Physicians started treating perimenopause symptoms in women with short courses of hormone replacement therapy (HRT) in the 1940s. When HRT demonstrated that it could protect women from osteoporosis, cardiovascular disease, and other age-related ailments, physicians started prescribing long-term HRT for all women who were postmenopausal.1 By 1995, approximately 38% of postmenopausal women in the United States were taking HRT to treat menopausal symptoms and decrease the risk of chronic conditions.2

In 1993, the National Institutes of Health commenced the Women's Health Initiative (WHI). The study was halted in 2002 because the investigators found an increased risk of breast cancer, heart attack, stroke, and blood clots in women taking HRT and an increased risk of ovarian cancer in women taking estrogen therapy.1 However, current research shows that when administered with careful supervision, HRT can safely relieve many symptoms of perimenopause.1-5 Most commonly, HRT is an effective treatment for hot flashes, atrophic vaginitis, and postmenopausal osteoporosis.5-8

BENEFITS OF TREATMENT

Hot flashes A common vasomotor symptom, hot flashes improve within several months in 30% to 50% of women and usually resolve completely within 4 to 5 years after the onset of menopause.4 Conjugated equine estrogen and medroxyprogesterone acetate (Depo-Provera, Provera, generics) were shown to improve hot flashes and sleep disturbances in women aged 50 to 54 years.5

Atrophic vaginitis The decrease in estrogen during menopause causes atrophic vaginitis, which leads to dryness, irritation, itching, soreness, dyspareunia, and discharge. In a study of the efficacy of low-dose estradiol vaginal tablets for the treatment of atrophic vaginitis, doses of 10 mcg and 25 mcg were found to improve atrophy, relieve vaginal symptoms, decrease vaginal pH, and increase maturation of the vaginal epithelium.6 Whereas greater improvements were seen with 25 mcg, both doses were effective for treating vaginal atrophy in postmenopausal women.6

Osteoporosis The WHI studied 16,608 women aged 50 to 79 years to determine if estrogen and progestin HRT can reduce the risk of hip, vertebral, and wrist fractures. Bone mineral density (BMD) of the hip and lumbar spine were measured at baseline, and at 1, 3, and 6 years.7 Study conclusions showed that HRT can significantly improve BMD and reduce fracture risk regardless of age, personal or family history, tobacco or alcohol use, or fracture risk rates.7

Colorectal cancer As part of the WHI, Chlebowski and colleagues analyzed the risk of colorectal cancer in women who were taking HRT and women who were not taking HRT.8 Chlebowski's group concluded that HRT use was associated with a statistically significant decrease in the incidence of colorectal cancer in perimenopausal women because of the chemical properties of estrogen.8 However, HRT can also delay the diagnosis of colorectal cancer, thus emphasizing the importance of bowel screening in these women as well as a thorough discussion of the benefits and risks before prescribing HRT.

BOTTOM LINE

HRT is effective for perimenopausal women who do not have contraindications for estrogen therapy. Contraindications include abnormal vaginal bleeding, thromboembolic disease, breast cancer, other estrogen-sensitive cancers, or liver disease.4 The recommended dosage is the lowest effective dose for the shortest duration. If the uterus is still present, combination estrogen and progestin or progesterone must be prescribed to prevent endometrial hyperplasia or cancer.4

The risk-to-benefit ratio increases after menopause; therefore, recommendations are to discontinue HRT 2 to 3 years after the onset of menopause. As long as the patient's symptoms do not return, dosage can be tapered by reducing the daily dose or decreasing the number of doses per week.4 JAAPA

Adrienne Miller is a student at Eastern Virginia Medical School, Norfolk, Virginia. She has indicated no relationships to disclose relating to the content of this article.

REFERENCES

1. Canderelli R, Leccesse L, Miller NL, Unruh Davidson J. Benefits of hormone replacement therapy in postmenopausal women. J Am Acad Nurse Pract. 2007;19(12):635-641.

2. Nelson HD. Commonly used types of postmenopausal estrogen for treatment of hot flashes: scientific review. JAMA. 2004;291(13):1610-1620.

3. American College of Obstetricians and Gynecologists (ACOG). Frequently asked questions about hormone replacement therapy. October 2004. ACOG Web site. http://www.acog.org/from_home/publications/press_releases/nr10-01-04.cfm. Accessed June 9, 2009.

4. Nelson HD. Postmenopausal estrogen for treatment of hot flashes: clinical applications. JAMA. 2004;291(13):1621-1625.

5. Hayes J, Ockene JK, Brunner RL, et al; Women's Health Initiative Investigators. Effects of estrogen plus progestin on health-related quality of life. N Engl J Med. 2003;348(19):1839-1854.

6. Bachmann G, Lobo RA, Gut R, et al. Efficacy of low-dose estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Obstet Gynecol. 2008;111(1):67-76.

7. Rossouw JE, Anderson GL, Prentice RL, et al; Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.

8. Chlebowski RT, Wactawski-Wende J, Ritenbaugh C, et al; Women's Health Initiative Investigators. Estrogen plus progestin and colorectal cancer in postmenopausal women. N Engl J Med. 2004;350(10):991-1004.