Hormonal Evaluation

Your doctor may decide to order some blood tests to evaluate your hormones. Depending on what symptoms the patient has, the physician may decide to check any of the following: estrogen, testosterone, prolactin, progesterone, TSH, LH, or FSH. Each of these tells the doctor something different about your problem.

What is hormone replacement therapy?
Hormone replacement therapy (HRT) refers to a program of taking estrogen, usually the lowest effective dose, and progesterone to replace the natural hormones that decrease at menopause.

Menopause is the time when menstruation stops. It is often a gradual process in which menstrual periods become irregular and eventually end completely. After you are through menopause, your ovaries no longer produce eggs and your body produces less estrogen.

Menopause is part of a natural aging process and not a disease. For many women menopause is an easy transition. However, some women will have a variety of difficulties that are related to their estrogen deficiency. If you are one of these women, you may benefit from therapy to replace some of the estrogen lost from menopause. Estrogen also benefits women with easy menopausal transitions by decreasing heart disease and strengthening the bones.

Estrogen is one of two major female hormones. The other is progesterone. For women who still have their uterus, progesterone is added to the estrogen program because it reduces the risk of cancer of the uterus, a major concern with estrogen replacement therapy (ERT) in the past. Treatment with both estrogen and progesterone is called hormone replacement therapy.

These hormones are available in tablets and are also given in the form of creams, skin patches, vaginal suppositories, or shots.

When is it used?
Hormone replacement therapy can be used to treat some women during the period before, during, and after menopause. Menopause means having no menstrual periods for a least 6 months to 1 year.

There are two kinds of menopause:

• Physiologic menopause refers to menopause that occurs naturally for most women between ages 45 and 60; the average age is 50 to 52.
• Artificial menopause refers to when a woman's menstrual periods stop because the ovaries have been removed by surgery or damaged by radiation therapy.

Many physicians recommend HRT for women who go through menopause prematurely, that is, for women who stop menstruation before the age of 40, either naturally or artificially. Symptoms of estrogen withdrawal may be severe after an early surgical menopause. If the uterus is removed, uterine cancer is no longer a concern.

Hormone replacement therapy is often recommended to relieve these symptoms associated with menopause:

• severe hot flashes
• sleeplessness
• vaginal dryness, resulting in discomfort or pain during sexual intercourse.
• In addition, a doctor may prescribe hormone therapy if you are at risk for osteoporosis or coronary heart disease.

What are the benefits of HRT?
Osteoporosis
Osteoporosis is a skeletal disorder that reduces the density of bone, thus making you prone to fractures. Bone loss begins around age 35 and accelerates rapidly at menopause. You are at greatest risk of the disease if you are Caucasian, do not participate in regular exercise, are thin and fair-skinned, if you smoke, or if your mother had osteoporosis.

Hormone therapy is the best prevention and treatment of the disorder. Low-dose estrogen therapy can stop or slow down bone loss if medication is begun soon after menopause. Calcium supplements can also help to cut down on bone loss in combination with HRT.

Coronary heart disease
The risk of heart disease dramatically increases for women who have gone through menopause. Evidence shows estrogen reduces the risk of coronary heart disease. Some doctors recommend estrogen if you are at high risk for coronary heart disease. If you have high blood pressure, diabetes, high blood-cholesterol levels, or a family history of heart disease before age 55, estrogen therapy may reduce your risk of heart disease.

Menopausal symptoms
Hormone replacement therapy is also prescribed to relieve these symptoms of menopause:

• hot flushes or flashes, which may last for several months to a few years and are accompanied by profuse sweating
• Sleep disturbances
• Atrophic vaginitis, an irritation of the vagina caused by loss of estrogen; less estrogen in the body causes the tissues of the vagina to shrink and become thin and dry. This can case painful intercourse.

What are the risks of HRT ?
--Endometrial cancer if you are given only estrogen replacement therapy, without progesterone, and you still have a uterus. If you do not have a uterus, estrogen alone is fine.

Constant exposure of the endometrium, which is the lining of the uterus, to estrogen without progestin is associated with a higher risk of endometrial cancer.

-- Breast cancer
Studies are still being done to determine if being on HRT increases your risk of getting breast cancer. It is best to talk to your doctor about this possible risk. Many physicians recommend women be checked thoroughly for any tumors and be given a mammogram before beginning HRT. They also advise women taking HRT to have yearly mammograms and physical exams and to examine their own breasts monthly. If you have a family history of estrogen-dependent breast cancer, discuss this factor with your doctor.

Side effects of estrogen
The side effects of estrogen may include :

• uterine bleeding and vaginal discharge
• bloating, fluid retention, and weight gain
• breast tenderness and enlargement
• nausea
• symptoms resembling those of premenstrual tension, such as headaches and mood swings
• increased risk of gallstones if estrogen is taken orally.

Side effects of the combination therapy
Use of combination estrogen-progestin therapy after menopause has been associated with vaginal bleeding, especially for the first six months of use. When you stop estrogen and progestin combination therapy or withdraw from it during the days in the cycle when you are not taking hormones, you will usually have withdrawal bleeding. Unlike a menstrual period, the flow typically lasts only 2 or 3 days and is not usually accompanied by cramps or bloating.

When not to take HRT
If you have any of the following conditions or diseases, you should not take HRT :

• unexplained vaginal bleeding
• liver disease
• thromboembolic disease (history of blood clots, strokes) ; however, transdermal estrogen (a skin patch) may decrease thromboembolic disease
• endometrial or breast cancer

If you have any of the following diseases or conditions, you may want to discuss HRT's pros and cons with your provider:

• Uterine fibroids, or benign tumors that grow in response to estrogen ; they begin to shrink at menopause unless a woman takes estrogen. Taking progestin with estrogen does not prevent their growth.
• Endometriosis
• Fibrocystic breast disease
• Seizure disorder
• Migraine headaches
• Gallbladder disease
• Hypertension

How to take care of yourself
If you are considering HRT :

• Have your doctor check your cholesterol levels. If you find yourself in the danger zone, talk to your doctor about taking HRT.
• Get a mammogram before you begin HRT to see if you are at risk for breast cancer

If you are already on HRT :

• Ask your doctor about any special precautions or side effects to consider while taking estrogen and progestin.
• If you are taking estrogen combined with progestin, it is important to tell your doctor if bleeding occurs at any other time except the drug-free part of your therapy.
• If you are taking estrogen without progestin (and you have not had a hysterectomy), ask you doctor how to monitor for risk of endometrial cancer
• Check your cholesterol levels periodically
• If you have a history of hypertension, monitor your blood pressure closely.