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Menopause and HRT

Holistic-online.com

Hormone Replacement Therapy (HRT)

How HRT Is Administered: Application of Estrogen

Estrogen may be given in five ways:

Oral pills
Intramuscular injections
Transdermal Patches
Subcutaneous pellets
Vaginal Hormone Creams

Each method has its advantages and disadvantages. These are discussed below.

Oral pills
bulletMicronized estradiol (Estrace)
bulletEsterified estrogen (Estratab)
bulletConjugated equine estrogens (Premarin)
bulletEstropipate (Ogen, Ortho-Est)
bulletEthinyl Estradiol (Estinyl)
bulletQuinestrol (Estrovis)

Estrone (Premarin, Ogen and other brands) is the most popular oral estrogen, but estradiol (Estinyl, for instance) is gaining in popularity. Both are effective and generally well-tolerated. For a variety of reasons some women are unable to take oral estrogen. And in some rare cases, oral estrogens are ineffective and useless.

Many people find the pill form very convenient as it is something they are comfortable with. However, it may not be the most efficient form of introducing hormones where you want it to be.

Many pills disintegrate in the stomach, and may not enter into your system. Newer micronized products in oil base help protect the product from the acids in the stomach and helps the hormone make its way intact into your system for a better blood level.

The daily dosage is much higher than in the cream form. The higher amount is necessary to compensate for the large percentage that is excreted by the liver. The absorption of the pills depends on many factors including how well your digestive system is operating and the health of your liver. All these factors requires that the oral dose be higher than the transdermal doses to create the equivalent biologic effects.

Advantages
bulletHighly effective in combating physical and emotional symptoms.
bulletTablets containing estrogen, progesterone, and testosterone are available.
bulletThe appropriate dose will offer a high level of protection against osteoporosis.
bulletYou can stop taking it immediately if it doesn't suit you.
bulletYou are responsible for your own medication.

Disadvantages
bulletYou may experience side effects such as breast tenderness, nausea, headaches and digestive irritation and swelling
bulletYou may experience breakthrough bleeding if you forget to take a tablet.
bulletMay be unsuitable if you have a history of high blood pressure, blood clotting, or liver disorders.

Intramuscular Injections.
bulletestradiol cypionate (Depo-Estradiol )
bulletestradiol valerate (Delestrogen , Estraval)

Estradiol in oil is most commonly used since it is absorbed slowly and needs be given only at 2 to 4-week intervals. Injected estrogen goes directly into the circulation without first passing through the liver. This has both good and bad effects. There is also some question about the predictability of absorption rates. The main drawbacks of intramuscular injections, however, are the discomfort of regular injections plus the peaks and valleys of estrogen levels that such a system inevitably produces.

Transdermal Patches.
bullettransdermal estradiol (Estraderm, Climara)

A medicated adhesive is attached to your abdomen, where it releases estradiol, a pure form of estrogen thought to be less cancer causing. Estradiol bypasses the liver and is best for women who can't take HRT orally but who have severe hot flashes and vaginal problems. The patches are worn constantly (below the waist and, by many women, on the buttocks and flanks) and are changed twice weekly. With this method, the estrogen is released through the skin in a consistent manner. The alcohol in the patch drives the hormone through the skin and into the blood vessels.

Their distinct advantage of the patch form is that it introduces a relatively constant and even flow of estrogen into the body day and night, with no peaks or valleys and, thus, fewer side effects related to over or undersupply. Early studies indicate that the patch may protect the bones and heart.

The major problem with patches at this time is that a significant number of women develop skin irritation and may be forced to discontinue their use.

Advantages
bulletAs effective as oral HRT in treating most menopausal symptoms.
bulletPreserves bone in 85-95 percent of women. Easily changed and simple to stop using if you decide to discontinue treatment.
bulletSince the dose of hormone is absorbed very gradually, the patch has fewer side effects than some other routes of administration.

Disadvantages
bulletA very few women develop red, itchy skin at the site of the patch. This may get worse in a hot climate.

Subcutaneous pellets

Pellets of estradiol are inserted beneath the skin- subcutaneously-under a local anesthetic. There are several problems inherent in this technique.

The duration of action is variable. Could be as long as 6 months. The pellets are difficult to remove should they prove disagreeable in any way.

Advantages
bulletExcellent relief from physical symptoms. Some women find that problems such as depression and irritability disappear more readily than with other forms of HRT.
bulletYou can forget you are on HRT because the implants are changed so infrequently. Testosterone can also be given as an implant. Protection against osteoporosis is high.

Disadvantages
bulletWrong doses cannot be adjusted.
bulletSome women experience symptoms at ever-decreasing intervals – too frequent implants lead to hormone overdose. If you decide to stop using HRT, implants are difficult to remove.
bulletYou need a minor surgical procedure for insertion of the implant.
bulletSome people experience severe side reactions that may not be correctable - excessive weight gain, extreme inflammation of the breast, etc.

Vaginal Hormone Creams
bullet17 beta-estradiol (Estrace)
bulletVaginal Cream estropipate (Ogen)
bulletVaginal Cream conjugated equine estrogens (Premarin)
bulletVaginal Cream dienestrol (Ortho Dienestrol Cream)
bulletdienestrol (Estragard Cream)

The creams are the most convenient form of application. It can be often applied locally to the vaginal wall making it thicker, more elastic, and less susceptible to infection. It increases lubrication and relieves dryness and itching. Effects may be noticed in less than a week. You can use cream on and off and resume treatment when symptoms return. Even though it is applied locally, the estrogen is still absorbed into the system and carries the same risks as estrogen taken in pill form. The amount absorbed will be relatively low if the cream is used infrequently (two or three times per week) or for short periods of time. There is evidence that at low doses, as little as one-eighth of that usually recommended for vaginal dryness, the estrogen cream can be effective. For women using estrogen cream who have not had a hysterectomy, progesterone may still be necessary to cause menstrual bleeding and prevent uterine cancer.

Advantages
bulletHelps to alleviate slight incontinence.
bulletCreams containing estrogen and progesterone are available. Easy to apply.
bulletEliminates vaginal dryness and irritation.

Disadvantages
bulletDoes not protect against osteoporosis.
bulletNot effective in combating hot flashes and night sweats.

Next Topic: How HRT Is Administered: Application of Progesterone/Progestin

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