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Finding Balance 

The use of hormones to treat menopause symptoms remains controversial. Here's what women should know about hormone therapy

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Every woman who reaches middle age will experience menopause (the cessation of the menstrual cycle) and the hormone changes it brings. But for many women, hormone therapy remains a confusing subject. In 2002, a clinical trial by The Women's Health Initiative (WHI) reported that women taking the oral hormone Prempro had a higher risk of developing breast cancer, heart disease, stroke and blood clots. That information caused many women to stop taking hormones prescribed for the symptoms and effects of menopause. Subsequent studies have had far more positive findings and some doctors believe the benefits outweigh the risks.

  "A lot of fear has been created by representing all the negative stuff, but the benefits are also very great," says Dr. Charles Farris, Jr., an obstetrician/gynecologist and menopause practioner with Ochsner Health System.

  In her book, The Wisdom of Menopause, Dr. Christiane Northrup, an obstetrician/gynecologist and menopause specialist, says not every woman needs hormone therapy to relieve menopause symptoms, which include hot flashes, night sweats, mood swings, irritability, depression, insomnia, headaches, dry skin, vaginal dryness and thinning, mental fuzziness, memory loss, urinary problems, weight gain and loss of libido. For those who want to take hormones, knowing where to begin can be tricky. Today, more choices in the field of hormone therapy mean more information to gather. Knowing some of the basics can help.

  The average age of menopause, technically defined as the last menstrual period, is 51. But many women begin to experience symptoms during the years that precede menopause, known as perimenopause. "Not many people know that you can have a period and be in menopause," says Dr. Kathleen Posey, an obstetrician/gynecologist with a fellowship in anti-aging and regenerative medicine who specializes in hormone therapy and usually begins testing her patients' hormone levels when they are between ages 45 and 50. In general, most women seek treatment when symptoms become bothersome. Talking to your obstetrician/gynecologist (or to your family doctor, who can refer you to a gynecologist with a specialty in menopausal management) is usually the first step. Education through reading and lectures also can help patients find doctors specializing in hormone therapy. Most doctors use blood tests to determine whether a patient is in menopause and where the hormonal deficiencies lie. "It's a matter of talking about your symptoms and having a doctor who's a good listener," Posey says.

  The American Medical Association recently advised against the use of hormone therapy. But the International Menopause Society has taken the stance that all women should have the right to decide for themselves whether they want to use hormone therapy. Doctors have patients in their 60s, 70s and 80s taking hormones. The following is a primer on hormone therapy today.

What is hormone replacement therapy or hormone therapy?

Hormone therapy is the use of medications containing female hormones to replace those no longer made by the body after menopause. The main hormones involved are estrogen, progesterone and testosterone. "Hormone decline is an inevitability of life," says Ricky Phillips of PMA Family Medicine in Kenner, a nurse practitioner with a fellowship in anti-aging and regenerative medicine. "But with that decline comes various disease states. A patient can do nothing, take drugs to alleviate the effects resulting from the decline or try tod treat the root cause and put back the hormones that are missing." Dr. William Von Almen, an obstetrician/gynecologist with Touro Infirmary, adds there is evidence that some herbs can have beneficial effects as well.

Who should consider hormone therapy?

Farris recommends hormone therapy for any woman who's gone through menopause. "[Hormone therapy] is a positive approach for a better quality of life," he says. Women who have had surgery on the female organs and those who have had radiation and chemotherapy also should have their hormone levels monitored for optimum health, Farris says. The key, von Almen says, is "individuality of each patient." "We've been through the age of 'everybody gets estrogen forever,' and we've been through the age of 'nobody gets estrogen ever [as a result of the WHI study],' and now with the reevaluation [of WHI data], there is room for individualization."

What do the terms "synthetic" and "bioidentical" mean?

"Doctors are divided on two things: whether you should take hormones and what kinds of hormones you should take," Posey says. Unfortunately, women researching their options may be confused by what they hear and read. Simply put, synthetic hormones are manufactured by drug companies and do not have the same chemical structure as those found in the female body. Bioidentical or body identical hormones are derived from plant sources and modified in a lab so their molecular structure matches that of hormones produced by the female body. There are bioidentical hormones that are FDA approved as well as bioidentical hormones that are not. Whether synthetic and bioidentical hormones are equally safe and effective is the subject of debate. Those in favor of bioidentical hormones argue "that the cost and convenience as well as the natural processing" are preferable to synthetic hormones, Posey says. Those who don't support their use argue that bioidentical hormones have not been studied thoroughly enough and there is insufficient evidence to support the claim that bioidenticals are biologically better.

   "There is no scientific study that shows that they're any safer than a proprietary estrogen," Von Almen says. Farris objects to the use of the terms "synthetic" and "bioidentical" altogether. "Nowadays, doctors do not use synthetic hormones," Farris says. "The only area it's used is in the progestin, depending on the patient's response and request and previous reactions to progestin."

What are compounded hormones?

Compounded hormones are mixed, or compounded, by a licensed compounding pharmacy into one dosage for convenience and cost. There is an ongoing debate over the safety and efficacy of compounded hormones, which have not been as widely studied as more traditional forms of hormone therapy. Some doctors prescribe them; others do not.

What forms of hormone therapy are used today?

Hormones come in various forms: pills, patches, creams and pellets implanted below the skin. Gels, suppositories and vaginal rings also are used for localized vaginal treatment. "We're beginning to see some literature that says there could be safety benefits of transdermal verses oral when it comes to (preventing blood clots)," Von Almen says.

What are the benefits of hormone therapy?

The book Womenopause: Stop Pausing and Start Living by doctors Lovera Wolf Miller and David C. Miller lists the following as benefits of estrogen therapy: improved mood, better memory, thicker hair, smoother, softer skin, stronger muscles, lowered cardiovascular disease, reduced breast cancer, reduction in colon cancer, reduced belly fat, improved sex response, reduction of vaginal dryness, stronger bones and less joint pain. (In the WHI study, cardiovascular disease and breast cancer were seen in higher rates in women who took Prempro, and despite reanalysis of the WHI data, these two touted benefits remain controversial.) Some doctors also administer testosterone to improve energy, libido and sleep.

What are the risks?

Controversy over the risks associated with hormone therapy stems largely from the findings of the WHI study published in 2002. The WHI study said Prempro increased the risk of breast cancer, stroke, blood clots and dementia. Womenopause: Start Pausing and Start Living says reanalysis of the WHI data reversed those findings. However, experts still disagree about the risks.

Are there side effects?

Estrogen can cause symptoms such as bloating, breast tenderness, headache and nausea. Too large a dose of testosterone can cause acne and hair growth. Intolerance to progestin can cause bloating, breast tenderness and emotional changes such as anxiety and irritability.

Do insurance companies cover hormone therapy?

Every insurance company is different but most cover hormone therapy with some exceptions. While testosterone is covered for men, Farris says it is not covered for women. Women over 65 also are not covered.

How often should you see your doctor if you're on hormone therapy?

In the first year of hormone therapy, women may need to see their doctor two or three times until the correct balance is found. After that, they're advised to see their doctor annually or biannually. "There is no such thing as an average woman," says Farris, who schedules an hour for each menopause management patient's initial visit. "Each woman is unique and requires her own special attention."

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