three hormones; oestrogen, progesterone and testosterone. HT can be prescribed as tablets, patches, skin gel, implants, oestrogen injections, vaginal preparations such as creams, tablets or pessaries (suppositories) or ring for local application inside the vagina.

The tablets are taken orally on a daily basis. The patch is applied to the skin on the lower body once or twice weekly, the gel is applied daily and the implant (hormone pellet) is inserted under local anaesthetic beneath the skin and usually lasts four to six months. In all the non-oral routes the hormones are absorbed directly into the blood stream whereas with tablets they are absorbed through the intestine first.

For more information go to Hormones

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HT & Breast Cancer

Note: Hormone therapy (HT) may also be referred to as hormone replacement therapy (HRT).

Questions and answers

The Women’s Health Sectrets answers your questions about the report on breast cancer from the Lancet 9 August 2003.

For expert comment about the report
Breast Cancer and hormone-replacement therapy in the Million Women Study – Comment

What is the significance of this new study?

This observational study of women who had been using hormone therapy (HT) for about six years prior to recruitment, calculates a similar increase in risk of breast cancer as reported in the overall figures from the Women’s Health Initiative (WHI) study released in July 2002. That study reported no increase in breast cancer risk over seven years in women who had not taken HT prior to study entry, but an apparently increased risk in prior users of oral combined HT (conjugated equine oestrogen and medroxyprogesterone acetate) compared with non-users.

In the study published in the Lancet the authors calculated the following:

  • For 1,000 women who go through menopause aged 50 and who have no HT, we would expect 27 breast cancers to be diagnosed in this group by the age of 55 years.
  • If the 1000 women had five years of combined oral HT, we would expect a total of 34 breast cancers (an extra seven cancers).
  • In a previous study the authors state that the risk associated with taking HT between 50 and 55 years is equivalent to the effect of menopause being delayed until the age of 55 years.

What new information is presented in this study?

This study also indicates a smaller but statistically significant increased risk of breast cancer for women taking oestrogen only with no difference between the type of formulation (oral versus transdermal patch).

  • If 1000 women took oestrogen only there would be a total of 28.5 breast cancers (an extra 1.5 cases). An increase in risk, similar to that of oestrogen only was also observed for progesterone alone and tibolone.

What does this report mean for Australian women?

These findings provide further information about the risk of breast cancer with hormone therapies including patches, implants and tibolone.

The authors have previously noted that studies such as this one where patients choose their own treatment are subject to bias and advised caution in the interpretation of the findings (British Journal of Obstetrics and Gynaecology 2002; Vol 109, Pg 1319). These findings need to be evaluated in randomised trials.

HT in Australia is prescribed for the management of symptoms that significantly impair a woman’s quality of life. Based on the findings of this study, continued use for this purpose remains appropriate where the woman is fully informed about the associated risks.

The commentary made on this report in the Lancet has talked, quite inappropriately, about HT as preventive therapy. This is no longer the recommended use of HT.

Are these findings relevant for all hormone treatments?

Yes, because no treatment is without risk (this includes non-hormonal and alternative therapies) and all women prescribed HT should be regularly reviewed.

Are ‘bioidentical hormone therapies’ a safe alternative?

These are simply the same hormones given in a different way and we would expect to convey the same risk. Some health professionals are promoting ‘bioidentical’ hormone therapy not only as safe but also as preventing cancer.

There is no published evidence that this is true and women should be cautious about taking any hormonal preparations that have not been subjected to careful research evaluation.

Should all women stop hormone therapy?

The new findings may indicate a small increase in risk of breast cancer with use of hormone therapy for six years or more. As previously recommended women taking this therapy for the management of severe menopausal symptoms need to balance their need for symptom relief with the long-term increased risk of breast cancer.

Women who are concerned should consult their health professional to discuss their individual risks and benefits.

Does HT cause breast cancer?

The evidence from the WHI study which is a randomised trial suggests that long-term use of combined oral therapy in prior users of the therapy, but not in first-time users, increases the risk of breast cancer. We need to be cautious in our interpretation of the data about other forms of HT.

This new study is not a randomised trial. Women taking other forms of HT may be on those treatments for reasons that could increase their risk of developing breast cancer. This could bias the results of the study.

Does tibolone cause breast cancer?

This is the first report of any association between tibolone (Livial) and breast cancer but it is not a randomised trial. Women at higher risk of breast cancer in the UK were more likely to take tibolone and this would bias the findings.

Why do doctors continue to treat women with HT?

Many women experience severe symptoms that substantially impair their quality of life. As long as women are aware of the small increase in breast cancer risk they have the right to choose hormone therapy.

Should HT be suspended until we know more?

No. HT may be prescribed for clear indications, to a woman who is fully informed of any risk and who has regular review.

Do women using hormone therapy need more mammograms and other investigations?

There is no simple answer to this question, as past history and family history all need to be taken into consideration. This study reinforces the importance of regular mammograms, annual clinical examination with a GP and breast self-examination so women become familiar with their own breasts.

What are the current recommendations for mammography screening in Australia?

Mammography screening is the best way to detect breast cancer at its earliest stages among women in the over 50 age group. Mammographic screening is recommended every two years for women aged 50-69 without breast symptoms or a strong family history, as this is when screening has shown to be most effective.

  • It is very important that women who develop anything that feels like a lump in their breast or any changes consult their doctor as early as possible.
  • The result of a mammogram must be interpreted in conjunction with a physical examination, taking into account age and personal family history.

How can women make an informed decision about using HT?

To greatly assist in comparing treatment and deciding what is right for you, ask yourself a series of questions:

  • How much do my symptoms impact on my quality of daily life?
  • What would happen if I did nothing?
  • What treatment / intervention choices are available to me?
  • What are the possible benefits or risks of different choices?
  • How reliable is the evidence for the proposed benefits or risks of any therapy? (Be sure of seeking evidence from RELIABLE sources).
  • How do the benefits and risks weigh up for me?
  • Have I now gathered enough information to make my decision?

Women need to assess the choices available based on best evidence from clinical trials against:

  • Resources available, cost and access to services.
  • A woman’s personal values.

What should women ask their health practitioners?

It is important to visit a health practitioner with some questions already planned. Write the questions down. This will promote clear and concise communication between a woman and her practitioner. It is often a good idea to book a longer consultation time.

Some examples may be:

  • Are the findings of this study relevant to my situation and my treatment?
  • What treatment / intervention choices are available to me?
  • What are the possible benefits and risks of the different choices?
  • What might happen if I stop taking my HT immediately?
  • Where else can I gather information? (websites, services, printed material)
  • How often does my treatment need to be reviewed?
  • Do I need to have a mammogram?
  • Should I stop my HT prior to having a mammogram?
  • What will happen if I have an abnormal mammogram?

Where to from here

  • All women over 50 years should attend for regular mammographic screening, regardless of whether they are on HT or not.
  • Short-term use of hormone therapy (for the management of menopause symptoms that unacceptably impair a woman’s quality of life) is a safe and effective option. But the benefits and risks need to be weighed up by each individual woman.
  • Women who have prolonged symptoms may choose to continue hormone therapy after balancing the risks of ongoing HT with quality of life issues on an individual basis.
  • Combined oral oestrogen plus progestin therapy is not recommended to prevent disease.
  • This study tells us nothing about the use of oestrogen plus progestin for women who undergo early menopause (before the age of 40). It is generally recommended that such women use HT until they approach the average age of menopause and then at that time re-evaluate their need for ongoing treatment in the light of their personal risk.
  • It is important that all women using HT should be reviewed at least annually by their prescribing health practitioner. Risks and benefits, and other alternatives can be discussed at this time for that individual woman.

Conclusion

The Women’s Health Secrets concurs that new information from this Lancet study reconfirms that the use of hormone therapy after menopause should primarily be for symptomatic relief.

The Women’s Health Secrets is committed to undertaking research in this area and to keeping up to date with new research findings and communicating these findings to women and their families.

The Women’s Health Secrets’s aim is to assist women to become well informed so they can be active participants with their health practitioners, in decision-making about issues that affect their health and wellbeing.

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MWS Breast Cancer

Note: Hormone therapy (HT) may also be referred to as hormone replacement therapy (HRT).

Background information

The Million Women Study (MWS) is a UK national observational study of women’s health, involving around one million women aged 50 and over presenting for breast screening. It aims to answer many outstanding questions about the factors affecting women’s health in this age group. The main focus of the study relates to the effects of hormone replacement therapy use.

Comment

In the Lancet, 9 August 2003 results were reported for a study of over one million UK women aged 50-64 years who had provided information about their use of hormone therapy (HT) prior to a screening mammogram and were followed up for cancer incidence and death.

 

The Million Women Study published in the Lancet
Breast Cancer and hormone-replacement therapy in the Million Women Study
Lancet 2003; 362419-427

 

 

The study reports findings in relation to risk of breast cancer for women on combined oral therapy very similar to those of the WHI study in 2002 and 2003.

These findings provide further information about the risk of breast cancer with hormone therapies.

The authors of the Lancet study presented the following calculations:

  • For 1,000 women who go through menopause aged 50 and who do not take HT, 27 breast cancers would be expected to be diagnosed by the age of 55 years.
  • If the 1000 women had five years of combined oral HT, a total of 34 breast cancers (an extra seven cancers) would be expected.

This is the first report of an increased risk of breast cancer for women taking oestrogen-alone (oral, skin patch or implant), progesterone or tibolone. It should be noted that there is evidence that tibolone was being prescribed preferentially to women in the UK considered at increased breast cancer risk.

The authors estimated that, if 1000 women took oestrogen alone for five years, there would be a total of 28.5 cases of breast cancer (an extra 1.5 cases per 1,000). It should be noted that in the WHI randomised controlled trial of oestrogen-alone, with its much stronger trail design, there was evidence for a decreased risk of breast cancer in the first five years of therapy.

An increase in risk, similar to that of oestrogen only was also observed for progesterone alone and tibolone.

In a previous publication, the authors themselves have urged people to be cautious in interpreting the findings from this study. This is because the design of the study is weaker than the WHI randomised trial so the conclusions are not as reliable.

The commentary accompanying the Lancet publication describes HT as preventive therapy. This is not the current recommended use of HT. Hormone therapy in Australia is prescribed for the management of symptoms that significantly impair a woman’s quality of life. Based on the findings of this study continued use for this purpose remains appropriate where the woman is fully informed about the associated risks.

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Million Women Study

Brief background

The Million Women Study (MWS) is a UK national observational study of women’s health, involving around one million women aged 50 and over, presenting for breast screening. It aims to answer many outstanding questions about the factors affecting women’s health in this age group. The main focus of the study relates to the effects of hormone replacement therapy use. Conclusions drawn from the study’s findings must be viewed cautiously because of how the women were recruited to the study and the potential for bias and confounding.

The study is investigating how various reproductive and lifestyle factors affect women’s health. In particular, the study is looking at how hormone replacement therapy affects a woman’s breasts and other aspects of her health. Other factors being investigated include diet, childbirth, breastfeeding, vitamin and mineral supplement use, oral contraceptive use and family history of illness.More than one in four women in the UK in the target age group are now participating in the study it is the largest study of its kind in the world.

Funds for The Million Women Study have been provided by Cancer Research UK, the UK National Health Service Breast Screening Programme and the UK Medical Research Council.

The Million Women Study (www.millionwomenstudy.org)

Expert comment on The Million Women Study results

The Jean Hailes Foundation for Women’s Health provides expert comment from the Australian perspective.

For more information go to MWS HT & Breast Cancer and HT & Breast Cancer Q & As

Hormone therapy

There are different ways of taking HT and different combinations of the three hormones; oestrogen, progesterone and testosterone. HT can be prescribed as tablets, patches, skin gel, implants, oestrogen injections, vaginal preparations such as creams, tablets or pessaries (suppositories) or ring for local application inside the vagina.

The tablets are taken orally on a daily basis. The patch is applied to the skin on the lower body once or twice weekly, the gel is applied daily and the implant (hormone pellet) is inserted under local anaesthetic beneath the skin and usually lasts four to six months. In all the non-oral routes the hormones are absorbed directly into the bloodstream whereas with tablets they are absorbed through the intestine first.

For more information go to Hormone Therapy

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About Hormone Therapy (HT) – Q&A

About hormone therapy (HT) (also known as hormone replacement therapy – HRT)

For more frequently asked questions about hormone therapy issues go to:
Answers to Questions about Hormone Therapy and Coronary Heart Disease

What is menopause and when does it start?

Menopause is literally the very last period of a woman’s reproductive life. It is said to occur when a woman has not menstruated naturally for 12 consecutive months. Menstruation ceases because the ovaries no longer produce ova (eggs) and the monthly reproductive cycles stop. The average age for menopause is 51 years with the normal range being from 45 to 60 years.

What are the common menopausal symptoms?

The most common menopausal symptoms are hot flushes, night sweats and vaginal dryness. Other symptoms that can occur include anxiety, poor memory, poor concentration, insomnia, fatigue, palpitations, decreased libido, muscle pains, crawling skin and urinary problems. Mild depression or other mood changes may occur during the time of physical and erratic hormonal changes (i.e. in the perimenopause or time before the periods stop) but severe depression is not caused by menopause nor is it more frequent at menopause. Women who have had a history of depression, before the menopause, or who have a history of PMS (premenstrual syndrome), may be more sensitive to the changes taking place.

Do all women experience symptoms at menopause?

No, between 10 and 20 per cent of women have no symptoms, 60 per cent experience mild to moderate symptoms and 10 to 20 per cent experience severe symptoms. In some women physical symptoms, like night sweats, are predominant while other women may have few or no physical symptoms but experience significant psychological symptoms. Women who have significant psychological problems such as depression or severe PMS may need specific treatment or counselling.

Is a woman menopausal if her periods are regular but she is feeling down and has difficulty remembering things?

It is possible for a woman, usually in her forties or early fifties, to have menopausal symptoms even if she still has a regular period. Some women experience mood symptoms, like anxiety and depression, for several months to several years before periods actually cease. This is due to gradual changes in the ovaries and fluctuating oestrogen levels. This transition time, which averages four to six years before the menopause, is called the perimenopause.

Is depression a symptom of menopause?

Depression is not a symptom of menopause. Although some of the physical changes may affect wellbeing, most women cope. In Western societies we are concerned about remaining young which often leads to us having negative attitudes about reaching menopause. In contrast, other societies, such as in many Asian countries, reaching menopause and growing older elevates women to a higher status within a community. Menopause may act as a trigger in women who have a history of depression.

Should hormone levels be checked?

Hormone levels are of relatively little value. They may help to gauge the onset of menopause when a woman has had a hysterectomy or if menopause is suspected in women under the age of 40; however hormone levels change rapidly from one day to another in the perimenopause and are not helpful in diagnosing menopause. Having symptoms is a better guide.

Is a woman likely to have an early menopause if she has had a hysterectomy but still has her ovaries?

Between 10 and 20 per cent of women who have had a hysterectomy have earlier menopause, between one to four years earlier than their expected menopause.

What are the best ways of coping with menopausal symptoms?

There are many ways of coping, though it often depends on the severity of the symptoms. Many women cope with mild symptoms without any medication. Regular exercise often helps because this promotes wellbeing, enhances relaxation and sleep, and may reduce menopausal symptoms.

Good eating habits with foods rich in phytoestrogens such as soy products or linseed may be beneficial. Women with mild to moderate symptoms may prefer to take herbal or plant hormone therapies, which should be either monitored or prescribed by a qualified naturopath or herbalist with an interest in women’s health. Women with more severe symptoms usually find hormone therapy (HT) the most beneficial.

What is HT or HRT?

This treatment is used to restore the important female hormones that the ovaries stop producing after menopause. Oestrogen is the main hormone prescribed to relieve menopausal symptoms. If a woman still has her uterus she must also take progesterone-like hormone (progestagen).

Progesterone protects the uterus lining from over-stimulation by oestrogen, which in the long-term may lead to uterine cancer. Women who have had a hysterectomy do not need progestagen. Women experiencing loss of libido (sex drive), lack of energy and on-going fatigue, even when taking oestrogen therapy, sometimes benefit from low-dose testosterone replacement. However, it is important to discuss with the individual woman psychological and relationship issues as well.

There are different ways of taking HT and different combinations of the three hormones; oestrogen, progesterone and testosterone. Usually tablets are orally prescribed but there are also patches, a gel, implants and vaginal preparations such as creams or pessaries.

The patch is applied to the skin on the lower body once or twice weekly, the gel is applied daily and the implant (hormone pellet) is inserted under local anaesthetic beneath the skin and usually lasts four to six months. In all the non-oral routes the hormones are absorbed directly into the blood stream whereas with tablets they are absorbed through the intestine first.

What are the effects of HT?

Oestrogen prevents postmenopausal bone loss of calcium and protects against osteoporosis, and oestrogen reduces the risk of colon or bowel cancer. The WHI study originally published in 2002, showed no increase in risk of heart disease and stroke in the 50-59 age group, and a small increase in risk in the 60-79 year old group. There was a small increase in risk of breast cancer after 4-5 years of HT.

However, in a younger woman taking HT for menopausal symptoms the risks are likely to be very small. All women should discuss their individual circumstances with their doctor.

What are the common side effects of HT?

The most common undesirable effects from oestrogen therapy are breast soreness and nausea. These symptoms generally improve over time or by altering the dose or treatment method. The progestagen may cause side effects including bloating, depression and mood swings which are similar symptoms to premenstrual syndrome.

Who should not take HT?

Most women are able to take HT. However, in some groups of women, therapy is not advisable and alternatives should be used where possible. These include women who have had cancer of the breast or uterus, a history of thrombosis (blood clots in veins or lung), severe liver disease or undiagnosed vaginal bleeding, heart disease or stroke.

Does HT cause weight gain?

Studies have shown that men and women tend to gain weight as they age. Genetic, family, environmental, lifestyle and some hormonal factors (like an underactive thyroid gland) can contribute to weight gain. With ageing, the base metabolic rate tends to decline and weight increases if the energy intake from food and beverages is more than the energy used in daily activities and exercise.

Gaining weight specifically from HT is uncommon. This may occur temporarily when starting HT, but it is usually from fluid retention and is related to the body readjusting to changing hormone levels.

Many women, but most commonly those not on HT, notice that they lose their waistline. This is due to a 10 per cent redistribution of body fat from the hips and thighs to the abdominal (stomach) region, and is related to hormonal changes at menopause as well as ageing. Regular exercise is particularly beneficial when combined with a well-balanced diet.

Having foods that are low in fat and high in calcium help reduce the risk of heart disease and osteoporosis. Phytoestrogens from soy products, seeds, legumes, fruits and vegetables may also decrease the risk of these diseases, help treat mild menopausal symptoms and prevent some cancers. .

Does HT cause breast cancer?

HT does not cause breast cancer, but long-term HT is associated with a slight increase in the risk of developing breast cancer. There has been much research into this issue with some studies indicating small risk and others indicating no risk. The report from the American Women’s Health Initiative (July 2002) indicated that there is a small increase in breast cancer risk in women taking combined continuous oral hormone therapy. To date this study has not indicated any increase in risk for women taking oestrogen alone after they have had a hysterectomy. The increase in risk translates to eight extra cases (41 women versus 33) for every 10,000 women treated for one year.

Any decision about HT is an individual one and should be made after each woman is informed about her individual risks, benefits, needs and concerns in consultation with her prescribing health practitioner.

How long should a woman stay on HT?

For the treatment of symptoms, women can stay on HT for two to five years. After five years, the need to continue should be reviewed annually and the reason for taking HT reassessed e.g. severe symptoms. In 10 per cent of women, menopausal symptoms may continue for longer than 10 years and these women may require HT for symptom control for longer periods. Current guidelines recommend that women who take HT for menopausal symptoms take the lowest effective dose for the shortest time period to alleviate symptoms.

For established osteoporosis or bone protection, less than five years use is also currently advocated and long-term use is considered a second-line choice.

Do menopausal women have decreased sexual interest and activity?

Sexual interest or libido depends on many factors, not just hormonal levels. Stresses of daily life, poor physical health, medications, relationship conflict or psychological problems can affect sexual wellbeing. Most studies on sexuality in menopausal women indicate wide variations. All factors need to be assessed.

Lower oestrogen levels can result in vaginal dryness and discomfort during intercourse but this problem can be treated with appropriate lubrication or oestrogen therapy.

bone

What is osteoporosis?

Osteoporosis occurs when bones lose their strength and density, and become fragile and fracture (break) more easily due to a loss of calcium and bone framework. This disease particularly affects women in their middle and later years and is painless until a fracture occurs. It is quite different from osteoarthritis which affects joint surfaces and is painful.

Should all women have a bone density measurement?

No, each woman should be assessed by her doctor about the risk of developing osteoporosis and then be referred for a bone density measurement if necessary.

What are the risk factors for osteoporosis?

The most reliable risk factors are a family history of osteoporosis, early menopause, (occurring before the age of 40), a thin, small body, and being Caucasian or Asian. Other equally relevant factors are smoking, a high intake of alcohol and caffeine, certain medications such as long-term cortisone, low vitamin D levels and diseases like an overactive thyroid or anorexia nervosa.

What tests are available to assess the risk of developing osteoporosis?

Several tests are available for measuring bone density, the most common and reliable being x-ray bone density (DEXA). The DEXA method measures bone density at the sites of greatest concern – the hip and the spine – using low dosage radiation. One in three women reaching the age of 60 years will suffer a hip fracture.

However the results of DEXA alone do not adequately predict a woman’s risk of fracture. To predict osteoporosis fracture risk, the risk factors discussed in Question 19 should also be considered..

How does taking HT prevent osteoporosis?

HT prevents the accelerated bone breakdown that occurs during the early post-menopausal years, therefore reducing the likelihood of fractures. However, because of the small but significant risks of long-term HT use over the age of 50, other alternatives should be considered. These include exercise, diet, calcium, adequate vitamin D levels and other medications.

Are calcium supplements necessary?

Post-menopausal women are recommended to have 1200-1500mg of dietary calcium each day (three glasses of milk or equivalent). Women who have difficulty consuming this amount should consider a calcium supplement at night. Although calcium does not prevent bone loss, it is important in the overall prevention of osteoporosis when combined with exercise, oestrogen and other therapies. Recently, studies in older women suggest one gram of calcium supplement (more than one tablet daily) may increase the risk of heart disease, but further research is needed.

What natural therapies can I take?

Women at midlife may decide to try a variety of natural or complementary therapies to manage symptoms or create more comfort for themselves. For more information about natural or complementary therapies go to Other Therapies

What can I use to make intercourse less painful and dry?

Oestrogen loss at midlife causes much of the discomfort (e.g. vaginal dryness or painful intercourse) that can occur during penetrative sex. Water based lubricants (e.g. Lubofax, Sylk, KY Jelly, Replens) may help to relieve discomfort during sex. Oestrogen vaginal cream, tablets or pessaries may improve vaginal secretions and relieve symptoms.

Does HT protect against heart disease?

For information about hormone therapy and heart disease please go to HT and Heart Disease Q&As

How long will my menopause symptoms last?

Menopause symptoms occur in 80 per cent of women. In 20 per cent of women symptoms are severe and in 60 per cent symptoms are mild to moderate in severity. In 75 per cent of women symptoms will last up to five years, and in 10 per cent symptoms will last longer than 10 years.

How early can a woman reach menopause?

The average age for menopause is 51 years with the normal range being from 45 to 60 years. Menopause before the age of 40 is termed ‘premature menopause’ and menopause between the ages of 40 and 45 is termed ‘early menopause’. It may occur spontaneously as a result of early failure of the ovaries; be caused surgically when a woman has her ovaries removed; or be caused chemically by chemotherapy for cancer.

For more information go to Early Menopause

Can exercise stop osteoporosis?

In the adult years exercise is beneficial for bone health even though peak bone mass has already been achieved. Exercise is beneficial in a number of ways as it increases muscle strength, assists with posture and balance and thereby reduces the likelihood of falls.

For more information go to Bonehealth

What should I know about testosterone?

Until menopause, a woman produces three different natural female hormones: oestrogen, progesterone, and testosterone. Oestrogen and progesterone are produced in the ovaries during a woman’s reproductive life. Testosterone is produced by the adrenal glands and the ovaries and is useful for muscle strength, wellbeing and sexual functioning. In women, testosterone levels start decreasing from age 35 but continues to be produced throughout life. Testosterone therapy may be helpful in some women.

For more information go to:
Testosterone
Testosterone for Women – written for health professionals.

What should I know about libido?

Libido is about your sexual interest and desire. Menopause is a natural event in a woman’s life cycle and loss of libido (reduced desire and sexual experiences that are no longer satisfying or pleasurable) may be one of the symptoms experienced around this time.

For more information see Libido

What should I know about ‘bio-identicals’ hormones?

For a discussion about ‘bio-identicals’ or ‘bio-identical hormones’ please go to Bio-identical Hormones

What is the best way to stop using HT?

There is no good research evidence on this, but it is generally accepted that the best way to stop HT is to reduce it gradually over a few weeks or months (unless there is a good health reason for stopping suddenly on your doctor’s advice). Hot flushes often return after stopping HT, sometimes immediately, sometimes after a few months, and weaning off gradually is the best way to adjust to and manage this.

Talk with your doctor before stopping or reducing your HT.

Will the symptoms return if I stop HT?

We do not know if hot flushes get better, worse or stay the same when HT is stopped; it depends on the length of time each individual woman will have her symptoms. There is no way at present to determine this.

Some women move to a lower dose after a while, and find that this is satisfactory to control symptoms. Later you may reduce the dose further by taking tablets every second or third day, or cutting your patch in half (this can only be done with a matrix patch). If symptoms return, you can go back up to a higher dose of HT and try reducing it again later. Eventually your symptoms will lessen – how long this takes varies from woman to woman.

Do the HT risks continue when I stop using it?

We do not know. The evidence to date is not clear on this except for breast cancer where evidence confirms that the risk returns to that of non users within five years of stopping HT.

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