Estrogen Replacement Therapy (ERT)

Common names include:

• Conjugated Equine Estrogens (Premarin, Premarin Vaginal Cream)
• Synthetic Conjugated Estrogens (Cenestin)
• Esterified Estrogens (Estratab, Menest)
• Estropipate (Ortho-Est, Ogen, Ogen Vaginal Cream)
• Micronized 17-beta Estradiol (Estrace, Matrix Patch: Alora, Climara, Esclim, Vivelle, Vivelle-Dot; Reservoir Patch: Estraderm; Estrace Vaginal Cream, Estring Vaginal Ring)
• Estradiol Hemihydrate (Vagifem Vaginal Tablet)
• Estradiol Transdermal Spray ( Evamist )

ERT provides you with a fraction of the amount of estrogen that was produced by your ovaries before menopause. It helps reduce hot flashes and vaginal dryness. Even low doses of estradiol (given as a skin patch) may help with vaginal dryness and pain during sexual activity. It may also reduce your risk of osteoporosis. Evamist, which is a spray, is another type of low-dose estradiol that may help reduce hot flashes.

Estrogen may be administered as an oral tablet, patch, injection, pellet placed under the skin, vaginal cream, ring, tablet, or spray.

Recent scientifically strong studies now show that estrogen replacement therapy increases a woman's risk of heart disease, endometrial cancer, ovarian and breast cancers, blood clots, and stroke.

In general, you should NOT be using ERT if you have cardiac risk factors or known cardiac disease, are or may be pregnant, have a history of breast cancer or other hormone-sensitive cancer, have unexplained bleeding from your uterus, or a history of blood clotting disorders. You should also avoid long-term use of ERT. You should discuss the risks and benefits of ERT with your doctor.

Possible side effects include:

• Uterine bleeding
• Enlargement of benign uterine tumors
• Sore breasts
• Abdominal bloating
• Nausea
• Fluid retention
• Headache, including migraine
• Lightheadedness
• Corneal changes in the eye
• Increased risk of breast, ovarian, and endometrial cancers
• Increased risk of heart attacks and strokes
• Increased risk of blood clots

Progestogen

If you choose ERT, the progesterone that your ovaries once produced must be replaced to reduce the increased risk of uterine cancer from taking ERT alone. Progesterone or progestin, a synthetic progesterone, is available as replacement therapy. If you have had your uterus removed, a hysterectomy, you are not at risk for uterine cancer and do not need to take progesterone with ERT.

Progestin Oral Tablet:

• Medroxyprogesterone Acetate (Amen, Cycrin, Provera)
• Norethindrone (Micronor, Nor-QD)
• Norethindrone Acetate (Aygestin)
• Norgestrel (Ovrette)
• Levonorgestrel (Norplant)
• Megestrol Acetate (Megace)

Progestin Injectable:

• Medroxyprogesterone Acetate (Depro-Provera)

Progestin IUD:

• Levonorgestrel (Mirena)

Progesterone Oral Capsule:

• Progesterone USP (Prometrium)

Progesterone: Vaginal Gel:

• Progesterone (Crinone)

Progesterone IUD:

• Progesterone (Progestasert)

Possible side effects include:

• Fluid retention
• Weight gain
• Headache
• Mood changes

Estrogen Plus Progestogen (Hormone Replacement Therapy–HRT) Oral, Continuous Cycle

• Conjugated Equine Estrogens and Medroxyprogesterone Acetate (Premphase)
• Oral, Continuous-Combined:
  • Conjugated Equine Estrogens and Medroxyprogesterone Acetate (Prempro)
  • Ethinyl Estradiol and Norethindrone Acetate (Femhrt)
  • 17-Beta Estradiol and Norethindrone Acetate (Activella)

• Oral, Intermittent-Combined:
  • 17-Beta Estradiol and Norgestimate (Ortho-Prefest)

• Skin Patch, Continuous Cycle:
  • 17-Beta Estradiol and Norethindrone Acetate (CombiPatch)

• Skin Patch, Continuous Combined:
  • 17-Beta Estradiol and Norethindrone Acetate (CombiPatch)

When progesterone is taken with estrogen, it is called Hormone Replacement Therapy (HRT). Options for HRT include cyclic, continuous-cyclic, continuous-combined, and intermittent-combined. Long-term HRT increases the risk of strokes, blood clots, heart attacks, ovarian, endometrial, and invasive breast cancers. Therefore, you and your doctor should carefully discuss the risks and benefits.

Possible side effects include:

• Uterine bleeding or spotting
• Fluid retention
• Sore breasts
• Headache
• Mood changes
• Increased risk of endometrial, breast, and ovarian cancers
• Increased risk of heart attacks and strokes
• Increased risk of blood clots
• Increased risk of gastroesophageal reflux disease (GERD)

Androgen

Androgen Oral Tablet:

• Methyltestosterone and Esterified Estrogens (Estratest, Menogen)

Androgen is a hormone produced by both males and females. In women, the ovaries secrete androgen as testosterone and androstenedione, which are then converted into estrogen and progesterone. As you get older, your ovaries produce less androgen and estrogen. As a result of less androgen, some women notice a decline in their sex drive. Androgen, which must be taken with estrogen, may help improve sex drive in some women.

Possible side effects* include:

• Restlessness
• Depression
• Growth of facial and body hair
• Acne
• An enlarged clitoris
• Increased muscle mass
• A lowered voice
• Increased cardiovascular risks

*These side effects often occur as the result of improper dosages of androgen.

Bisphosphonates

Common names include:

• Alendronate (Fosamax)
• Risedronate (Actonel)
• Pamidronate (Aredia)
• Etidronate (Didronel)

These non-hormonal medications are used to prevent or treat osteoporosis. These agents effectively reduce both bone loss and your risk of fractures. Alendronate may cause gastrointestinal problems and irritation of your esophagus.

Selective Estrogen Receptor Modulators (SERMs)

Common names include:

• Raloxifene (Evista)

SERMs are used to treat or prevent osteoporosis in postmenopausal women. They have some of the beneficial effects of estrogen, especially improved bone strength. They do not increase your risk of breast cancer or uterine bleeding. However, these medications tend to cause, rather than relieve, hot flashes. They also increase your risk of blood clots and gallstones.

Nonhormonal Medications for Hot Flashes

Your doctor may prescribe other types of medication to relieve hot flashes. Examples include:

• Clonidine (Catapres)—a blood pressure lowering medicine
• Gabapentin (Neurontin)—an antiseizure medicine
• Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs)
  • Common names: fluoxetine (Prozac), paroxetine (Paxil), venlafaxine (Effexor), desvenlafaxine (Pristiq)
  • Note: SSRIs and SNRIs should not be used if you are taking tamoxifen, a medication to reduce the risk of breast cancer recurrence.

Special Considerations

If you are taking medications, follow these general guidelines:

• Take your medications as directed. Do not change the amount or the schedule.
• Know what side effects could occur. Discuss them with your doctor.
• Drugs can be dangerous when mixed. Talk to your doctor if you are taking more than one drug, including over-the-counter products and supplements.