THE PRO'S AND CON'S OF HORMONAL REPLACEMENT THERAPY The Pro's and Con's of Hormonal Replacement Therapy LaSalle University In this paper I will be focusing on the positive and negative aspects of hormonal replacement therapy. To understand replacement therapy we first need to look at what occurs in a women's body during menopause. As a woman is my 40's like so many others, I will be in need of this information in the not so distant future, and as such this topic serves a considerable purpose. Awareness and education in this area can alleviate problems and make what could be a traumatic experience more manageable thereby raising the quality of ones life.

Hopefully, women today will no longer have to suffer through menopause, as most of our mother's did. All women experience menopause. There are periods of pre-menopause, peri-menopause and post-menopause. The period from pre-menopause to post-menopause can be as longer a 30 years. Pre menopause is the stage in a women's life when menstrual cycles are normal, or the reproductive years before the change of life. Perimenopause can be as long as ten years.

This is the period when women go through what is sometimes called the change of life. This is the period when the signs and symptoms of menopause occur. Menopause is when you have had your final period and have been amenorrhea for one full year. Post menopause overlaps with peri menopause. It is the years after you have your last menstrual period. The pattern of menopause is similar in all women, but there are considerable individual differences.

All women have a drop in their hormone levels. How their bodies react to these drops can vary significantly. Until fairly recently women have been made to suffer in silence. There are several disease processes associated with menopause. One of these diseases is osteoporosis. A bone density test can be ordered to help in the diagnosis of osteoporosis.

Estrogen helps bones absorb and hold calcium to keep the bones strong. Due to low estrogen levels in menopausal women the bones are unable to absorb calcium as well. A women's bones can become brittle. They can experience an increase in fractures. Bone is lost quickly in the 10 years after estrogen levels fall. Women who do not take hormones or osteoporosis medication can lose 3% to 5% of their bone mass in each of the 5 years following menopause, for a total loss of 15% to 25%.

After that, bone loss slows to 1% to 2% each year. If you are a 50-year old woman who is not taking medication, you have a 50% chance of having a bone fracture during the remainder of your life that is related to osteoporosis. You have a 20% to 30% chance of developing a spinal deformity known as dowager's hump. (CAM, 2001) Even though it is beneficial to increase their intake of calcium and vitamin D, women will still experience bone loss due to the decrease in estrogen. Although more research is needed some recent studies have found that Alzheimer's disease may develop in women with a family history of said disease with the onset of menopause.

Cardiovascular disease is the major cause of death in post-menopausal women. This is believed to be due to postmenopausal women being estrogen-deficient. The word menopause is used by patients and health care providers to describe a period of time in which the functions of a women's' ovaries are declining. The true definition of menopause is the last menstrual period in woman's reproductive life. In order to have a correct diagnosis of menopause women has to have one year of amenorrhea following her last menstrual cycle.

The terms climacteric and peri menopause are used to describe the period preceding actual menopause. At about 45 to 52 years of age the supply of ovarian follicles declines, with the majority becoming arte tic or degenerated. With the depletion of ovarian follicles, secretion of estrogen and progesterone by the ovaries declines, and the menstrual cycle becomes irregular. When too little estrogen is secreted to cause endometrial growth, menstrual periods stop permanently (Copstead, Lee-Ellen & Banasik, Jacquelyn L. , 2000). The predominant estrogen in premenopausal women is estradiol.

The mean serum levels of estradiol vary during the menstrual cycle. The average value over a 28-day cycle is 100 pg / d L. Estrone is derived primarily from the metabolism of estradiol and from the peripheral of the androgen, , in adipose tissue. Serum levels of estrone including the menstrual cycle vary from 40-170 pg / d L. The estradiol to estrone ratio is usually greater than one. With progressive atre sia of the ovarian follicles, the estradiol values fall to below 20 pg / dd L, and the predominate estrogen is estrone, with a resultant estradiol: estrone ratio of less than one.

(Notelovitz, Morris MD, 1999). Progesterone levels are so low postmenopausal that they cannot even be measured. Serum plasma levels of follicle stimulating hormone and hormone increase. The rise in these plasma levels is due to a decline in two ovarian peptides inhibit-B and inhibit-A. Menopausal women a have a total lack of progesterone and varying degrees in their lack of estrogen.

The decline in a women's hormones cause certain physiologic changes is her body. Some women begin to experience symptoms during peri menopause and some do not. One of the symptoms noted during peri menopause are hot flashes. Women state that they suddenly feel extremely warm.

The general area that the flashes occur is from the abdomen upward to the face. This is when we may see women suddenly turn red and begin to fan themselves. Hot flashes usually last between 3 to 6 minutes and can occur as much as several times in a day. What clinicians need to understand is that the response to the drop in hormone levels varies in all women. We cannot have one-dose fits all approach to hormone replacement. These hot flashes may be due to the decrease in estrogen levels having an effect on the temperature-regulating center in the hypothalamus.

Hot flashes are often accompanied by other symptoms of autonomic nervous system instability such as tachycardia, palpitations, and feelings of faintness. Other distressing symptoms, including pain and stiffness in the joints, sleep pattern disturbances, and women have noted changes in gastrointestinal function, in the peri menopausal period. (Copstead, Lee-Ellen & Banasik, Jacquelyn L. , 2000). Other symptoms that occur are the skin becoming thinner and the breasts decreasing in size. Sex may become difficult due to the labia becoming thinner and the vaginal epithelium becoming thinner and vaginal epithelium atrophy.

This leaves women at an increase risk of vaginal infections. Also, due to the change in hormone levels a women's sex drive may decrease. They are at an increased risk of developing bladder infections due to the possible dropping of the bladder secondary to the bladder and surrounding ligaments atrophying. If the bladder drops the emptying is not complete leading to bacteria formation and subsequent infection. Women also suffer from night sweats, which only adds to their inability to sleep. At this stage you will begin to see irregular bleeding.

They can either have a decrease in flow or begin to miss periods or an increased flow and longer and more frequent periods. Mood swings are very common during this period. Although it has been noted that depression is not caused by menopause if a woman suffered from depression previously it may return or increase during menopause. Although premenopausal women have a lower rate of heart attacks than men, after menopause their risk are the same. There have been studies to see if this is due to their loss of estrogen. Estrogen raises HDL (good cholesterol, lowers LDL (bad) cholesterol, reduces fibrinogen (a clotting factor), raises levels of some natural clot inhibitors, ad improves arterial wall elasticity.

(Women's Health Watch, 2001). Due to the decrease in estrogen women experience thinning of their hair and their hair will become drier. Women always have a certain amount of the hormone testosterone. When their estrogen levels decrease testosterone may have more of an effect and they may begin to see facial hair above their lip and on their chin. Hormone replacement therapy has come to the forefront in women's fight against the symptoms and associated diseases of menopause. There have been many studies done on the positive and negative effects of hormonal replacement therapy.

This paper will begin with the positive effects of using hormone replacement therapy. Due to the bones being unable to absorb calcium as well in menopausal women and women's bones becoming brittle due to low estrogen levels, hormone replacement therapy is currently considered first-line therapy for the prevention of osteoporosis for menopausal women. Women who take estrogen after menopause have a decrease risk of bone fractures and dowager's hump. One of the non-hormonal therapies for menopause, Fosamax, as been noted in clinical studies to increase the amount of bone is most patients in as little as three months.

The benefits of estrogen replacement therapy, alone or in conjunction with a progestin, range from relief of the acute symptoms of menopause (such as hot flashes, insomnia, vaginal dryness) to prevention of osteoporosis, and as much as a 50 percent reduction in the risk of cardiovascular disease. (PCS Health Systems, 1997). Treatment with hormonal replacement therapy has been noted to increase serum levels of HDL and lower levels of LDL. Also, estrogen acts directly on blood vessels increasing vasodilation and preventing blood vessel injury. It helps to decrease the risk of atherosclerosis. It has not been established whether HRT improves cognition and short-term memory.

These improvements may be due to the decrease in night sweats and insomnia, thereby giving the women a better nights sleep. In studies done on women with type 2 diabetes it has been noted that exogenous estrogens might reduce some effects that accompany menopause. Due to the changes in hormone levels, abdominal fat and insulin metabolism during menopause, diabetic patients experience trouble with good glyceric control. Some studies have shown that HRT with estrogen alone has improved Hb Alc levels in women with type 2 diabetes. The New England Journal of Medicine published a study in June 1997, which reported that women who take hormone replacement therapy for ten years reduce their risk of dying form all causes by 37 percent. The study followed 60, 000 postmenopausal women for sixteen years.

The percent drops to 20 percent beyond ten years. (Goldstein, Steven R. MD & Asher, Laurie, 1998). Even though menopause has not been proven to induce depression, it has been noted that the decrease in hormone levels may make women who have suffered from depression in the past more vulnerable to it. HRT appears to enhance the mood of patients and reduce the anxiety noted with menopause. HRT also assists in alleviating some of the problems and discomforts women experience with sexual activity during menopause.

It helps to reduce vaginal dryness. An estrogen cream is usually a preferred choice for this. Estrogen also helps to preserve collagen keeping the skin moist. HRT may help with some of the side effects women experience in reference to hair thinning and the texture of hair changing.

Estrogen maintains the growth and rest cycle of hair. HRT helps women fall asleep faster and wake less often during the night. Because estrogen assists in the health of bones women experience less tooth loss if taking HRT. Estrogen has also been noted to alleviate the urinary tract infections associated with menopause. There have been many debates in the past several years as to whether or not women should use hormonal replacement therapy.

Here we will examine some of the negative concerns for women using HRT. Women on estrogen are more likely to suffer from gallbladder disease. They are also more likely to require surgery for the removal of the diseased gallbladder. Women on estrogen replacement in addition to thyroxine for hypothyroidism may need to increase their dose of thyroxine.

Studies have shown that thyroxine serum-free levels decrease when estrogen is administered. The latest reports from the Nurses' Health Study published this year represent 12 and 16 years of follow-up (1976-1992, 2000). 23-25 During that period, 1, 935 cases of breast cancer were identified among more than 69, 000 postmenopausal women. The analysis revealed that women who had used estrogen in the past (even for >10 years) were not at increased risk of breast cancer. However, the relative risk (RR) for current users was 1.

46 for 5 to 9 years of use, and 1. 46 for 10 or more years of use. Among 58, 520 women aged 30 to 55 in 1980, followed through June 1, 1994, 1, 761 incident invasive breast cancer cases were identified. All risks were multivariate adjusted. A 57% increase in cumulative risk of breast cancer by age 70 was associated with a history of benign breast disease. Other conclusions include the following: Compared with a woman who never used hormones, use of unopposed postmenopausal estrogen from ages 50 to 60 years increases risk of breast cancer to age 70 by 23%.

Estrogen plus progestin use for 10 years increased risk to age 70 years by 67%. One drink per day from age 18 years increased risk to age 70 by 7% compared with those who never drank alcohol. Use of unopposed postmenopausal hormones for 10 years significantly increased the risk of breast cancer, and the addition of progestin further increased the risk. 25 By virtue of the large numbers in the Nurses' Health Study and the careful analyses by the investigators, reports from this study must be given great credibility. (Spero ff, Leon, 2001. ) There is an increased risk of endometrial cancer in women using unopposed estrogen therapy.

One thing that needs to be discussed with the patient before treatment is the question of whether they have had menstrual irregularities this appears to increase the risk of developing endometrial cancer with use of HRT. Treatment may cause PMS like symptoms in some women. Women may experience increased vaginal bleeding, nausea, loss of hair, headaches, itching, increased cervical mucus, and corneal changes that prevent the use of contact. Women can have bloating, sore breasts and fluid retention.

Physicians have several different options for treating women. They may prescribe estrogen alone or progesterone alone. They can use a combination of estrogen and progesterone. The HRT can come in varying forms. They can be orally administered or delivered through a skin patch. Some women use a vaginal cream.

This form helps with vaginal dryness and bladder irritation. Estrogen can also be given in the form of a vaginal ring. The two most common regimens of HRT are continuous combined and cyclic. Continuous combined mean estrogen plus progestin are taken together every day, without a break in either.

Prempro is an example of this. Cyclic HRT means estrogen is taken every day, but progestin is taken only for a certain number of days each month, such as the last 14 days of the month. Prem phase is an example of a cyclic HRT. (Wyeth-Ayers t Laboratories, 1998).

Women may make the decision to use Selective Estrogen Receptor Modulators for their choice of therapy. A widely used SERUM is Raloxifene (Evista). These drugs bind to estrogen receptors into the bone and lipids, activating them. However, it binds but does not activate estrogen receptors in the breast and uterus. It acts like estrogen were you need it in the bone and lipid but acts like an anti estrogen where you don't want it, the breast and the uterus. Due to these actions it has been proven to prevent bone loss, significantly reduce the onset of breast cancer and decreases a women's risk for uterine cancer.

Women do not experience a menstrual period like they do with HRT. It also lowers cholesterol and triglycerides. There is also a move to find alternative forms of therapy for women experiencing menopause. One of these therapies is soy. Some studies have shown that 20-40 grams of soy daily can help to alleviate hot flashes. Soy contains that mimic the effects of estrogen on the body.

Some studies have shown that it may help to reduce the risk of osteoporosis. However, the studies were short and need to be investigated further. Due to the uncertainties of soy, it is recommended that women only eat soy in moderation. They may incorporate this in their diets with such things as soymilk, tofu and soybeans. A natural herb called black cohosh as has been most studied as Remifemin, a German commercial preparation. Although it's unclear how black cohosh achieves its effects, there's increasing evidence that it works.

Several European studies have found that 40 mg of Remifemin twice a day compares favorably with a standard dose of estrogen in relieving and menopausal symptoms. (Harvard Women's Health Watch, 2001). There is an oral form of the wild yam Dios corea, called Promethium, which has been approved by the FDA for use with estrogen. This is a natural form of progesterone.

It helps to protect the endometrium from estrogen's effects. Some studies have shown it to help relieve hot flashes. Other products that have been promoted and sold for use in relieving symptoms of menopause are red clover, ginseng and flaxseed. No scientific evidence exists to prove their effectiveness. Some other more reliable things women can do to help alleviate some of the symptoms are reducing their stress levels, stopping smoking, and eating diets high in calcium and low in fat and cholesterol. Aerobic, weight bearing and stretching exercises can help to strength and protect women's bones and help to decrease the risk of cardiovascular disease.

The price of these drugs may be a hindrance to some patients. A list of some of the most common drugs and there prices are listed below: Cenestin 0. 625 mg 30 tablets $25. 79 Premarin 0.

625 mg 30 tablets $ 28. 89 Estraderm 50 ug 8 patches @ 1 patch twice a week $ 42. 89 Premarin cream 1 tube $75. 59 E string 2. 0 mg 1 ring $110. 99 Open cream $68.

99 E strace cream &68. 99 Provera 5. 0 mg 30 tablets $40. 79 Generic Provera () $14. 59 These drugs can be brought on line at higher quantities for slightly less in price. For example you can get Estraderm, 8 patches, for $21.

00. Premarin 0. 625 mg for $20. 00 for 28 tablets. Provera 5 mg is $45. 00 for 100 tablets.

Women need to be prepared to do their homework when it comes to finding out the best price for HRT. Some of the other expenses women can incur are loss of time at work for sick days due to the side effects of menopause. Doctors visits and laboratory testing to examine if the women is going through menopause. Also, if they are not sure what is happening to them or if depression from a previous time in their lives reoccurs women may need care to help them to realize what is occurring.