Hormone Replacement Therapy – Hormones During Menopause

In hormone replacement therapy (HRT), the hormone deficiency that develops during menopause is artificially compensated for by medication. 

Hormone replacement therapy does not aim to exactly restore the previous hormone concentration in the body, but rather to specifically eliminate the estrogen deficiency-related complaints and diseases of menopause. 

Menopausal symptoms such as vasomotor symptoms like hot flashes as well as sleep disorders, depressive moods, urological complaints and other ailments, which sometimes considerably impair the quality of life and performance of some women, can be effectively treated casually by hormone replacement therapy. 

The symptoms mentioned can be improved or ideally eliminated if they occur for the first time or intensify during the menopause. 

Medical reasons (indications) for the use of hormone replacement therapy are currently considered to be the treatment of climacteric symptoms such as hot flushes and tissue atrophy of the genital mucosa (atrophy) and associated urogenital complaints. 

The prevention of diseases (e.g. osteoporosis, depression) is not a conventional medical indication for hormone replacement therapy. For primary prevention of osteoporosis, hormone replacement therapy is recommended only when there is a high risk of bone fracture and intolerance or contraindications (contraindications) to other drugs approved for prevention of osteoporosis.

Before hormone replacement therapy is recommended by a gynecologist, a comprehensive examination, thorough questioning and counseling of the patient, and possibly a determination of hormone levels by blood test are essential. 

The doctor and patient will then jointly weigh up the benefits and risks of the therapeutic options. A therapeutic decision for the use of hormones is always made together with the patient – as with other treatments. Two principles are always observed in hormone replacement therapy: the lowest effective dose is used for the individually required duration of treatment. 

There should also be regular assessment of intake. In particular, this should assess whether the menopausal symptoms being treated are receding and whether there is satisfaction with the results of treatment. During the course of treatment, regular annual check-ups should be carried out, including recording of blood pressure, body weight and gynecological check-ups as well as breast examinations.

To date, no binding recommendation can be made regarding the duration of hormone replacement therapy. One can, for example, consider the conclusion of hormone replacement therapy in the form of a slow discontinuation (“phasing out”) of the medication after 3-5 years of use. 

Of course, this must always be discussed with the treating physician. To end therapeutic measures, the dose can be slowly reduced over a period of about 2-3 months, for example. If symptoms reappear, hormone replacement therapy can be prolonged.  

BENEFITS AND RISKS OF HORMONE REPLACEMENT THERAPY

The decision for or against treatment with hormones always focuses on the personal level of suffering and the severity of the symptoms, which are weighed against the individual risks. Ultimately, the therapy is designed according to the personal wishes of the patient, who can decide for or against hormone replacement therapy after intensive information.

It is clear that vasomotor menopausal symptoms with the leading symptom of hot flashes can be effectively treated by hormone replacement therapy. In addition, other complaints such as depressive mood, sleep disturbances, performance and memory disorders, bone and joint complaints as well as urogenital complaints (skin and mucous membrane changes), which in some cases considerably impair the quality of life of women, can be alleviated. On the other hand, as with almost all drug treatments, various risks exist that necessitate a careful risk-benefit assessment. 

Various constellations have emerged in which hormone treatment has a clear benefit or should be considered only in exceptional cases. Today, treatment considerations are even more strongly geared to the individual medical needs of women, and risk factors and pre-existing conditions can be included in treatment planning in a more defined way. Likewise, the various active ingredients and preparations can be used in a more targeted manner. There are different estrogens and progestins with different risks.

 

For women with menopausal symptoms, a well-founded explanation of the advantages and disadvantages of hormone replacement therapy is very important in order to be able to make a competent and self-determined decision in connection with the treatment of their menopausal symptoms.

Among other things, the age of the women and the timing of their individual menopause are key factors in the therapy decision. Ideally, replacement therapy should begin at the onset of menopause, but no later than age 60 or less than 10 years after the onset of menopause. Furthermore, there should be no contraindications or increased risks, e.g. for cardiovascular diseases or breast cancer. 

For women in the younger age groups, various preventive effects of hormone replacement therapy have been described, which, however, do not constitute an indication for HRT from a conventional medical point of view – but can be taken into account in individual cases: Protective effect against colon cancer (colon carcinoma), risk reduction with regard to the development of diabetes mellitus II and myocardial infarction. 

In women over the age of 60, hormone replacement therapy should be started under a strict risk-benefit assessment, as the risk of cardiovascular disease (CVD) increases from this age in predisposed women. 

Adverse effects of hormone replacement therapy.

An increased risk of breast cancer (mammary carcinoma) cannot be ruled out with long-term use of hormone replacement therapy (longer than 3-5 years). 

A corresponding increase in risk has been observed for the combination of estrogens with progestins (medroxyprogesterone acetate, norethisterone acetate) for more than five years of treatment. In this context, the treatment does not appear to initiate breast cancer initially, but rather to stimulate existing cancer cells to grow.

With estrogen monotherapy, the risk of endometrial cancer (cancer of the endometrium) is increased after 2-3 years of use. The increased risk is reliably reduced by the additional administration of progestogens. 

Hormone replacement therapy carries an increased risk of blockage of the bloodstream by endogenous substances (venous or arterial thromboembolism), at least in the case of a corresponding pre-existing condition or older age. 

The term “pre-existing condition” is used if the woman has a history of thrombosis, has a family history of thrombosis, is overweight, or has had to lie down for long periods (e.g., after a bone fracture, surgery, etc.). An increase in risk was observed here only with oral hormone replacement therapy. These risks can be reduced by estrogen substitution via the skin (transdermal) with a dosage below 50 micrograms. 

When making decisions, comparison with other factors that increase the risk of heart disease or cancer may be helpful. 

For example, severe obesity, regular alcohol consumption, physical inactivity and smoking increase the risk of breast cancer significantly more than hormone replacement therapy – another factor that has been shown in the past. 

However, the basic rule for the use of hormone replacement therapy is that the lowest effective dosage should be taken over the individually required period of time in order to minimize risks.

ACTIVE INGREDIENTS AND DOSAGE FORMS OF HORMONE REPLACEMENT THERAPY

A basic distinction is made between monotherapy, in which only estrogens are used, and combination therapy, in which a combination of estrogen and progestin is used. 

The use of estrogens with the aim of alleviating hormone deficiency-related symptoms is referred to as estrogen substitution. 

The choice of active ingredients, dosages and dosage forms depends on various factors. Active ingredient administration by mouth through swallowing is also referred to as “oral”, while active ingredient absorption through the skin is referred to as “transdermal”.

Tablets, patches, creams and gels are available as dosage forms. For local treatment of exclusively urogenital complaints (e.g. vaginal dryness, urinary tract infections), estrogen-containing creams and ointments as well as vaginal tablets or ovules, pessaries and vaginal rings can be used.

The dosage of hormones is based on the lowest dose that adequately treats menopausal symptoms.

So far, there are no clear recommendations for the use of herbal medicines (phyto-therapeutics) – also because there is a lack of conclusive studies that clearly prove their efficacy.

LIFESTYLE ADJUSTMENT DURING MENOPAUSE

With age, muscle mass decreases and energy requirements also decrease. Women who do not adjust their dietary habits accordingly must expect to gain weight. With sports and exercise, you can increase your energy needs and prevent weight gain.

Calorie intake can also be reduced by eating a balanced, whole-foods diet with little sugar, fat, sausage and white flour. Dietary or lifestyle changes can also include avoiding nicotine, alcohol, coffee, black tea or hot spices. 

DEALING WITH HOT FLASHES

Women who suffer from hot flashes can dress accordingly. For example, depending on the outside temperature, they can wear several thin layers of clothes on top of each other and flexibly take off individual layers when necessary. 

Functional underwear can better wick sweat away from the body. In addition, it can be helpful for women who suffer from sweating to also have a change of clothes on hand. 

Also, while sleeping in bed at night, they can be flexible to hot flashes and sweats by using two thin blankets instead of a thick one and functional underwear. Also, fanning yourself with a fan during hot flashes can provide relief. 

Hot flashes can also be suppressed during the onset if sufferers run cold water over their wrists. 

Regular exercise and sports, as well as relaxation exercises and alternating showers, can also help relieve the symptoms of hot flashes. Exercise and avoiding stress also helps with sleep disturbances. 

DEALING WITH BLADDER WEAKNESS AND DRY MUCOUS MEMBRANES

Bladder weakness can be counteracted by pelvic floor exercises – combined with ample fluid intake to avoid concentrated acidic urine. However, they should be permanently incorporated into the daily routine. For women with a frequent urge to urinate, there is also targeted bladder training aimed at increasing bladder capacity again. 

If the mucous membranes are dry, care creams can help against itching and soreness in addition to estrogens, while lubricants can protect against pain and irritation during sex. 

To support the skin, care should generally be taken to ensure sufficient fluid intake. This is a prerequisite for the skin to be well hydrated and also to look firmer. 

It should be at least 1.5 to 2 liters per day, unless a heart or kidney disease is against it. (Piped) water, unsweetened juices or tea are best. In addition, it is advisable to ensure adequate protection against UV radiation.

DEALING WITH DEPRESSIVE MOODS

If they occur at the onset of menopause, immediate hormone replacement therapy can be effective. In the case of pronounced psychological problems, psychotherapeutic support may be necessary. 

Depression does not necessarily occur more frequently during the menopause than in other phases of life. However, women who have already experienced depressive episodes are more vulnerable during this phase of life. 

Other women may learn to adapt the demands they place on themselves to their resilience and adjust their lives to meet their needs. (2,6) Depressive mood cannot be safely prevented. But something can be done to reduce the risk and to feel balanced and better. 

In addition to plenty of exercise, preferably in nature, relaxation exercises help to reduce tension and stress and to improve one’s own body awareness and perception of one’s own needs. Healthy nutrition is also an important aspect as well as the perception of social contacts and an exchange with other people. 

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