Hormone Replacement Therapy(HRT),medicaltreatment that relieves symptoms experienced by some women during and after menopause. Menopause is the cessation of menstrual periods marking the end of a woman's ability to reproduce, and it is characterized by significant hormonal changes in a woman's body. One such change is a drop in the level of estrogen, a hormone primarily related to reproduction, which causes some women to experience unpleasant symptoms, including hot flashes, vaginal dryness, irritability, and depression. HRT partially restores the estrogen balance in a woman's body to lessen or eliminate these symptoms. HRT can alleviate symptoms not only in mature women experiencing natural menopause, but also in younger women who may be facing premature menopause for medical reasons, such as when cancer or other disorders cause the ovaries to stop producing estrogen.
Inadditiontolessening symptoms associated with menopause, HRT was long thought to offer many health benefits and even protection from certain diseases, including osteoporosis, heart disease, and stroke. Ongoing medical studies, however, have demonstrated that long-term use of HRT is not always beneficial, and that in some instances it may actually raise the likelihood of cancer, heart attack, and other diseases. Thus the choice of whether or not to undergo HRT means weighing the potential benefits of relieving menopausal symptoms against a possible increased risk for disease.
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HORMONAL CYCLE
Startingwithpuberty and continuing for the next three or four decades, a woman's body undergoes a regular cycle of hormonal fluctuations that signals her capacity to conceive and bear children. Estrogen and another hormone, progesterone, are secreted by the ovaries during ovulation, the monthly process in which an egg is released from the ovaries and prepared for possible fertilization with a man's sperm. Estrogen and, in turn, progesterone, affect the tissues lining the vagina and uterus, creating conditions more favorable for an egg to be fertilized. If pregnancy does not occur, part of the endometrium (uterine lining) is discarded through the vagina during menstruation. In addition to its role in reproduction, estrogen circulates in the bloodstream, affecting other parts of the body, including the brain, blood vessels, bone, and fat cells.
Atmenopause,whichmost women experience in their late 40s or early 50s, the ovaries gradually stop producing estrogen, causing a reduction of estrogen levels in the blood. Over the course of a few years, this estrogen decline produces changes in various body tissues, including the vagina, vulva, uterus, bladder, urethra, breasts, bones, heart, blood vessels, and brain.
Insomewomen,thesechanges trigger unpleasant side effects. Common symptoms associated with menopause include hot flashes. These episodes, which may last several minutes, bring sudden, intense feelings of warmth in the face and upper body, with accompanying perspiration and flushed skin. Heart palpitations and feelings of suffocation can also occur. Hot flashes result from loss of estrogen in the hormone-signaling system located in the part of the brain known as the hypothalamus, near the area that regulates body temperature.
Anothersymptomofmenopause that affects some women involves changes in the lining and elasticity of the vagina. The vagina may shrink and become prone to dryness, leading to pain during sexual intercourse. A number of emotional and psychological changes occur during menopause that, in some women, cause chronic sleep deprivation, a loss of interest in sex, memory lapses, mood swings, and depression.
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TYPES OF HRT
Forwomenwhoelectto undergo it, HRT can take different forms. Some women take estrogen alone, usually those who have undergone a hysterectomy (the surgical removal of the uterus and sometimes ovaries). Assorted varieties and dosages of estrogen can be administered in the form of a daily pill or tablet. One widely used type of estrogen is a pill containing conjugated estrogens, a mixture of several forms of estrogen taken from the urine of pregnant horses. Estrogen also can be administered as a transdermal patch stuck to the skin and replaced every few days; the patch continuously releases estrogen into the bloodstream.
Somewomenexperience side effects from taking estrogen, including headaches, and swelling and tenderness of the breasts. Women with an intact uterus who take estrogen are also more likely to develop benign uterine growths called fibroids.
Inthelate1960sand early 1970s, when estrogen therapy was first widely given to menopausal women, doctors noted an alarming increase in cases of cancer of the endometrium. Prescriptions for estrogen fell dramatically, until researchers combined progesterone with estrogen. Progesterone, as part of a woman's natural cycle, counteracts estrogen's effect on the endometrium.
Todaydoctorscommonly prescribe a type of HRT that combines estrogen and a synthetic form of progesterone, known as progestin. The two hormones may be administered in a sequential series, with estrogen given daily and progestin added for about 12 days each month. Estrogen and progestin treatments are also commonly given in the form of a combined pill taken daily. About 90 percent of women with an intact uterus continue to menstruate while undergoing combined estrogen and progestin therapy; some women think that this is too much of a drawback and prefer not to take HRT because of it.
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BENEFITS OF HRT
HRTcanlessenorhalt some of the most bothersome short-term symptoms of menopause. Hot flashes may lessen within 24 hours of starting HRT, and can disappear within a few weeks of continued treatment. Increased levels of estrogen via HRT also relieve vaginal dryness. A locally applied cream containing estrogen can also treat the symptom.
Inadditiontorelieving the relatively short-term symptoms of menopause, HRT has also been observed to offer some long-term health benefits. HRT offers benefits against osteoporosis. Estrogen blocks the actions of parathyroid hormone and other hormones that decrease the level of calcium in the blood. These hormones, produced by the parathyroid gland, cause bones to become porous and less dense. HRT restores estrogen levels, thereby halting the loss of calcium from bones and preventing hip fractures and other consequences of osteoporosis. Studies have also indicated that HRT is beneficial in lowering the risk of colorectal cancer.
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HRT RISKS
Formanyyears,studies seemed to indicate that postmenopausal women treated with estrogen had lower incidences of heart attack, stroke, and other cardiovascular disorders. In many instances, HRT was actually prescribed for older women to help protect cardiovascular health. However, many scientists questioned the studies indicating a link between estrogen and cardiac health. One criticism was that women who elected to undergo estrogen therapy tended to be younger and already living a health-conscious lifestyle, with regular doctor visits and proper diet and exercisefactors that in and of themselves could have explained the cardiovascular benefits credited to estrogen.
In2002aUnitedStates government-sponsored research program called the Women's Health Initiative reported on a five-year trial involving more than 16,000 menopausal women, some of whom took a combination of estrogen and progestin, while the others received a placebo pill. Results indicated that there was no cardiovascular benefit from HRT. In fact, rates of heart attack, stroke, and blood clots in the lungs and legs were actually higher in women taking the hormone supplements than in those taking placebo pills. A subsequent report from the Women's Health Initiative published in 2003 found that HRT nearly doubles a woman's risk of having a heart attack during her first year of treatment.
Similarly,studieshave also produced troubling results on the link between HRT and cancer. During the 1990s, research indicated a slight increase in the risk of breast cancer in women who had been on HRT regimens for more than five years. More definitive results emerged in the 2002 report from the Women's Health Initiative. Officials in charge of the clinical trial studying the effects of combined estrogen and progestin therapy stopped the study two years before the scheduled completion date after discovering that breast cancer rates were notably higher among those on HRT. Other studies indicated that HRT involving estrogen and progestin apparently raised the incidence of breast cancer and, by changing the character of breast tissue, actually made cancers harder to detect via a mammogram. And in a study of 1 million British women published in 2003, those who took combined estrogen and progestin therapy for five years or more had a 66 percent increased risk of developing breast cancer. For those taking only estrogen, the increased risk of developing breast cancer was 30 percent.
Otherresearchhascast further doubts on the supposed benefits of HRT. Scientists had hoped, for example, that HRT might benefit the brains of menopausal women, protecting them from the effects of Alzheimer's disease and other forms of dementia. A 2003 study of women over 65 undergoing HRT, however, indicated a higher incidence of Alzheimer's.
Clearlywomenwhoare at risk for heart disease or breast cancer should avoid the long-term use of HRT or should undertake it under very close supervision by medical specialists. But for all women, determining the benefits and risks of HRT is a complex matter, particularly as the results of past medical studies can seemingly be contradicted overnight by new medical findings.
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