If your hormone levels look below the normal range, there is a good chance you could end up taking hormone replacement therapy.
If a woman is looking for relief from menopause symptoms, knowing the pros and cons of hormone replacement therapy (HRT) can help her decide whether it’s right for her.
What is hormone replacement therapy?
During menopause, your estrogen levels fall. Some women get uncomfortable symptoms like hot flashes and vaginal dryness. HRT (also known as hormone therapy, menopausal hormone therapy, and estrogen replacement therapy) is the most effective treatment for menopause symptoms.
Estrogen Therapy
If a woman is having symptoms of menopause after a hysterectomy (surgery to remove the uterus) or a hysterectomy with bilateral salpingo-oophorectomy (surgery to remove the uterus, fallopian tubes, and ovaries), doctors may suggest a low dose of estrogen. Estrogen comes in different forms. The daily pill and patch are the most popular, but the hormone also is available in a vaginal ring, gel, or spray.
Estrogen pill. Pills are the most common treatment for menopausal symptoms. Among the many forms of pills available are conjugated estrogens (Cenestin, Estrace, Estratab, Femtrace, Ogen, and Premarin) or estrogens-bazedoxifene (Duavee). Follow a doctor’s instructions for dosing. Most estrogen pills are taken once a day without food. Some have more complicated dosing schedules.
Estrogen patch. The patch is worn on the skin of your abdomen. Depending on the dose, some patches are replaced every few days, while others can be worn for a week. Examples are Alora, Climara, Estraderm, and Vivelle-Dot.
Combination estrogen and progestin patches — like Climara Pro and Combipatch — are also available. Menostar has a lower dose of estrogen than other patches, and it’s only used for reducing the risk of osteoporosis. It doesn’t help with other menopause symptoms.
Topical Estrogen. Creams, gels, and sprays offer other ways of getting estrogen into your system. Examples include gels (like EstroGel and Divigel), creams (like Estrasorb), and sprays (like Evamist). As with patches, this type of estrogen treatment is absorbed through the skin directly into the bloodstream.
The specifics on how to apply these creams vary, although they’re usually used once a day. EstroGel is applied on one arm, from the wrist to the shoulder. Estrasorb is applied to the legs. Evamist is applied to the arm.
Vaginal estrogen. Vaginal estrogen comes in a cream, vaginal ring, or vaginal estrogen tablet. In general, these treatments are for women who are troubled specifically by vaginal dryness, itchiness, and burning or pain during intercourse. Examples are vaginal tablets (Vagifem), creams (Estrace or Premarin), and insertable rings (Estring or Femring). Dosing schedules vary, depending on the product.
Most vaginal rings need to be replaced every three months. Vaginal tablets are often used daily for a couple of weeks; after that, you only need to use them twice a week. Creams might be used daily, several times a week, or according to a different schedule.
Estrogen/Progesterone/Progestin HRT
This is often called combination therapy since it combines doses of estrogen and progestin, the synthetic form of progesterone. It’s meant for women who still have their uterus. Taking estrogen with progesterone lowers your risk for cancer of the endometrium, and the lining of the uterus, compared with taking estrogen alone.
While generally used as a form of birth control, progesterone can help treat many menopausal symptoms such as hot flashes.
Oral progestins. Taken in pill form, progestin medications include medroxyprogesterone acetate (Provera) and synthetic progestin pills (norethindrone, norgestrel). Many experts now treat the majority of their menopausal patients with natural progesterone rather than synthetic progestins.
Research suggests that natural progesterone may not have a negative effect on lipids and is a good choice for women with high cholesterol levels. In addition, natural progesterone might have other advantages when compared with medroxyprogesterone acetate.
Intrauterine progestin. Low-dose intrauterine devices (IUD) with levonorgestrel are sold under the brand names Liletta, Kyleena, Mirena, and Skyla.
These are approved for pregnancy prevention and bleeding control in the United States, and they’re sometimes used “off-label” along with estrogen. If you have one of these IUDs when you enter perimenopause, a doctor may suggest that you keep it in until perimenopause is complete to help with uneven periods.
What Are the Benefits of Hormone Replacement Therapy?
HRT may:
- Relieve hot flashes and night sweats
- Help you sleep better
- Ease vaginal dryness and itching
- Make sex less painful
- Help prevent fractures caused by osteoporosis (thinning bones)
- Make some women less likely to have heart disease
- Lower your chances of dementia
What Are the Risks of Hormone Replacement Therapy?
Research has shown that the benefits can be greater than the risks for many women. But HRT may still raise your chances of:
- Endometrial cancer, if you take estrogen without progestin and you still have your uterus
- Blood clots
- Stroke
- Breast cancer
You may be less likely to have problems if you:
- Start HRT within 10 years of menopause or before age 60
- Take the lowest dose that works for you for the shortest possible time
- Take progesterone or progestin if you still have your uterus
- Ask about other forms of HRT besides pills, like patches, gels, mists, vaginal creams, vaginal suppositories, or vaginal rings
- Get regular mammograms and pelvic exams
Who Shouldn’t Take Hormone Replacement Therapy?
If you have these conditions, you may want to avoid HRT:
- Blood clots
- Cancer (such as breast, uterine, or ovarian)
- Heart, liver, or gallbladder disease
- Heart attack
- Known or suspected pregnancy
- Stroke
- Unexplained vaginal bleeding
Do you smoke? A doctor may encourage you to stop before prescribing HRT.
What Are the Side Effects of Hormone Replacement Therapy?
HRT comes with side effects. Address a doctor if you have any of these:
- Bloating
- Breast swelling or tenderness
- Headaches
- Mood changes
- Nausea
- Vaginal bleeding
How Do I Know If Hormone Replacement Therapy Is Right for Me?
A doctor can help you weigh the pros and cons and suggest choices based on the severity of your symptoms and your medical history.
Here are some questions to ask:
- Based on my medical history, is there any reason I shouldn’t use HRT?
- Do you think it could help my symptoms, especially hot flashes, sleep issues, and vaginal dryness?
- Are there other treatments I should consider? (Vaginal moisturizers may help vaginal dryness, for example.)
- Do you think I’ll have side effects from HRT? (Be sure to tell a doctor if you had any issues with taking birth control pills.)
- Does my family medical history make me a good or bad candidate for HRT? (If your mom had osteoporosis, HRT will help lower your chances of it. But if your mom had breast cancer, you’ll want to talk about that with a doctor.)
- What type of HRT might be best for me?
Testosterone Therapy
Millions of American men use a prescription testosterone injection or gel as a form of testosterone replacement therapy (often referred to as TRT therapy) to restore normal levels of the manly hormone. The ongoing pharmaceutical marketing blitz promises that low T treatment can make men feel more alert, energetic, mentally sharp, and sexually functional. However, legitimate safety concerns linger. For example, some older men on testosterone replacement therapy could face higher cardiac risks.
“Because of the marketing, men have been flooded with information about the potential benefit of fixing low testosterone, but not with the potential costs,” says Dr. Carl Pallais, an endocrinologist and assistant professor of medicine at Harvard Medical School. “Men should be much more mindful of the possible long-term complications.”
The low-T boom
A loophole in FDA regulations allows pharmaceutical marketers to urge men to talk to their doctors if they have certain “possible signs” that mean they could need low T treatment. “Virtually everybody asks about this now because the direct-to-consumer marketing is so aggressive,” says Dr. Michael O’Leary, a urologist at Harvard-affiliated Brigham and Women’s Hospital. “Tons of men who would never have asked me about it before started to do so when they saw ads that say ‘Do you feel tired?'”
Just being tired isn’t enough to seek testosterone replacement therapy. “General fatigue and malaise are pretty far down my list,” Dr. O’Leary says. “But if they have significant symptoms, they’ll need to have a lab test. In most men the testosterone level is normal.”
If a man’s testosterone looks below the normal range, there is a good chance he could end up on TRT hormone supplements — often indefinitely. “There is a bit of a testosterone trap,” Dr. Pallais says. “Men get started on testosterone replacement and they feel better, but then it’s hard to come off of it. On treatment, the body stops making testosterone. Men can often feel a big difference when they stop therapy because their body’s testosterone production has not yet recovered.”
This wouldn’t matter so much if we were sure that long-term hormone therapy is safe, but some experts worry that low-T therapy is exposing men to small risks that could add up to harm over time.
Take a cautious approach
A large, definitive trial for hormone treatment in men is still to come. Until then, here is how to take a cautious approach to testosterone therapy.
Take stock of your health first
- Have you considered other reasons why you may be experiencing fatigue, low sex drive, and other symptoms attributable to low testosterone? For example, do you eat a balanced, nutritious diet? Do you exercise regularly? Do you sleep well? Address these factors before turning to hormone replacement therapy for men.
- If your sex life is not what it used to be, have you ruled out relationship or psychological issues that could be contributing?
- If erectile dysfunction has caused you to suspect “low T” as the culprit, consider that cardiovascular disease can also cause erectile dysfunction.
Get an accurate assessment
- Inaccurate or misinterpreted test results can either falsely diagnose or miss a case of testosterone deficiency. Your testosterone level should be measured between 7 am and 10 am when it’s at its peak. Confirm a low reading with a second test on a different day. It may require multiple measurements and careful interpretation to establish bioavailable testosterone or the amount of the hormone that is able to have effects on the body. Consider getting a second opinion from an endocrinologist.
- After starting therapy, follow up with your physician periodically to have testosterone checks and other lab tests to make sure the therapy is not causing any problems with your prostate or blood chemistry.
Be mindful of unknown risks of testosterone replacement therapy
- Approach testosterone therapy with caution if you are at high risk for prostate cancer; have severe urinary symptoms from prostate enlargement; or have been diagnosed with heart disease, a previous heart attack, or multiple risk factors for heart problems.
- Ask a doctor to explain the various side effects of the different formulations of testosterone. The different treatments include testosterone injections, gels, and patches. Know what to look for if something goes wrong.
Have realistic expectations
Testosterone therapy is not a fountain of youth. There is no proof that it will restore you to the level of physical fitness or sexual function of your youth, make you live longer, prevent heart disease or prostate cancer, or improve your memory or mental sharpness. Do not seek TRT therapy with these expectations in mind.
If an erectile function has been a problem, testosterone therapy might not fix it. In fact, it might increase your sex drive but not allow you to act on it. You may also need medication or other therapy for difficulty getting or maintaining erections.
Be sure to get in touch with our medical experts and apply for a free consultation.