Hormone Replacement Therapy: The Right Regimen for You

You’ve discussed your symptoms and risk factors with your healthcare provider, you’ve done some research, and you’ve decided to take hormone replacement therapy (HRT). Before you take any pills, apply patches, or rub in creams, you need the answers to some questions: What should you take, how much should you take, and when should you take it?

What to take

While there is no set combination or dosage of hormones that works for every woman, a hormone replacement therapy regimen will commonly include a combination of:

  • a form of estrogen
  • a form of progesterone
  • and, if needed, an androgen such as testosterone

The estrogens: Not all alike

While we tend to think of estrogen’s relationship to our reproductive function first, this hormone actually nourishes and protects our bodies in hundreds of ways, from our hearts, to our bones, to our skin and hair. In the uterus, estrogen causes the lining (endometrium) to thicken and build up each month until it is sloughed as a menstrual period.

“Estrogen” is often used as a general term, but it is actually a category of hormones. Of the many types of estrogen our bodies make, these are those produced in major amounts:

  • Estradiol is the most potent form of estrogen, and the one produced in the largest amounts by a woman’s ovaries before menopause. Estradiol levels fall after menopause. The brand names Estrace, Estraderm, Vivelle, Alora, FemPatch, Estring, and Climara contain estradiol.
  • Estrone is the predominant estrogen in a woman’s body after menopause. When ovarian function declines, the fat cells in a woman’s body take over the role of synthesizing estrone. Premarin and Ogen contain estrone (Premarin also contains other estrogens derived from the urine of pregnant horses).
  • Estriol is known as the “weak” or “forgotten” estrogen. Produced in large amounts by the placenta during pregnancy, estriol is also converted in small amounts by the liver. Estriol is not commercially available in the U.S. and must be compounded by a pharmacist.

You have a variety of estrogen preparations to choose from.

Commonly prescribed estrogens include:

  • Premarin (oral tablet)
  • Estraderm (transdermal skin patch)
  • Estring (vaginal ring)
  • Climara (transdermal skin patch)
  • Vivelle (transdermal skin patch)
  • FemPatch (transdermal skin patch)
  • Estrace (oral tablet, vaginal cream)
  • Ogen (oral tablet, vaginal cream)

When taken alone as a medication, estrogen can cause the cells in the uterine lining to become crowded or malformed. Progesterone, on the other hand, controls that effect, protecting you from endometrial abnormalities. You can choose between synthetic forms of progesterone, called progestins, and natural progesterone (progesterone USP), which must be compounded by a pharmacist.
Arriving at the right hormone replacement therapy formulation for you can take some time and adjustment. For many women, 0.625 mg Premarin or 1 mg Estrace are good starting dosages of estrogen. Dosages of progesterone vary depending on the type of progesterone you are taking, and whether you are on a continuous or cyclical regimen.

If the initial hormone replacement therapy dose gives you uncomfortable side effects or doesn’t alleviate your symptoms, your healthcare provider can adjust the dose, try a different form of estrogen, or use natural progesterone instead of synthetic progestin, depending on your individual situation.

Patch, pill, or cream?

In choosing the form of hormone replacement therapy that is best for you, there are several factors you will want to consider, including which symptoms are most important for you to manage.
Because the level of heart and bone protection differs with various forms of hormone replacement therapy, your individual profile and family history of these conditions may come into play. Some women value convenience very highly and choose a form of hormone replacement therapy that is easiest for them to remember how and when to take. Finally, some women weigh the costs of various forms, and factor that into their decision.

Points you may want to keep in mind in deciding between oral (taken by mouth), transdermal (skin) patch, transdermal (skin) cream or vaginal cream estrogen:

  • The estrogen skin patch may not have as great an effect in preventing heart disease, it’s more expensive than oral estrogen, and the adhesive sometimes causes skin irritation.
  • The skin patch may be a good choice for you if your triglyceride levels are abnormally high. Transdermal estrogen enters the body through the skin and does not raise triglyceride levels. Oral estrogen appears to increase triglyceride levels somewhat because it passes through the liver.
  • Estrogen in cream form is very effective in treating urinary and vaginal problems. (Premarin, Estrace, and Ogen are commercially available as vaginal creams; the “weak” estrogen, estriol, while not commercially available, can be compounded as a cream or suppository by a pharmacist).
  • Vaginal estrogen creams may not protect against heart disease or bone loss.

Natural hormone options

Used in connection with hormones, the term natural can be confusing. More and more the term bioidentical is used instead of natural when pertaining to prescription compounded hormones. When we say natural we mean chemically identical to the hormones produced in your body. That’s the key difference between the synthetic progestins and natural progesterone, for example.

The synthetic progestins (Provera is a commonly-prescribed synthetic progestin) are similar to the progesterone your body produces, but the subtle chemical differences can significantly influence the hormone’s action and side effects in the body. Synthetic progestins can cause side effects of irritability, nausea, depression, and water retention in some women. Natural progesterone is identical to the hormone made in the body, and many women find it easier to tolerate.

Many women are often surprised to learn that commercially manufactured and frequently-prescribed forms of estrogen (Estrace and Estraderm for example) are “natural” estrogens. Choosing among estradiol, estrone (both potent forms of estrogen) or estriol (the weaker estrogen) is a decision best made based on the specific perimenopausal symptoms that need to be managed.

For instance, estriol, the “weak” estrogen is good for managing vaginal dryness, urinary infections, hot flashes and stress incontinence. The fact that estriol is “weak” has pluses and minuses. Estriol does not provide as much heart and bone protection as other more potent estrogens like estradiol and estrone. But it has little or no effect on breast or uterine tissue, so estriol avoids the risk of breast or uterine cell abnormalities associated with estradiol and estrone.

Unlike estradiol or estrone, estriol can be taken alone, without progesterone, because it has no effect on the uterine lining. A woman who has no family history of heart disease or osteoporosis, has cholesterol levels and bone density levels within normal ranges, but who suffers from vaginal dryness and/or incontinence and hot flashes, may be a good candidate for estriol.

Women who are taking the hormone testosterone to alleviate lack of sex drive also have the option of taking the natural form of this hormone. Natural testosterone is not commercially available and must be compounded by a pharmacist.

When to take it

If you’re taking hormone replacement therapy, you can choose between two types of regimens: cyclical and continuous combined.

Taking hormone replacement therapy cyclically, the most frequently prescribed regimen, mimics a menstrual pattern: you take estrogen every day and progesterone for 12-14 days.

When you finish taking progesterone each month, you experience bleeding as your body “withdraws” from the hormone progesterone, and the endometrial lining sloughs away (you have a period).

Continuous combined therapy, in which women take estrogen and progesterone every day, eliminates the breakthrough bleeding after some initial spotting in the first 1 to 3 months. Women also experience fewer side effects with this regimen.

Evaluating your choices

Whatever hormone replacement therapy regimen you choose, be aware of two very important points, says Dr. Wulf H. Utian:

  1. The therapy must be evaluated at least annually by both you and your healthcare provider, sooner if you experience side effects or problems. No hormone therapy should ever be considered permanent, although you may be taking the hormones indefinitely.
  2. No single hormone “recipe” exists that will fit every woman. The first regimen you try may not work for you, but don’t give up. Your healthcare provider should fine-tune your hormone regimen to your individual needs – your risk factors, your symptoms before and during therapy, and your lifestyle.

Caution: Some women should not take estrogen: women who have had breast or uterine cancer; women with chronic blood-clotting problems, unexplained vaginal bleeding, or serious gall bladder or liver disease: or women who are or might be pregnant.
(Source: More reasons than ever for HRT,” T.L.Bush, R.D. Gambrell, Jr., and V. Miller, Patient Care, Nov. 15, 1993, pp. 103-132.)

Synthetic progestin – Provera
– Cycrin – Oral tablet
– Oral tablet – 2.5 – 10 mg/day
– 2.5 – 10 mg/day

Natural progesterone – Not commercially available – must be compounded by a pharmacist.
– Even release micronized tablet
– Micronized oral capsule
– Vaginal suppositories
– Rectal suspension
– Topical skin cream, gel or lotion
– Sublingual capusule
– Injection – 200 – 600 mg/day

– 200 – 600 mg/day
– 200 – 800 mg/day
– 200 – 800 mg/day
– 10 – 30 mg/day

– 50 – 100 mg/day
– 50 – 100 mg/day

Synthetic Testosterone
– Methyltestosterone
– Testosterone cypionate
– Fluoxymesterone
– Oreton
– Depotestosterone
– Halotestin
– Oral tablet
– Injection
– Oral tablet
– 1.5 – 2.5 mg/day
– 1.5 – 2.5 mg/day
– 1.5 – 2.5 mg/day
Synthetic Testosterone combined with estrogen
– Conjugated estrogens with methyltestosterone

– Esterified estrogen with methyltestosterone
– Premarin with methyltestosterone

– Estratest
– Oral tablet

– Oral tablet
– 1 tablet daily (contains estrogens with 10 mg methyltestosterone – also available in 1/2 strength tablets)
– 1 tablet daily (contains 1.25 mg petrified estrogens with2.4 mg methyltestosterone – also available in 1/2 strength tablets
Natural testosterone – Not commercially available – must be compounded by a pharmacist. – Oral capsule
– Topical skin cream
– Vaginal cream – 1.0 – 5.0 mg/day
– 0.1 – 0.5 mg/gm day

– 1 – 2% strength – to be used 1 – 2 times weekly

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Elle Michels

Elle Michels

Based in Washington, D.C., Elle Michels is a contributing writer to Womenshealth.com.

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