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The Right Regiment for You

You've discussed your symptoms and risk factors with your doctor, you've done some research, and you've decided to take hormone therapy (HT)1. 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 therapy regimen may 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 the three 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.

You have a variety of estrogen preparations to choose from.

Commonly prescibed estrogens include:

* 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)
* Premarin® (oral tablet)

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 pharmacist2.

Arriving at the right HT 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 will vary depending on the type of progesterone you are taking, and whether you are on a continuous or cyclical regimen.

If the intitial HT dose gives you uncomfortable side effects or doesn't alleviate your symptoms, your doctor can adjust the dose, try a different form of estrogen, or low-dose natural progesterone instead of synthetic progestin, depending on your individual situation.


Patch, Pill, or Cream?

In choosing the form of hormone therapy that is best for you, there are several factors you and your healthcare provider 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 HT, your individual profile and family history of these conditions may come into play. Some women value convenience very highly, and choose a form of HT 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 is typically more expensive than oral estrogen, and the adhesive sometimes causes skin irritation.
* The skin patch may be a good choice for you if your triglyeride 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 can be very effective in treating urinary and vaginal problems. (Premarin®, Estrace®, and Ogen® are commercially available as vaginal creams; natural low-dose estrogen therapy can be compounded as a cream or suppository by a pharmacist per your healthcare provider's direction).
* Vaginal estrogen creams may not have protective benefits in regard to heart or bone health.

Natural Hormone Options

Used in connection with hormones, the term ''natural'' can be confusing. When we say ''natural'' we mean molecularly 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 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 molecularly identical to the hormone made in the body, and many women find it easier to tolerate.

Many women call Women's Health America and the consulting pharmacists at Madison Pharmacy Associates to ask if there is a ''natural estrogen'' they can take with their natural progesterone. They are often surprised to learn that commerically manufactured and frequently-prescribed forms of estrogen (Estrace® and Estraderm® for example) are ''natural'' estrogens. Choosing among the various low-dose estrogens is a decision best made by you and your healthcare provicer based on the specific symptoms that need to be managed.

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. The section on ''Checking Testosterone After Hot Flashes'' tells more about how to decide if testosterone may be helpful for you.


When to Take It

If you're taking hormone therapy, you can choose between two types of regimens: cyclical and continuous combined. Taking HT cyclically, the most frequently prescribed regimen, mimics a menstrual pattern: you take estrogen every day and progesterone for 12-14 days of the month.

When you finish taking progesterone each month, you experience bleeding as your body ''withdraws'' from the hormone progesterone, and the endometrial lining sloughs away. Continuous combined therapy, in which women take estrogen and progesterone every day, typically eliminates the breakthrough bleeding after some initial spotting in the first one to three months. Most women report fewer side-effects with this regimen.


Evaluating Your Choices

Whatever hormone 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 doctor, 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 doctor should fine-tune your hormone regimen to your individual needs -- your risk factors, your symptoms before and during therapy, and your lifestyle.

The consulting pharmacists at Madison Pharmacy Associates routinely work with women and their healthcare providers to individualize low-dose natural hormone therapy regimens, and are available to advise you. You can have your healthcare provider call 1-800-558-7046 for a comprehensive consultation with a pharmacist.

1 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.

2 Madison Pharmacy Associates P O Box 259690, Madison, WI 53717-9690, 1-800-558-7046 specializes in compounding natural hormones.

3 More reasons than ever for HT,'' T.L. Bush, R.D Gambrell, Jr., and V. Miller, Patient Care, Nov. 15, 1993, pp. 103-132.
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1 comments:

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