Estrogen replacement therapy is commonly prescribed for women as their natural estrogen levels decline due to a hysterectomy or after menopause. Taking hormones is a decision that each woman will have to make on an individual basis.
Premarin®, made from a combination of estrogens including conjugated estrogens derived from pregnant mare's urine (which many argue is cruelly-obtained), has been the most commonly prescribed estrogen
supplement in the U.S. for the past 50 years. It is the estrogen used in many well-publicized studies, including the Women's Health Initiative study (where Premarin® and Prempro™ were used.) It is important to note that the conjugated estrogens in Premarin® are not bioidentical (natural) hormones, but must be converted by the body into active estrogens. Therefore, the results of studies using Premarin® can not necessarily be applied to bioidentical estrogens.
Bioidentical estrogens, derived from soy, are identical in chemical structure and act in the same way as the estrogen
your body naturally produces.
Estrogen replacement types include Estriol, Estradiol, Biest (80% Estriol, 20% Estradiol), and conjugated estrogens (estrone combined with other estrogens, some derived from the urine of mares). These compounds may be compounded by a pharmacist, or bought under names such as Estrace®, Estring®, Alora®, Estraderm®, Climara®, Vivelle®, FemPatch™, Menostar™, EstroGel®, Estrasorb™, Premarin®, Premphase™, Prempro™, or as their generic form.
They come in the form of oral capsules, vaginal tablets, vaginal suppositories, vaginal creams, facial serum, transdermal cream or gel, sublingual tablet, oral tablet, vaginal rings, transdermal patches, or transdermal emulsion
. Daily dosage ranges are typically 7.5mcg to 4mg.
The different forms are probably of equal efficacy. The exception is the patches, which may not provide all the beneficial effects of oral estrogen
. They are certainly better than not taking any estrogen at all and are sometimes better tolerated than oral estrogen. The patches don't seem to provide the same degree of beneficial effect on the cholesterol
as does oral estrogen.
Why it is RecommendedMenopause
usually occurs around the age of fifty years old and occurs secondary to failure of the ovaries
to produce estrogen
and progestin, which are the female hormones. This is a gradual process, occasionally taking two to three years. Symptoms vary from only the cessation periods to a multitude of annoying symptoms such as sweating, hot flashes
, vaginal drying, pain with intercourse, low sex drive and depression
. Usually these symptoms will eventually resolve even without taking hormones. Taking estrogen will definitely stop these symptoms.
One of the long-term problems that occurs with the loss of estrogen at menopause
include is the loss of calcium
from the bones, causing them to become thin and brittle. This markedly increases the risk of bone fractures. More than 120,000 elderly women fracture their hips each year and about 15% die from complications of the hip fracture.
The process in which the bones become weak and brittle is called osteoporosis
. Collapse of the vertebrae in elderly women can occur because of the thin, weak bones. This is responsible for the loss of height as well as the "stooped-over" appearance known as a "Dowager's hump." Much of the bone loss occurs in the first five to ten years after menopause
replacement therapy stops this rapid bone loss and reduces hip fractures by 25% and spine fractures by about 50%. Unfortunately the process of osteoporosis
is not reversible with estrogen replacement therapy. That makes it important to start hormones early after going through "the change" before the process has already resulted in weak bones.
Preliminary studies suggest that estrogen replacement therapy may also reduce the risk of Alzheimer's disease
by up to 40%.
Another long-term problem due to menopause
is the change in cholesterol
that occurs with the loss of hormones. The total cholesterol will increase and the good (HDL
) cholesterol will decrease. Both of these changes result in a higher likelihood of developing coronary artery
disease and subsequently having a heart attack. Estrogen
replacement therapy prevents these changes and will reduce the risk of dying from a heart attack by about 35%. This is really the most significant advantage to taking hormones after going through menopause
As with all of the major hormones, baseline and follow-up testing of estrogen
levels is critical for maintaining hormone levels in the correct range and avoiding the side-effects of supplementing with too much or too little.NOTE:
When taking estrogen alone, cells in the uterine
lining can become crowded or malformed and possibly cancerous
. Therefore, for patients who still have a uterus
, estrogen is often prescribed in combination with progesterone
, which controls that effect and protects from endometrial abnormalities. Testosterone
, which benefits libido and bone health, may also be prescribed. Even women who do not have a uterus and use progesterone therapy along with their estrogen experience beneficial effects with mood, fluid retention, and sleep.
Expected Outcome; Side-Effects; Counter-Indicators and Warnings
Several studies have looked at the life expectancy of women taking estrogen
versus those that don't take estrogen. In about all situations, the life expectancy is increased if you take estrogen. This is mainly because of the lower risk of heart attacks when one takes estrogen. The prevention of osteoporosis
can also potentially save lives. One study showed that taking estrogen after menopause
was associated with an increased life expectancy of up to 2.3 years. Heart attacks are the leading cause of death overall in females. The annual death rate from heart disease in females in the United States is 359,000. Anything that will reduce deaths from heart attacks by 35% will save a lot of lives.
Unfortunately there are some potential risks from taking Estrogen
. Taking estrogen (Premarin) without progestin (Provera) will increase the risk of endometrial cancer by up to eight fold. This is why it is generally recommended that one take progestin with the estrogen. Studies have shown that the combination of Premarin and Provera does not result in an increased risk of endometrial cancer. In women who have had a hysterectomy
, it is not necessary to take Provera since they do not have a uterus
and therefore are not susceptible to endometrial cancer. The addition of progestin to the estrogen will slightly decrease the beneficial effect that estrogen has on lowering cholesterol
Another risk of taking estrogen is the increased chance of developing breast cancer. There is a lot of disagreement as to whether there is truly an increased risk of breast cancer, but a general consensus is that the risk is increased by about 25% if estrogen is taken for ten to twenty years.
About 5% to 10% of women who take estrogen alone will experience side-effects such as bloating
, headaches and breast tenderness. However, in most women the symptoms are mild and will resolve after a few months of therapy. The addition of progestin to estrogen therapy may occasionally have some undesirable side effects. The most common are bloating, weight gain, irritability and rarely, depression
. These symptoms may also improve with time. For the first three to six months, vaginal spotting will occur in 30% to 50% of women taking continuous estrogen and progestin. This bleeding will generally stop permanently in about 95% of women within a six-month period.
If you have a markedly positive family history of breast cancer then the decision whether or not to take estrogen
becomes more difficult.