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Category Archives: Hormone Replacement Therapy

Hormone replacement therapy (male-to-female) – Wikipedia

Posted: December 16, 2017 at 7:40 pm

Hormone replacement therapy (HRT) of the male-to-female (MTF) type is hormone replacement therapy and sex reassignment therapy used to change the secondary sexual characteristics of transgender and transsexual people from masculine (or androgynous) to feminine. It is one of two types of HRT for transgender and transsexual people (the other being female-to-male) and is predominantly used to treat transgender women. Some intersex people also receive this form of HRT, either starting in childhood to confirm the assigned sex or later if the assignment proves to be incorrect.

The purpose of this form of HRT is to cause the development of the secondary sex characteristics of the desired sex, such as breasts and a feminine pattern of hair, fat, and muscle distribution. It cannot undo many of the changes produced by naturally occurring puberty, which may necessitate surgery and other treatments (see below). The medications used in HRT of the MTF type include estrogens, antiandrogens, and progestogens.

While HRT cannot undo the effects of a person’s first puberty, developing secondary sex characteristics associated with a different gender can relieve some or all of the distress and discomfort associated with gender dysphoria, and can help the person to “pass” or be seen as the gender they identify with. Introducing exogenous hormones into the body impacts it at every level and many patients report changes in energy levels, mood, appetite, etc. The goal of HRT, and indeed all somatic treatments, is to provide patients with a more satisfying body that is more congruent with their gender identity.

Some medical conditions may be a reason to withhold hormone replacement therapy because of the harm it could cause to the patient. Such interfering factors are described in medicine as contraindications.

Absolute contraindications those that can cause life-threatening complications, and in which hormone replacement therapy should never be used include histories of estrogen-sensitive cancer (e.g., breast cancer), thrombosis or embolism (unless the patient receives concurrent anticoagulants), or macroprolactinoma.[citation needed] In such cases, the patient should be monitored by an oncologist, hematologist or cardiologist, or neurologist, respectively.

Relative contraindications in which the benefits of HRT may outweigh the risks, but caution should be used include:

As dosages increase, risks increase as well. Therefore, patients with relative contraindications may start at low dosages and increase gradually.[citation needed]

Hormone therapy for transgender individuals has been shown in medical literature to be safe when supervised by a qualified medical professional.[1]

Inducers of CYP3A4 and other cytochrome P450 enzymes can reduce the effects of MTF HRT. (For a list of CYP3A4 inducers, see here.)

Estrogen is one of the two major sex hormones in women (the other being progesterone), and is responsible for the development and maintenance of feminine secondary sexual characteristics, such as breasts, wide hips, and a feminine pattern of fat distribution. Estrogens act by binding to and activating the estrogen receptor (ER), their biological target in the body. A variety of different forms of estrogen are available and used medically. The most common estrogens used in transgender women include estradiol (which is the predominant natural estrogen in women) and estradiol esters such as estradiol valerate and estradiol cypionate (which are prodrugs of estradiol). Conjugated equine estrogens (CEEs), marketed as Premarin, and ethinylestradiol are also sometimes used, but this is becoming less common. Estrogens may be administered orally, sublingually, transdermally (via patch), topically (via gel), by intramuscular or subcutaneous injection, or by an implant.

Prior to gender confirmation surgery, dosages of estrogen for transgender people are often higher than replacement dosages used for cisgender women. Hembree et al. (2009) recommend “maintain[ing] sex hormone levels within the normal range for the persons desired gender”.[2] Dosages are typically reduced after an orchiectomy (removal of the testes) or sex reassignment surgery. However, that practice has been carried over from an era in which very high doses of estrogen were required to decrease testosterone, since antiandrogens were not used concurrently. Today, high doses of a less potent estrogen estradiol, which is endogenous to the human body, rather than the riskier ethinylestradiol and conjugated estrogens used in the past are recommended during the first ten or so years of HRT, with or without an orchiectomy or genital reassignment. After that period, dosages can be reduced.

Androgens, such as testosterone and dihydrotestosterone (DHT), are the major sex hormones in XY chromosomed individuals, and are responsible for the development and maintenance of masculine secondary sexual characteristics, such as a deep voice, broad shoulders, and a masculine pattern of hair, muscle, and fat distribution. In addition, they stimulate sex drive and the frequency of spontaneous erections and are responsible for acne, body odor, and masculine-pattern scalp hair loss. Androgens act by binding to and activating the androgen receptor (AR), their biological target in the body. In contrast to androgens, antiandrogens are drugs that prevent the effects of androgens in the body. They do this by preventing androgens from binding to the AR or by preventing the production of androgens. The most commonly used antiandrogens in transgender women are cyproterone acetate, spironolactone[citation needed], and GnRH analogues.

The most commonly used antiandrogens for transgender women are steroidal: spironolactone and cyproterone acetate. Spironolactone, which is relatively safe and inexpensive, is the most frequently used antiandrogen in the United States. Cyproterone acetate, which is unavailable in the United States, is more commonly used in the rest of the world.

Spironolactone is a potassium-sparing diuretic that is mainly used to treat low-renin hypertension, edema, hyperaldosteronism, and low potassium levels caused by other diuretics. It can cause high potassium levels (hyperkalemia) and is therefore contraindicated in people who have renal failure or already-elevated potassium levels. Spironolactone prevents the formation of androgens in the testes (though not in the adrenal glands) by inhibiting enzymes involved in androgen production.[3][4][5] It is also an androgen receptor antagonist (that is, it prevents androgens from binding to and activating the androgen receptor).[6][7][8][9][10]

Cyproterone acetate is a powerful antiandrogen and progestin that suppresses gonadotropin levels (which in turn reduces androgen levels), blocks androgens from binding to and activating the androgen receptor, and inhibits enzymes in the androgen biosynthesis pathway. It has been used as a means of androgen deprivation therapy to treat prostate cancer. If used long-term in dosages of 150mg or higher, it can cause liver damage or failure.[11][12][13][14][15][16][17][18][19]

Nonsteroidal antiandrogens (NSAAs) used in HRT for transgender women include flutamide, nilutamide, and bicalutamide, all three of which are primarily used in the treatment of prostate cancer in cisgender men.[20][21] Unlike steroidal antiandrogens such as spironolactone and cyproterone acetate, these drugs are pure androgen receptor antagonists. They do not lower androgen levels; rather, they act solely by preventing the binding of androgens to the androgen receptor. However, they do so very strongly, and are highly effective antiandrogens. Bicalutamide has improved tolerability and safety profiles relative to cyproterone acetate, as well as to flutamide and nilutamide, and has largely replaced the latter two in clinical practice for this reason. Enzalutamide is a more recently introduced NSAA with even greater potency and efficacy as an antiandrogen than bicalutamide, but it is still under patent protection and in relation to this is currently (and for the foreseeable future) extremely expensive. Moreover, enzalutamide has been found to act as a negative allosteric modulator of the GABA receptor and has been associated with central side effects such as anxiety, insomnia, and, most notably, seizures (in 1% of patients), properties that it does not share with bicalutamide.

NSAAs may be an appealing option for those who wish to preserve sex drive and function[22] and/or fertility,[23] as well as for those who desire more selective action with fewer side effects than spironolactone and cyproterone acetate (which increase the risk of depressive symptoms, among other adverse effects).[24] Bicalutamide specifically may also be a safer drug than cyproterone acetate or spironolactone, as it has a much lower risk of hepatotoxicity relative to cyproterone acetate and, unlike spironolactone, has no risk of hyperkalemia or other antimineralocorticoid-associated adverse reactions. However, bicalutamide does have a very small risk of hepatotoxicity itself, as well as of interstitial pneumonitis.

In both sexes, the hypothalamus produces gonadotropin-releasing hormone (GnRH) to stimulate the pituitary gland to produce luteinizing hormone (LH) and follicle-stimulating hormone (FSH). This in turn cause the gonads to produce sex steroids such as androgens and estrogens. In adolescents of either sex with relevant indicators, GnRH analogues such as goserelin acetate can be used to stop undesired pubertal changes for a period without inducing any changes toward the sex with which the patient currently identifies. GnRH agonists work by initially overstimulating the pituitary gland, then rapidly desensitizing it to the effects of GnRH. After an initial surge, over a period of weeks, gonadal androgen production is greatly reduced. Conversely, GnRH antagonists act by blocking the action of GnRH in the pituitary gland.

There is considerable controversy over the earliest age at which it is clinically, morally, and legally safe to use GnRH analogues, and for how long. The sixth edition of the World Professional Association for Transgender Health’s Standards of Care permit it from Tanner stage 2 but do not allow the addition of hormones until age 16, which could be five or more years later. Sex steroids have important functions in addition to their role in puberty, and some skeletal changes (such as increased height) that may be considered masculine are not hindered by GnRH analogues.

GnRH analogues are often prescribed to prevent the reactivation of testicular function when surgeons require the cessation of estrogens prior to surgery.

The high cost of GnRH analogues is a significant factor in their relative lack of use in transgender people. However, they are prescribed as standard practice in the United Kingdom.

Certain antiandrogens do not reduce testosterone or prevent its action upon tissues, but instead prevent its metabolite, dihydrotestosterone (DHT), from forming. These medications can be used when the patient has male-pattern hair loss and/or an enlarged prostate (benign prostatic hyperplasia), both of which DHT exacerbates. Two medications are currently available to prevent the creation of DHT: finasteride and dutasteride. DHT levels can be lowered up to 6075% with the former, and up to 9394% with the latter. These medications have also been found to be effective in the treatment of hirsutism in women.

Progesterone, a progestogen, is the other of the two major sex hormones in women. Unlike estrogen, progesterone is not overtly involved in the development of female secondary sexual characteristics, and is instead involved mainly in the menstrual cycle and pregnancy. For this reason, progestogens are not commonly prescribed for transgender women. However, there may be a role of progestogens in breast development (though controversial and disputed) and in regulation of skin and hair,[citation needed] and progesterone specifically may have positive effects on sex drive, sleep, and levels of anxiety. Moreover, due to their antigonadotropic and/or antiandrogen effects, progestogens can be useful in helping to suppress the effects of androgens in the body. The most common progestogens used in transgender women include progesterone and progestins (synthetic progestogens) like CPA and medroxyprogesterone acetate (MPA). These drugs are usually taken orally, but may also be administered by intramuscular injection.

High doses of progestogens exert negative feedback on the hypothalamicpituitarygonadal axis by activating the progesterone receptor. As a result, they have antigonadotropic effects that is, they suppress the gonadal production of sex hormones such as androgens. As such, sufficient dosages of progestogens, such as cyproterone acetate, gestonorone caproate, hydroxyprogesterone caproate, megestrol acetate, and MPA, can considerably lower androgen levels. In addition, certain other progestogens, such as cyproterone acetate, megestrol acetate, drospirenone, and nomegestrol acetate, bind to and block the activation of the androgen receptor.[25] On the other hand, certain other progestogens, including 19-nortestosterone derivatives like levonorgestrel, norgestrel, norethisterone, and norethisterone acetate, as well as, to a lesser extent, the 17-hydroxyprogesterone derivative MPA, have weak androgenic activity because they bind to and activate the androgen receptor similarly to testosterone, and may produce androgenic effects such as acne, hirsutism, and increased sex drive.[26][27][28]

Progestogens, in conjunction with the hormone prolactin, are involved in the maturation of the lobules, acini, and areola during pregnancy: mammary structures that estrogen has little to no direct effect on.[29] However, there is no clinical evidence that progestogens enhance breast size, shape, or appearance in either transgender women or cisgender women, and one study found no benefit to breast hemicircumference over estrogen alone in a small sample of transgender women given both an estrogen and an oral progestogen (usually 10mg/day medroxyprogesterone acetate).[30] However, the authors of the paper stated that the sample size was too small to make any definitive conclusions, and that further studies should be carried out to confirm whether progestogens significantly affect breast size and/or shape in transgender women.[30] As of 2014, no additional study had looked at the issue.[31] Anecdotal evidence from transgender women suggests that those who take progesterone supplements may experience more full breast development, including stage IV on the Tanner scale (many transgender women do not develop Tanner stage V breasts).[citation needed] However, there have been no formal studies with sufficiently large sample sizes to confirm this.[31]

Progestogens reportedly alter fat distribution (e.g., by increasing fat in the buttocks and thighs),[32][33] increase sex drive (specifically progesterone, via its active metabolite allopregnanolone; this does not occur through activation of the progesterone receptor),[34][35] cause increased appetite and weight gain (only in combination with estrogen),[33] produce a sense of calm (i.e., anxiolysis), and promote sleep (i.e., sedative and hypnotic effects).[36][37][38][39]

Progesterone specifically is essential for bone health[citation needed] and seems to have a role in skin elasticity and nervous system function.[40] Other effects seen with progesterone include reducing spasms and relaxing smooth muscle tone; reducing gallbladder activity; widening bronchi,[41] which helps respiration; reducing inflammation and immune response; and normalizing blood clotting and vascular tone, zinc and copper levels, cell oxygen levels, and use of fat stores for energy.[citation needed] Progesterone also assists in thyroid function and bone building by osteoblasts.[citation needed]

The main effects of HRT of the MTF type are as follows:[42]

The psychological effects of hormone replacement therapy are harder to define than physical changes. Because HRT is usually the first physical step taken to transition, the act of beginning it has a significant psychological effect, which is difficult to distinguish from hormonally induced changes.

Highly developed breasts of transgender woman induced by hormone therapy.

Breast, nipple, and areolar development varies considerably depending on genetics, body composition, age of HRT initiation, and many other factors. Development can take a couple years to nearly a decade for some. However, many transgender women report there is often a “stall” in breast growth during transition, or significant breast asymmetry. Transgender women on HRT often experience less breast development than cisgender women (especially if started after young adulthood). For this reason, many seek breast augmentation. Transgender patients opting for breast reduction are rare. Shoulder width and the size of the rib cage also play a role in the perceivable size of the breasts; both are usually larger in transgender women, causing the breasts to appear proportionally smaller. Thus, when a transgender woman opts to have breast augmentation, the implants used tend to be larger than those used by cisgender women.[44]

In clinical trials, cisgender women have used stem cells from fat to regrow their breasts after mastectomies. This could someday eliminate the need for implants for transgender women.[45]

In transgender women on HRT, as in cisgender women during puberty, breast ducts and Cooper’s ligaments develop under the influence of estrogen. Progesterone causes the milk sacs (mammary alveoli) to develop, and with the right stimuli, a transgender woman may lactate. Additionally, HRT often makes the nipples more sensitive to stimulation.

The uppermost layer of skin, the stratum corneum, becomes thinner and more translucent. Spider veins may appear or be more noticeable as a result. Collagen decreases, and tactile sensation increases. The skin becomes softer,[46] more susceptible to tearing and irritation from scratching or shaving, and slightly lighter in color because of a slight decrease in melanin.

Sebaceous gland activity (which is triggered by androgens) lessens, reducing oil production on the skin and scalp. Consequently, the skin becomes less prone to acne. It also becomes drier, and lotions or oils may be necessary.[44][47] The pores become smaller because of the lower quantities of oil being produced. Many apocrine glands a type of sweat gland become inactive, and body odor decreases. Remaining body odor becomes less metallic, sharp, or acrid, and more sweet and musky.[citation needed]

As subcutaneous fat accumulates,[44] dimpling, or cellulite, becomes more apparent on the thighs and buttocks. Stretch marks (striae distensae) may appear on the skin in these areas. Susceptibility to sunburn increases, possibly because the skin is thinner and less pigmented.[citation needed]

Antiandrogens affect existing facial hair only slightly; patients may see slower growth and some reduction in density and coverage. Those who are less than a decade past puberty and/or whose race generally lacks a significant amount of facial hair may have better results. Patients taking antiandrogens tend to have better results with electrolysis and laser hair removal than those who are not. In patients in their teens or early twenties, antiandrogens prevent new facial hair from developing if testosterone levels are within the normal female range.[44][47]

Body hair (on the chest, shoulders, back, abdomen, buttocks, thighs, tops of hands, and tops of feet) turns, over time, from terminal (“normal”) hairs to tiny, blonde vellus hairs. Arm, perianal, and perineal hair is reduced but may not turn to vellus hair on the latter two regions (some cisgender women also have hair in these areas). Underarm hair changes slightly in texture and length, and pubic hair becomes more typically female in pattern. Lower leg hair becomes less dense. All of these changes depend to some degree on genetics.[44][47]

Head hair may change slightly in texture, curl, and color. This is especially likely with hair growth from previously bald areas.[citation needed]Eyebrows do not change because they are not androgenic.[48]

The lens of the eye changes in curvature.[49][50][51][52] Because of decreased androgen levels, the meibomian glands (the sebaceous glands on the upper and lower eyelids that open up at the edges) produce less oil. Because oil prevents the tear film from evaporating, this change may cause dry eyes.[53][54][55][56][57]

The distribution of adipose (fat) tissue changes slowly over months and years. HRT causes the body to accumulate new fat in a typically feminine pattern, including in the hips, thighs, buttocks, pubis, upper arms, and breasts. (Fat on the hips, thighs, and buttocks has a higher concentration of omega-3 fatty acids and is meant to be used for lactation.) The body begins to burn old adipose tissue in the waist, shoulders, and back, making those areas smaller.[44]

Subcutaneous fat increases in the cheeks and lips, making the face appear rounder, with slightly less emphasis on the jaw as the lower portion of the cheeks fills in.

HRT causes a reduction in muscle mass and distribution towards female proportions.[citation needed]

Male-to-female hormone therapy causes the hips to rotate slightly forward because of changes in the tendons. Hip discomfort is not uncommon.

If estrogen therapy is begun prior to pelvis ossification, which occurs around the age of 25, the pelvic outlet and inlet open slightly. The femora also widen, because they are connected to the pelvis. The pelvis retains some masculine characteristics, but the end result of HRT is wider hips than a cisgender man and closer to those of a cisgender woman.[citation needed]

HRT does not reverse bone changes that have already been established by puberty. Consequently, it does not affect height; the length of the arms, legs, hands, and feet; or the width of the shoulders and rib cage. However, details of bone shape change throughout life, with bones becoming heavier and more deeply sculptured under the influence of androgens, and HRT does prevent such changes from progressing further.

The width of the hips is not affected in individuals for whom epiphyseal closure (fusion and closure of the ends of bones, which prevents any further lengthening) has taken place. This occurs in most people between 18 and 25 years of age.[citation needed] Already-established changes to the shape of the hips cannot be reversed by HRT whether epiphyseal closure has taken place or not.[citation needed]

Established changes to the bone structure of the face are also unaffected by HRT. A significant majority of craniofacial changes occur during adolescence. Post-adolescent growth is considerably slower and minimal by comparison.[58] Also unaffected is the prominence of the thyroid cartilage (Adam’s apple). These changes may be reversed by surgery (facial feminization surgery and tracheal shave, respectively).

During puberty, the voice deepens in pitch and becomes more resonant. These changes are permanent and are not affected by HRT. Voice therapy and/or surgery may be used instead to achieve a more female-sounding voice.

Facial hair develops during puberty and is only slightly affected by HRT. It may, however, be eliminated nearly permanently with laser hair removal, or permanently with electrolysis.[citation needed]

Mood changes, including depression, can occur with hormone replacement therapy. However, many transgender women report significant mood-lifting effects as well. The risk of depressive side effects is more common in patients who take progestins. Medroxyprogesterone acetate, in particular, has been shown to cause depression in certain individuals,[59][60][61][62][63] perhaps by affecting dopamine levels.[64]

Some transgender women report a significant reduction in libido, depending on the dosage of antiandrogens. A small number of post-operative transgender women take low doses of testosterone to boost their libido. Many pre-operative transgender women wait until after reassignment surgery to begin an active sex life. Raising the dosage of estrogen or adding a progestogen raises the libido of some transgender women.

Spontaneous and morning erections decrease significantly in frequency, although some patients who have had an orchiectomy still experience morning erections. Voluntary erections may or may not be possible, depending on the amount of hormones and/or antiandrogens being taken.

Recent studies have indicated that hormone therapy in transgender women may reduce brain volume toward female proportions.[65]

All aforementioned physical changes can, and reportedly do, change the experience of sensation compared to prior to HRT. Areas affected include, but aren’t limited to, the basic senses, erogenous stimulus, perception of emotion, perception of social interaction, and processing of feelings and experiences.

The most significant cardiovascular risk for transgender women is the pro-thrombotic effect (increased blood clotting) of estrogens. This manifests most significantly as an increased risk for thromboembolic disease: deep vein thrombosis (DVT) and pulmonary embolism, which occurs when blood clots from DVT break off and migrate to the lungs. Symptoms of DVT include pain or swelling of one leg, especially the calf. Symptoms of pulmonary embolism include chest pain, shortness of breath, fainting, and heart palpitations, sometimes without leg pain or swelling.

Deep vein thrombosis occurs more frequently in the first year of treatment with estrogens. The risk is higher with oral estrogens (particularly ethinylestradiol and conjugated estrogens) than with injectable, transdermal, implantable, and nasal formulations.[66] DVT risk also increases with age and in patients who smoke, so many clinicians advise using the safer estrogen formulations in smokers and patients older than 40.

Because the risks of warfarin which is used to treat blood clots in a relatively young and otherwise healthy population are low, while the risk of adverse physical and psychological outcomes for untreated transgender patients is high, pro-thrombotic mutations (such as factor V Leiden, antithrombin III, and protein C or S deficiency) are not absolute contraindications for hormonal therapy.[67]

Estrogens may increase the risk of gallbladder disease, especially in older and obese people.[68] They may also increase transaminase levels, indicating liver toxicity, especially when taken in oral form.[citation needed]

A patient’s metabolic rate may change, causing an increase or decrease in weight and energy levels, changes to sleep patterns, and temperature sensitivity.[citation needed] Androgen deprivation leads to slower metabolism and a loss of muscle tone. Building muscle takes more work. The addition of a progestogen may increase energy, although it may increase appetite as well.[citation needed]

Both estrogens and androgens are necessary in all humans for bone health. Young, healthy women produce about 10mg of testosterone monthly,[citation needed] and higher bone mineral density in males is associated with higher serum estrogen. Both estrogen and testosterone help to stimulate bone formation, especially during puberty. Estrogen is the predominant sex hormone that slows bone loss, even in men.

In spite of the induction of breast development, transgender women who undergo HRT do not have an increased risk of breast cancer.[69][70][71] Only a handful of cases of breast cancer have ever been described in transsexual women who have undergone male-to-female HRT.[70][71] This is in accordance with research in cisgender men in which gynecomastia has been found not to be associated with an increased risk of breast cancer, suggesting a protective role of the male sex-determination chromosome.[72] On the other hand, men with Klinefelter’s syndrome (two X chromosomes and one Y chromosome), which causes hypoandrogenism, hyperestrogenism, and a very high incidence of gynecomastia (80%), have a dramatically (20- to 58-fold) increased risk of breast cancer compared to men with one X chromosome, closer to the rate of homogametic females.[72][73][74] The incidences of breast cancer in karyotypical men (46,XY karyotype), men with Klinefelter’s syndrome (47,XXY karyotype), and karyotypical women (46,XX karyotype) are approximately 0.1%,[75] 3%,[73] and 12.5%,[76] respectively. Individuals with the 46,XY karyotype affected by complete androgen insensitivity syndrome never develop male sex characteristics and have normal and complete female morphology, and accelerated breast growth during puberty,[77][78] but appear to have little (or possibly even no) incidence of breast cancer.[79][80] The risk of breast cancer in women with Turner syndrome (45,XO karyotype) also appears to be significantly decreased, though this may be related to ovarian failure/hypogonadism rather necessarily than to genetics.[81]

Prostate cancer is extremely rare in orchidectomized transgender women who have been treated with estrogens for a prolonged period of time.[69][82][83] Whereas as many as 70% of men show prostate cancer by their 80’s,[84] only a handful of cases of prostate cancer in transgender women have been reported in the literature.[69][82][83] As such, and in accordance with the fact that androgens are responsible for the development of prostate cancer, HRT appears to be highly protective against prostate cancer in transgender women.[69][82][83]

Migraines can be made worse or unmasked by estrogen therapy.[citation needed]

Estrogens can also cause prolactinomas. Milk discharge from the nipples can be a sign of elevated prolactin levels. If a prolactinoma becomes large enough, it can cause visual changes (especially decreased peripheral vision), headaches, depression or other mood changes, dizziness, nausea, vomiting, and symptoms of pituitary failure, like hypothyroidism.

Especially in the early stages of hormone replacement therapy, blood work is done frequently to assess hormone levels and liver function. The Endocrine Society recommends that patients have blood tests every three months in the first year of HRT for estradiol and testosterone, and that spironolactone, if used, be monitored every 23 months in the first year.[85] The optimal ranges for estradiol and testosterone are not limited to but include the following:

The optimal ranges for estrogen apply only to individuals taking estradiol (or an ester of estradiol), and not to those taking synthetic or other non-bioidentical preparations (e.g., CEEs or ethinylestradiol).[88]

Physicians also recommend broader medical monitoring, including complete blood counts; tests of renal function, liver function, and lipid and glucose metabolism; and monitoring of prolactin levels, body weight, and blood pressure.[89]

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Bioidentical Hormone Replacement Therapy (BHRT) Dr Mark …

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Bioidentical Hormone Replacement Therapy (BHRT) Dr Mark Richards

Mark E. Richards M.D.

Get Started, Call(301) 468-3458

Bio-identical testosterone or estrogen hormones taken by mouth are inactivated in the liver before ever getting into your circulation. Bio-identical creams or injections have large variations in their blood levels and an inconsistency in the amount of hormone they provide to your tissues. Bio-identical pellets have been shown to provide close to a steady state availability of hormone for months. Bio-identical hormone pellets have been used in the United States since 1939.

Bio-identical hormones have the exact same chemical and molecular structure as hormones that are made in the human body. The difference between a bio-identical hormone versus a hormone that is not bio-identical is the molecular structure and shape of the hormone. Why is this important? Think of a hormone as a key and the receptor which it activates as a lock. In order for a replacement hormone to exactly replicate the function of the hormone that humans naturally produce, the bio-identical replacement I provide must exactly match the human hormone. It is the structural differences that exist between human bio-identical and non-bio-identical hormones that are responsible for serious side effects and sometimes fatal health risks that occur when non bio-identical hormones are used in humans.

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Dr. Mark Richards is one of a handful of nationally and internationally recognized experts in the emerging field of bio-identical pellet hormone therapy. He instructs physicians in how to start this therapy in their practices. He also lectures to physicians at medical specialty conferences (Plastic Surgery and Anti-Aging) regarding the extensive science of the last 70 years supporting the use of bio-identical hormone pellets to enhance and restore health and well-being in aging humans. He has practiced and taught Plastic Surgery for over 21 years, and has practiced and educated others in bio-identical pellet therapy since 2008. He is board certified in Plastic Surgery.

Has Been Selected by The Washingtonian Magazine as one of the best Washington DC area cosmetic surgeons

Recognition in the Consumers Research Council of Americas Guide to Americas Top Surgeons has been an annual accolade since 2002

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Hormone Replacement Therapy – Menopause Home Page

Posted: December 15, 2017 at 4:43 pm

Interested in a Discount on Hormone Replacement Therapy?

The lower levels of hormones that occur during menopause may lead to:

To help alleviate these problems, some women receive hormone replacement therapy. The medicines used in hormone replacement therapy contain estrogen or estrogen with progestin (another hormone). Hormone replacement therapy works by replacing the natural estrogen your body loses during menopause.

Like all medicines, hormone replacement therapy has risks and benefits. After reading this article, talk to your doctor, nurse, or pharmacist for more information about this treatment. If you decide to use hormone replacement therapy, use it at the lowest dose possible that provides relief of your menopausal symptoms. Also, only use the therapy as long as needed — long-term use of hormone replacement therapy can increase the possible risks involved.

Hormone replacement therapy has been shown to be beneficial in:

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Hormone replacement therapy is given to some women during menopause when the body stops making the hormones estrogen and progesterone. It is used to treat common symptoms of aging and menopause, such as hot flashes, vaginal dryness, mood swings, and even osteoporosis. Menopause occurs when a womans monthly menstrual cycle stops, which causes a drop in hormone levels. Hormone replacement therapy replaces the hormones the body no longer makes and is the most effective treatment for menopause symptoms.

* HealthPrep does not provide medical advice, diagnosis or treatment. See Content Disclaimer below.

Women who take hormone replacement therapy are usually given a combination of estrogen and progesterone; however, women who have had a hysterectomy do not need progesterone, so their doctor may prescribe estrogen-only therapy. Hormone replacement therapy should not last longer than five years. It may begin as soon as a woman begins to experience menopausal symptoms, which usually occurs around the age of fifty-two. According to the National Health Service, menopause ages in women can range from the early forties to the late sixties. There is no way to predict when a woman will go through menopause.

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Bioidentical Hormone Replacement Therapy (BHRT) Dr Mark Richards

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Bioidentical Hormone Replacement Therapy (BHRT) Dr Mark Richards

Mark E. Richards M.D.

Get Started, Call(301) 468-3458

Bio-identical testosterone or estrogen hormones taken by mouth are inactivated in the liver before ever getting into your circulation. Bio-identical creams or injections have large variations in their blood levels and an inconsistency in the amount of hormone they provide to your tissues. Bio-identical pellets have been shown to provide close to a steady state availability of hormone for months. Bio-identical hormone pellets have been used in the United States since 1939.

Bio-identical hormones have the exact same chemical and molecular structure as hormones that are made in the human body. The difference between a bio-identical hormone versus a hormone that is not bio-identical is the molecular structure and shape of the hormone. Why is this important? Think of a hormone as a key and the receptor which it activates as a lock. In order for a replacement hormone to exactly replicate the function of the hormone that humans naturally produce, the bio-identical replacement I provide must exactly match the human hormone. It is the structural differences that exist between human bio-identical and non-bio-identical hormones that are responsible for serious side effects and sometimes fatal health risks that occur when non bio-identical hormones are used in humans.

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Dr. Mark Richards is one of a handful of nationally and internationally recognized experts in the emerging field of bio-identical pellet hormone therapy. He instructs physicians in how to start this therapy in their practices. He also lectures to physicians at medical specialty conferences (Plastic Surgery and Anti-Aging) regarding the extensive science of the last 70 years supporting the use of bio-identical hormone pellets to enhance and restore health and well-being in aging humans. He has practiced and taught Plastic Surgery for over 21 years, and has practiced and educated others in bio-identical pellet therapy since 2008. He is board certified in Plastic Surgery.

Has Been Selected by The Washingtonian Magazine as one of the best Washington DC area cosmetic surgeons

Recognition in the Consumers Research Council of Americas Guide to Americas Top Surgeons has been an annual accolade since 2002

Has been selected as a Top Doctor in Plastic Surgery by U.S. News & World Report in 2012

*Individual Results May Vary

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Bioidentical Hormone Replacement Therapy (BHRT) Dr Mark Richards

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Hormone replacement therapy – Susan’s Place Transgender Resources

Posted: at 4:43 pm

This is a disambiguation page a navigational aid which lists other pages that might otherwise share the same title. If an article link referred you here, you might want to go back and fix it to point directly to the intended page.

There are two variants of Hormone replacement therapy for transsexuals:

Hormone Replacement TherapyIf you are interested in information about HRT or are currently on HRT and wish to discuss the issues we face this forum is for you.

Editor’s Note: While discussion of hormone replacement therapy (HRT) and its medications is permitted, discussing the means to acquire them without a prescription, and self medication without a doctors care is prohibited. We cannot in good conscience condone the self administering of these medications. Not only may self medication be illegal there can also be serious health consequences resulting from the taking of these medicines. See a qualified medical professional before taking any prescription drugs.

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Hormone replacement therapy – Susan’s Place Transgender Resources

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Using HRT (Hormone Replacement Therapy)

Posted: at 4:43 pm

Current or recent past users of hormonal replacement therapy (HRT) have a higher risk of being diagnosed with breast cancer. Before the link between HRT use and breast cancer risk was established, many postmenopausal women took HRT for many years to ease menopausal symptoms (hot flashes, fatigue) and to reduce bone loss. Since 2002, when research linked HRT and risk, the number of women taking HRT has dropped dramatically. Still, many women continue to use HRT to handle bothersome menopausal symptoms.

There are two main types of HRT:

Each type of HRT seems to have a different effect on breast cancer risk.

Combination HRT increases breast cancer risk by about 75%, even when used for only a short time. Combination HRT also increases the likelihood that the cancer may be found at a more advanced stage, as well as increasing the risk that a woman diagnosed with breast cancer will die from the disease. Breast cancer risk increases the most during the first 2 to 3 years of taking combination HRT. Higher-dose combination HRT increases breast cancer risk more than lower-dose combination HRT. Breast cancer risk goes back down to average about 2 years after you stop taking combination HRT.

Estrogen-only HRT increases the risk of breast cancer, but only when used for more than 10 years. Estrogen-only HRT also can increase the risk of ovarian cancer.

The higher breast cancer risk from using HRT is the same for so-called “bioidentical” and “natural” hormones as it is for synthetic hormones. “Bioidentical” means the hormones in the product are identical to the hormones your body produces. Bioidentical hormones are said to be “natural” — derived from plants. Synthetic hormones are made in a lab and are also chemically identical to the hormones in your body. It’s important to know that many herbal and bioidentical HRT products fall outside the jurisdiction of the United States Food and Drug Administration and so aren’t subject to the same regulations and testing that medications are.

Menopausal side effects can dramatically reduce quality of life for some women. These women have to weigh the benefits of HRT against the risks. If you’re having severe hot flashes or other menopausal side effects and are considering HRT, talk to your doctor about ALL of your options. Ask how you can minimize your breast cancer risk AND relieve your symptoms. Be sure to discuss the pros and cons of different types of HRT. Research strongly suggests that estrogen-only HRT appears to increase breast cancer risk less than combination HRT. If you do decide to take HRT, ask if you can take a lower-dose formula and talk to your doctor about taking it for the shortest time possible.

If you’ve been diagnosed with breast cancer or have tested positive for an abnormal breast cancer gene (BRCA1 or BRCA2) and so are at high risk, you shouldn’t use HRT. The hormones in HRT can cause hormone-receptor-positive breast cancers to develop and grow. While only a few small studies have looked at HRT use in women with a personal history of breast cancer, the fact that HRT use increases breast cancer risk among women in general makes almost all doctors advise women with a personal history of breast cancer to avoid HRT. The prescribing sheet included with HRT clearly states that it is “contraindicated in women with a diagnosis of breast cancer.” Not being able to use HRT can present a challenge for many women. If you’re having severe hot flashes or other menopausal side effects and have a personal history of breast cancer, talk to your doctor about non-hormonal options, such as dietary changes, exercise, weight management, acupuncture, or meditation.

For more information on hot flashes and how to manage them, visit the Breastcancer.org Menopause Symptoms: Hot Flashes page.

Whether or not you take HRT, there are also lifestyle choices you can make to keep your breast cancer risk as low as it can be:

These are just a few of the steps you can take. Review the links on the left side of this page for more options.

Think Pink, Live Green: A Step-by-Step Guide to Reducing Your Risk of Breast Cancer teaches you the biology of breast development and how modern life affects breast cancer risk. Order a free booklet by mail or download the PDF of the booklet to learn 31 risk-reducing steps you can take today.

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Using HRT (Hormone Replacement Therapy)

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Menopausal Hormone Therapy and Cancer Risk

Posted: December 13, 2017 at 9:40 pm

For decades, women have used hormone therapy to ease symptoms of menopause, such as hot flashes and sweating. This is called menopausal hormone therapy, and you may see it abbreviated as HT or MHT. You may also hear it described as hormone replacement therapy (HRT), postmenopausal hormone therapy (PHT), or postmenopausal hormones (PMH).

In the past, many doctors and their patients believed that MHT didnt just help with hot flashes and other symptoms it had important health benefits. But well-conducted studies have led many doctors to conclude that the risks of MHT often outweigh the benefits.

This document discusses only how MHT can affect a womans risk of getting certain cancers. It does not discuss other possible risks of MHT such as heart disease or stroke.

You can use this information when you talk to your doctor about whether MHT is right for you.

Menopause is the time in a womans life when the ovaries stop working and she stops having menstrual periods for good. Menopause is sometimes called the change of life, or the change.

The ovaries stop releasing eggs and making the female hormones, estrogen and progesterone. In the months or years leading up to natural menopause, menstrual periods may become less frequent and irregular, and hormone levels may go up and down. This time is called perimenopause or the menopausal transition. Since periods can become less frequent during this time, it can be hard to know when they have actually stopped (and you have gone through menopause) until you look back at a later time.

Women who have their ovaries removed by surgery (oophorectomy) or whose ovaries stop working for other reasons go through menopause, too, but much more suddenly (without the menopausal transition).

Women who have had their uterus removed (hysterectomy) but still have their ovaries stop having periods, but they dont really go through menopause until their ovaries stop working. This is often determined based on symptoms, but your doctor can tell for certain by testing your blood for levels of certain hormones. Hormones made by the pituitary gland called luteinizing hormone (LH) and follicle stimulating hormone (FSH) help regulate the ovaries before menopause. When levels of estrogen get lower during menopause, the levels of FSH and LH go up. High levels of FSH and LH, along with low levels of estrogen, can be used to diagnose menopause. Blood tests for these may be helpful in a woman who has had her uterus removed.

Some drugs can turn off the ovaries and cause menstrual periods to stop for a time. Although this is not the same as menopause, it can lead to many of the same symptoms.

Most of the symptoms of menopause are linked to lower estrogen levels. Some symptoms hot flashes and night sweats, for instance tend to fade away at some point, whether or not they are treated. Other problems that start after menopause, like dryness and thinning of vaginal tissues and bone thinning, tend to get worse over time.

Because many of the symptoms and problems of menopause are linked to low levels of estrogen, this hormone has often been used in the past to treat menopause.

The hormones most commonly used to treat symptoms of menopause are estrogen and progesterone. (Progesterone and drugs that act like it are called progestins). Often, these 2 hormones are used together, but some women are given estrogen alone. Its important to know which hormones you are talking about when looking at the risks.

Common estrogen preparations used to treat menopausal symptoms include conjugated equine estrogens (CEE or Premarin) and estradiol, but several forms or types of estrogen are available.

There are also many progestins available, but medroxyprogesterone acetate (MPA or Provera), is often used with an estrogen to treat menopausal symptoms. Some preparations contain both an estrogen and a progestin.

Androgens (male hormones like testosterone) are also sometimes used to treat menopausal symptoms. This is not common, though, and because only a few studies have looked at this practice, it isnt clear how safe it is in the long run.

Tibolone is a synthetic hormone drug that can act like estrogen, progesterone, and testosterone in different tissues of the body. Because this drug isnt available in the US, its not discussed here.

Treating menopausal symptoms with estrogen and progestin together is known as estrogen-progestin therapy (EPT) or combined hormone therapy. Although estrogen alone improves the symptoms of menopause, it increases the risk of cancer of the uterus ( endometrial cancer). Adding a progestin to the estrogen lowers the risk of endometrial cancer back to normal. Because of this, EPT is given to women who still have a uterus (those who have not had a hysterectomy). EPT can be given 2 ways:

Bio-identical hormones

The word bio-identical is sometimes used by sellers to describe hormone preparations that contain estrogens and progesterone with the same chemical structure as those found naturally in people. Sometimes, how much of the hormones the woman takes are adjusted based on blood tests of hormone levels. Marketers often describe bio-identical hormones as natural, and buyers often think that theyre safer than other forms of estrogen and progestin used to control menopause symptoms. But so far, there are no long-term studies of bio-identical hormones, and no studies have found that women taking bio-identical hormones have less serious side effects than women taking other forms of these hormones. For this reason, bio-identical hormones should be assumed to have the same health risks as any other type of hormone therapy.

Some herbal remedies and supplements are also described as natural ways to treat the symptoms of menopause. For more on this, see Herbs and supplements in the section called What does it all mean?

Treating menopausal symptoms with estrogen alone is known as estrogen therapy (ET). ET improves the symptoms of menopause, but it increases the risk of cancer of the uterus (endometrial cancer). Because of this, ET is only safe for women who dont have a uterus (such as those who have had a hysterectomy).

Hormones can be given so that they enter the bloodstream and circulate to reach all parts of the body. This is called systemic hormone therapy, and its often used to treat the symptoms of menopause. Systemic hormone therapy includes:

Systemic hormones can help with certain symptoms of menopause, such as hot flashes and night sweats, as well as problems linked to thinning of the lining of the vagina (such as dryness that can make sex painful). They can also help prevent and treat osteoporosis (severe bone thinning).

Hormones, most often estrogen, can also be placed in or near the place that needs treatment. This is called topical hormone therapy. If small doses are used, little of the hormone is absorbed into the bloodstream, so it has little if any effect on the rest of the body.

For women in menopause, very small doses of estrogen can be placed inside the vagina as topical therapy to help treat dry or thinned vaginal tissues. This type of estrogen comes in the form of vaginal creams, rings, and tablets. Even though tiny amounts of hormone may enter the blood, most of it stays in the vaginal tissues. Because so little of the hormone gets into the blood, topical treatment doesnt help with problems like hot flashes, night sweats, or osteoporosis. Generally, topical estrogen is not needed in women taking systemic hormones.

(As noted earlier, theres a type of vaginal ring that delivers high doses of hormones to the whole body, which would be considered systemic treatment. If youre unsure about the type of ring you have, check with your doctor.).

Different types of studies can be used to look at cancer risk from menopausal hormone therapy (MHT).

Randomized controlled trials: In this kind of study, a group of patients get the drug being studied (like MHT), and another (control) group gets a placebo (like a sugar pill). Results from this kind of study are powerful because which group a patient is in is based on chance. This helps assure that the groups are similar in all ways, such as risk for cancer, except for the drug thats being studied. This is the best way to see the effects of a drug. These types of studies can also be double-blinded, which means neither the people in the study nor their doctors know which group they are in. This lowers the chance that thoughts or opinions about treatment could affect the study results. Unfortunately, these kinds of studies are costly, which limits the number of people in the study, how long the study can continue, and the number of studies done.

Observational studies: These kinds of studies collect information about a large group of people but dont give them a certain treatment, such as a drug. In observational studies of MHT, the women and their doctors decide what hormone drugs, if any, the women take and for how long. These kinds of studies can also gather information about other factors that can influence cancer risk. Some observational studies gather data about what happened over previous years. Others follow (observe) people for years to look at how different factors (like MHT) affect cancer risk. Observational studies can be less costly than randomized clinical trials, so theyre more common and often enroll many more patients.

A major drawback of observational studies is that the people getting the treatment being studied may have different cancer risk factors than the people who arent. Plus, the treatment (like which drugs are used for MHT and how long theyre taken) can differ between the people being studied. This makes it less clear that the differences seen are only due to the drug being studied (like MHT) and not other factors.

When observational studies and randomized controlled trials have different results, most experts give more weight to the results of the randomized controlled trial.

Several large studies have looked at possible links between systemic hormone therapy in menopausal women and different types of cancer.

The main randomized studies of MHT were part of the Womens Health Initiative (WHI). The WHI included 2 randomized placebo-controlled clinical trials of MHT in healthy women:

The WHI also conducted some observational studies. However, when we mention a WHI study below, were referring to one of the randomized studies.

Many observational studies have looked at MHT and cancer risk. One example is the Million Women Study. It enrolled over a million women aged 50 to 64 in the UK, collected information about hormone use and other health and personal details, and followed the women for many years. Not all of the women in the Million Women Study took MHT. Some of the women taking MHT were on ET, some were on EPT, and some took another drug. Some of the women on ET still had their uterus.

Studies show that EPT does not increase the risk of endometrial cancer (cancer in the lining of the uterus). It is linked to a higher risk of abnormal vaginal bleeding. Because vaginal bleeding after menopause can be a symptom of endometrial cancer, this often leads to further testing.

Based on the WHI study, taking EPT is linked to a higher risk of breast cancer. The longer EPT is used, the higher the risk. The risk returns to that of a woman who never used EPT (the usual risk) within 3 years of stopping the hormones. Breast cancers in women taking EPT are more likely to be found when they are bigger and have spread beyond the breast.

To put the risk into numbers, if 10,000 women took EPT for a year, it would result in up to about 8 more cases of breast cancer per year than if they had not taken hormone therapy (HT).

Taking EPT is also linked to increased breast density (as seen on a mammogram). Increased breast density can make it harder to find breast cancer on a mammogram.

Risk factors for ovarian cancer are harder to study because it is a less common cancer. Even when something increases the risk of developing ovarian cancer, the risk of actually getting this cancer is still likely to be low.

The WHI did not find a real difference in ovarian cancer risk with EPT. Although there were more cases of ovarian cancer in the women on EPT, this may have been due to chance because of the small number of women who were affected with this cancer.

However, a recent analysis combined the results of more than 50 studies, including randomized controlled trials and observational studies. This analysis found that women who took estrogen and progestin (progesterone) after menopause did have an increased risk of getting ovarian cancer. The risk was highest for women taking hormones, and decreased over time after the hormones were stopped.

To put the risk into numbers, if 1,000 women who were 50 years old took hormones for menopause for 5 years, one extra ovarian cancer would be expected to develop.

In the WHI study of EPT, the results were mixed. Women who took EPT had a lower risk of getting colorectal cancer at all, but the cancers they got were more advanced (more likely to have spread to lymph nodes or distant sites) than the cancers in the women not taking hormones.

Some observational studies have found a lower risk of colorectal cancer in women taking EPT, but some did not. So far, though, observational studies have not linked EPT with a higher risk of colorectal cancer.

EPT is not linked to a higher risk of getting lung cancer, but it is linked to a higher risk of dying from lung cancer.

EPT is not linked to a higher risk of any type of skin cancer (including both melanoma and other types of skin cancer).

In women who still have a uterus, using systemic ET has been shown to increase the risk of endometrial cancer (cancer of the lining of the uterus). The risk remains higher than average even after ET is no longer used. Although most studies that showed an increased risk were of women taking estrogen as a pill, women using a patch or high-dose vaginal ring can also expect to have an increased risk of endometrial cancer.

Because of this increased cancer risk, women who have gone through menopause and who still have a uterus are given a progestin along with estrogen. Studies have shown that EPT does not increase the risk for endometrial cancer.

Long-term use of vaginal creams, rings, or tablets containing topical estrogen doses may also increase the levels of estrogen in the body. Its not clear if this leads to health risks, but the amounts of hormone are much smaller than systemic therapies.

ET is not linked to a higher risk of breast cancer. In fact, certain groups of women taking ET, such as women who had no family history of breast cancer and those who had no history of benign breast disease, had a slightly lower risk of breast cancer.

The WHI study of ET did not report any results about ovarian cancer.

However, a recent analysis combined the results of more than 50 studies, including randomized controlled trials and observational studies. This analysis found that women who took estrogen after menopause did have an increased risk of getting ovarian cancer. The risk was highest for women currently taking estrogen, and decreased over time after estrogen was stopped.

To put the risk into numbers, if 1,000 women who were 50 years old took estrogen for menopause for 5 years, one extra ovarian cancer would be expected to develop.

Observational studies have shown that women who take ET have a higher risk for ovarian cancer compared with women who take no hormones after menopause. The overall risk remains low, but it does increase the longer a woman uses ET. The risk of ovarian cancer goes down after a woman stops taking the hormone.

In the WHI study, ET did not seem to have any effect on the risk of colorectal cancer.

Observational studies have found a lower risk of colorectal cancer in women who have used ET for many years.

ET does not seem to have any effect on the risk of lung cancer.

ET is not linked to a higher risk of any type of skin cancer (including both melanoma and other types of skin cancer).

The decision to use estrogen, alone (ET) or with a progestin therapy (EPT), after menopause should be made by each woman and her doctor after weighing the possible risks and benefits. Things to think about include:

Other factors to consider include how bad the womans menopausal symptoms are and the type and dose of the hormones the doctor recommends.

The American Cancer Society has no position or guidelines regarding menopausal hormone therapy.

If you and your doctor decide that MHT is the best way to treat symptoms or problems caused by menopause, keep in mind that it is medicine and like any other medicine its best to use it at the lowest dose needed for as short a time as possible. And just as you would if you were taking another type of medicine, you need to see your doctor regularly. Your doctor can see how well the treatment is working, monitor you for side effects, and let you know what other treatments are available for your symptoms.

All women should report any vaginal bleeding that happens after menopause to their doctors right away it may be a symptom of endometrial cancer. A woman who takes EPT does not have a higher risk of endometrial cancer, but she can still get it.

Women using vaginal cream, rings, or tablets containing only estrogen should talk to their doctors about follow-up and the possible need for progestin treatment.

For women who have had a hysterectomy (surgery to remove the uterus), a progestin does not need to be a part of hormone therapy because theres no risk of endometrial cancer. Adding a progestin does raise the risk of breast cancer, so ET is a better option for women without a uterus.

Women should follow the American Cancer Society guidelines for cancer early detection, especially those for breast cancer. These guidelines can be found inBreast Cancer Early Detection.

Many over-the-counter natural (herbal) products are promoted in stores and online as helpful with menopausal symptoms. These include vitamins and soy-based and herbal products (like black cohosh and red clover). There are also endless arrays of special blends of herbs and vitamins that claim to reduce the discomforts of menopause.

These products are considered dietary supplements (not drugs). They have not been evaluated by the Food and Drug Administration (FDA) to be sure that they work or even that they are safe. Some supplements have been tested in small clinical trials, but often the studies only looked at taking the substance for a short time (months), so it isnt clear how safe it would be if taken for a long time. Another concern has been applying the results of a study of a particular version and dose of a supplement to others that werent tested.

Most of the plain herbs that are touted for menopausal symptoms carry a low risk of harm for most women, but some can interact with other drugs and/or cause unexpected problems. You should discuss herbs or supplements with your doctor before taking them.

Well-controlled scientific studies are needed to help find out if these products work and if they are any safer than the hormone therapy drugs now in use.

Beware of products with secret formulas or hormone-like ingredients that may cause harm. In the past, some natural herbal supplements made in other countries have been found to contain actual drugs, some of which have been banned from the United States because they are dangerous. Its your right to know exactly what youre taking and what side effects and drug interactions it may have.

You can learn more in Dietary Supplements: What Is Safe?

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Menopausal Hormone Therapy and Cancer Risk

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Hormone Replacement Therapy (Risks and Benefits). HRT …

Posted: at 9:40 pm

Approximately 80% of menopausal women experience symptoms. While a quarter have severe symptoms, only a small proportion of menopausal women currently take hormone replacement therapy (HRT).

Symptoms of the menopause last far longer than most women anticipate. Frequent menopausal vasomotor symptoms, including night sweats and hot flushes, persist in more than half of women for more than seven years.[1]

HRT is an effective treatment for the typical menopause-related symptoms. There are also other long-term health problems associated with the menopause – the risk of osteoporosis, cardiovascular disease and stroke all increase after the menopause. HRT can also have a positive influence on these health problems.

This article discusses HRT in detail. The separate Menopause and its Management article discusses menopausal symptoms, differential diagnosis and possible investigations (although the diagnosis is usually clinically based on the typical symptoms). It also discusses health problems associated with the menopause and gives an overview of management.

See also separate HRT – Initial Consultation, HRT – Follow-up Assessments and HRT – Topical articles.

Current guidelines advise consideration of HRT for troublesome vasomotor symptoms in perimenopausal and early postmenopausal women without contra-indications and after individualised discussion of likely risks and benefits.[2]

Starting HRT in women over the age of 60 years is generally not recommended.

For women with premature (age

Current indications for the use of HRT are:

The benefits of HRT outweigh the risks for the majority of women aged under 60 years.[2, 4]

Benefits of HRT include:

Reduction in vasomotor symptoms

Improvement in quality of life

Improvement in mood changes

Improvement of urogenital symptoms

Reduction in osteoporosis risk

Reduction in cardiovascular disease

Lower risk of colorectal cancer

Other benefits

The principal risks of HRT are thromboembolic disease (venous thromboembolism (VTE) and pulmonary embolism), stroke, breast and endometrial cancer, and gallbladder disease.

Large studies, including the WHI and the Million Women Study (MWS), in the past cast concerns and controversy over the use of HRT.[18, 26]

However, data accumulated from the WHI and other studies over the past decade have shown that, in women with symptoms or other indications, initiating HRT near menopause usually provides a favorable benefit:risk ratio;[2].

VTE[2]

StrokeThe risk of ischaemic (but not haemorrhagic) stroke:[2]

Breast cancer

NB: there is no evidence of an increased risk of breast cancer in women on HRT under the age of 51 years compared with menstruating women of the same age.

Endometrial cancer

Ovarian cancer

Investigations are not usually necessary before starting HRT unless:

It is important that an individualised approach is undertaken at all stages of diagnosis, investigation and management of menopause.[2]

The dose, regimen and duration of HRT need to be individualised. There is no maximum duration of time for women to take HRT; for the women who continue to have symptoms, their benefits from HRT usually outweigh any risks. Systemic HRT should not be arbitrarily stopped at age 65 years; instead treatment duration should be individualised based on patients’ risk profiles and personal preference.[35]

Micronised progesterones are natural, ‘body-identical’ progesterones, devoid of any androgenic as well as glucocorticoid activities but being slightly hypotensive due to their anti-mineralocorticoid activity. These appear to be the optimal progestogen in terms of cardiovascular effects, blood pressure, VTE, probably stroke and even breast cancer.[36]Utrogestan is the only one currently available to prescribe in the UK. This can be prescribed with oral or transdermal oestrogen. It is commonly prescribed at a dose of 200 micrograms a day for two weeks followed by a two-week break for those women who are still having periods. For a continuous combined use, it should be prescribed as 100 micrograms daily. It is usually taken at night.

As transdermal oestrogen is associated with fewer risks than oral HRT, a transdermal route may be preferable for many women. This route is also advantageous for women with diabetes, history of VTE and also those with thyroid disorders. In addition, transdermal HRT is preferable to those women with a history of migraine or gallbladder problems.

Delivery routes include:

The choice of delivery route depends partly on patient preference but there are also other advantages to certain delivery routes.

By avoiding the first pass metabolism through the liver, non-oral preparations (ie patches or gels):

Other considerations

See separate HRT – Follow-up Assessments article for a discussion of how to manage these side-effects.

See separate HRT – Initial Consultation article.

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Hormone Replacement Therapy (Risks and Benefits). HRT …

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Hormone replacement therapy – Wikipedia

Posted: December 11, 2017 at 12:45 pm

Hormone replacement therapy (HRT) is any form of hormone therapy wherein the patient, in the course of medical treatment, receives hormones, either to supplement a lack of naturally occurring hormones or to substitute other hormones for naturally occurring hormones. Common forms of hormone replacement therapy include:

As recently as 2005, cisgender (non-transgender) women have had a positive attitude towards hormone replacement therapy, but based on the empirical data, these attitudes may be overly optimistic.[3] There is still much to learn about how HRT affects people. In the combined hormone trial, the WHI tested only one estrogen (Premarin) and one progestin (Provera), in a single pill (Prempro), at a single dose (0.625mg Premarin and 2.5mg Provera). Therefore, the results are not reliable nor representative.

To avoid HRT risks, it is essential to use the most effective delivery method of both estrogen and progesterone. Bioidentical estradiol (estrogen) when taken orally is converted in the liver to estrone, a weaker bioidentical estrogen. However, when estrogen as estradiol is used transdermally as a patch, gel, or pessary, it enters the bloodstream as bioidentical estradiol. When estrogen is ingested it is subjected to first pass metabolism (Phase I drug metabolism) and is processed through the liver. This first pass metabolism stimulates proteins associated with heart disease and stroke, such as C-reactive protein, activated protein C, and clotting factors. Using a patch, gel, or pessary to take estrogen avoids first pass metabolism and the risks associated with it and the same level of blood concentration can be achieved avoiding the serious side effects associated with oral estradiol HRT. Current research shows that the transdermal route of estradiol administration can also be advantageous for women with diabetes, hypertension and other cardiovascular risk factors, as those risks increase with advancing age.[4] Women taking bioidentical estrogen, orally or transdermally, who have a uterus should still take a progesterone to lower the risk of endometrial cancer. The plant-derived progesterone creams sold over the counter contain too little progesterone to be effective. Wild yam extract creams are not effective since the natural progesterone present in the extract is not bioavailable.[5]

Past research has highlighted potential risks of HRT. The principal results from the Women’s Health Initiative Randomized Controlled Trial was that hazard rate of invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits.[6]

A study where women going through menopause using HRT with Progestin as a major component of the therapy showed a few negative effects on hearing, which highlights the importance of choosing bioidentical progesterone instead of synthetic progestin. Not only does the Progestin decrease the functionality of many regions of the ear it also reduces the effectiveness in parts of the central nervous system used for hearing.[7] Also, in some situations, it has been shown that menopausal women who are caregivers and receive HRT can have an increased chance for cardiovascular issues. As caregivers, it is implied that they have more acute stress in their lives and that acute stress along with the HRT is priming negative cardiovascular effects.[8]

Recent research done by the Million Women Study, funded by Cancer Research UK has proven that certain forms of HRT increase the risk of endometrial (womb) cancer. However, previous research has shown that the combined type of HRT poses a greater breast cancer risk than tibolone or oestrogen (estradiol)-only HRT and, because breast cancer is more common than endometrial cancer, the researchers believe that when considering the overall effect of HRT it is important to look at both breast and endometrial cancer.[9] However, this study was conducted using oral estradiol instead of transdermal estradiol which avoids the risks which the study highlights. Again, this shows that the combined estrogen patch (such as Evorel Conti) or gel (ESTROGEL PROPAK – 17-estradiol and micronized progesterone) is the preferable treatment choice.[10]

The Society of Obstetricians and Gynaecologists of Canada recommends Transdermal Estrogen and Micronized Progesterone as a first line hormone therapy option stating that the overall benefits of this therapy include reduction of vasomotor symptoms (hot flashes), lower risk of osteoporotic fractures, lessening of urogenital atrophy, lowering somatic pain and arthralgia, lowering the risk of colorectal cancer and mood stabilization.[10]

There is a structural difference between hormone therapies that are bioidentical and those that are non-bioidentical, as non-bioidentical are responsible for side effects and health risks in humans. However, they can have positive health benefits for women, and bioidentical hormones can be customized from individual to individual.[11]

Hormone replacement therapy has been shown to have other beneficial effects. In a study women taking estrogen through HRT showed that the estrogen positively affects the prefrontal cortex by boosting the working memory. This suggests that estrogen may play a key role in certain frontal lobe functions in women.[12] Women using HRT after menopause have no additional weight gain compared to women who do not use HRT.[13] Also women who use HRT with an estrogen component show positive effects in their sex life (mainly increasing their sex drive and sexual sensitivity) but the effects are inconsistent across women. These sexual improvements may dissipate after receiving some forms of HRT for extended periods of time.[14]

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Hormone replacement therapy – Wikipedia

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