Estrogen Replacement Therapy

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Q: I am a single female who had a hysterectomy with a removal of my ovaries when I was 42. I have been on Premarin ever since. I take a fairly low dosage, but I was wondering if there is anything new on the market, or is this the drug I need to stay with? I know there are some side effects, such as an increased risk for breast cancer, but my doctor has never suggested anything else. I have heard of other women taking other things—what’s best?

A: While I do not know your present age or the length of time you have been on oral estrogen therapy, it is very important to have a frank and thorough discussion with your physician. You do have treatment choices that balance the health benefits versus risks of each and every approach considered. What is best for you would depend upon personal preferences as well as your menopausal symptoms, age and current state of health.

When discussing options or a change in therapy, factors to consider include but aren’t limited to:

Your personal health history and risks (breast or other cancers, heart disease, blood clots, stroke, liver disease, osteopenia or lower mineral bone density, osteoporosis, etc.)
Family history (breast, lung, colon or other cancers, heart disease, osteoporosis, stroke, others)
Current age. The further from your natural menopause years (the average onset age for menopause is 51), the greater the potential for a slightly increased risk for breast cancer and stroke in those using oral estrogen therapy (please speak with your physician, as studies are ongoing).
Smoking tobacco, as this in combination with oral estrogen increases the risk for blood clots, pulmonary embolism, etc.
Current menopausal symptoms such as hot flashes, sleep disturbances, vaginal dryness, mood swings, increased anxiety, thinning hair, dry skin and other related symptoms

While menopause itself does not require medical intervention, preventing its health risks (osteoporosis, others) as well targeting the potential symptoms (hot flashes, vaginal dryness, etc.) are major reasons to consider a treatment or enhanced lifestyle approach. Suggestions include but aren’t limited to:

Antidepressants such as Venlafaxine, citalopram and similar agents that may help to decrease the severity and number of hot flashes, as well as lessen the feeling of anxiety and mood swings
Estrogen therapy using the oral and transdermal route (applied to the skin) has been shown to greatly reduce hot flashes
Estrogen therapy using vaginal cream or the low-dose vaginal ring helps to reduce vaginal dryness and irritation
Prescription medications in the biphosphonate (consider this instead of oral estrogen) or selective estrogen receptor modulator category as options in the fight against osteoporosis
Naturally occurring phytoestrogens found in soybeans, flaxseed, whole grains, and others, which could potentially relieve some menopausal symptoms (although studies are mixed). Get clearance from your physician—large amounts of phytoestrogens have the potential to act like estrogens.
Acupuncture (reduction in hot flashes)
Black cohosh, an herb that may ease hot flashes (check with your physician first)
Regular exercise (may improve mood, increase energy levels, improve sleep, aid in circulation and enhance your libido)
A balanced diet to improve energy levels, mood (omega 3 fatty acids) and enhance bone health (vitamin D 3 and calcium)
Yoga or Tai Chi (assist in muscle strength, balance, feeling of wellness, ability to focus and concentrate)
Kegel exercises (enhance sexual enjoyment, decrease the risk for stress urinary incontinence)
Quitting the tobacco habit (better for your heart, lung and bone health, and it decrease the flares of hot flashes)

Given that you have been on oral estrogen therapy, potential benefits include but aren’t limited to a reduction in the amount and intensity of hot flashes; decreased risk for osteoporosis; decreased risk for gum and dental disease; increased ability for vaginal lubrication; decreased risk for depression; and alleviation of the restless sleep that may be related to the decline in hormone function.

Regarding the potential risks, these include but aren’t limited to a slightly increased risk for blood clots (pulmonary embolism and deep vein thrombosis); stroke; gallstones; and possibly a small increase in the risk for breast cancer (this is controversial, but the risk may be higher than normal in those using this option for 10 years or more).

When all is said and done, if the decision is made to continue your use of oral estrogen treatment, the current recommendation is to use the lowest dose for the shortest amount of time that’s needed to relieve symptoms and maintain your quality of life.

Lastly, if the discussion with your personal physician does not give you peace of mind, please seek a second opinion from a physician (family doctor, gynecologist, endocrinologist) knowledgeable in women’s post-menopausal health. For further information, please check out The Red Hot Mommas as well The North American Menopause Society and The American College of Obstetricians and Gynecologists.

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Robert Danoff, D.O., M.S., is a family physician and program director of The Family Practice Residency, as well as the combined Family Practice/Emergency Medicine Residency programs at Frankford Hospitals, Jefferson Health System, Philadelphia, Pa. He is the medical correspondent for CN8, The Comcast Network, a regular contributor to Discovery Health Online and a contributing writer to The New York Times Special Features. (Read his full bio.)