HORMONE REPLACEMENT THERAPY (HRT)
Hormone replacement therapy refers to any form of hormone therapy wherein the patient, in the course of medical treatment, receives hormones, either to supplement a lack of naturally occurring hormones, or to substitute other hormones for naturally occurring hormones.
Around the time of the menopause, declining levels of oestrogen and progesterone can bring about many symptomatic changes for women
Hormone replacement therapy (HRT) can be an effective treatment for the typical menopause-related symptoms. There are also other long-term health problems associated with the menopause: the risk of osteoporosis, cardiovascular disease and stroke all increase after the menopause. HRT may also have an influence on these health problems.
Androgen replacement therapy (andropausal and ergogenic use) is a hormone treatment often prescribed to counter the effects of male hypogonadism. It is also prescribed to lessen the effects or delay the onset of normal male aging. Additionally, androgen replacement therapy is used for men who have lost their testicular function to disease, cancer, or other causes.
TESTOSTERONE REPLACEMENT THERAPY (in males)
It could be said that testosterone is what makes men, men. It gives them their characteristic deep voices, large muscles, and facial and body hair, distinguishing them from women. It stimulates the growth of the genitals at puberty, plays a role in sperm production, fuels libido, and contributes to normal erections. It also fosters the production of red blood cells, boosts mood, and aids cognition.
Over time, the testicular “machinery” that makes testosterone gradually becomes less effective, and testosterone levels start to fall, by about 1% a year, beginning in the 40s. As men get into their 50s, 60s, and beyond, they may start to have signs and symptoms of low testosterone such as lower sex drive and sense of vitality, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and anemia. Taken together, these signs and symptoms are often called hypogonadism (“hypo” meaning low functioning and “gonadism” referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the United States. Yet it is an underdiagnosed problem, with only about 5% of those affected receiving treatment.
Studies have shown that testosterone-replacement therapy may offer a wide range of benefits for men with hypogonadism, including improved libido, mood, cognition, muscle mass, bone density, and red blood cell production. But little consensus exists on what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face. Much of the current debate focuses on the long-held belief that testosterone may stimulate prostate cancer.
Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men’s Health Boston, specializes in treating prostate diseases and male sexual and reproductive difficulties. He has developed particular expertise in treating low testosterone levels. In this interview, Dr. Morgentaler shares his views on current controversies, the treatment strategies he uses with his own patients, and why he thinks experts should reconsider the possible link between testosterone-replacement therapy and prostate cancer.
Many men with low testosterone report improved energy levels, sex drive, and mood after testosterone treatment. If testosterone is low, why not replace it?
Not so fast. A low testosterone level by itself doesn’t need treatment. Testosterone replacement therapy can have side effects, and the long-term risks and benefits aren’t known. Only men with symptoms of low testosterone and blood levels that confirm this as the cause of symptoms should consider testosterone replacement. Talking with your doctor is the only way to know if testosterone therapy is right for you.
SUBTLE SYMPTOMS OF LOW TESTOSTERONE
The symptoms of low testosterone are sometimes obvious, but they also can be subtle. Testosterone levels decline naturally in men as they age over decades. But certain conditions can also lead to an abnormally low level.
Symptoms of low testosterone include:
- Low sex drive (libido)
- Erectile dysfunction
- Fatigue and poor energy level
- Decreased muscle mass
- Hair loss
- Difficulty concentrating
- Low sense of well-being
If a man has symptoms of low testosterone and tests show he has an abnormally low testosterone level, a doctor may suggest treatment. For millions of men who have low testosterone levels but no symptoms, no treatment is currently recommended. It is has also not been approved for treating men with low levels because of aging.
FORMS OF TESTOSTERONE SUPPLEMENTS
Testosterone replacement therapy is available in several forms. All can improve testosterone levels:
Skin patch (transdermal): Androderm is a skin patch worn on the arm or upper body. It’s applied once a day.
Gels: AndroGel and Testim come in packets of clear testosterone gel. Testosterone is absorbed directly through the skin when you apply the gel once a day. AndroGel, Axiron, and Fortesta also come in a pump that delivers the amount of testosterone prescribed by your doctor. Natesto is a gel applied inside the nose.
Mouth patch:Striant is a tablet that sticks to the upper gums above the incisor, the tooth just to the right or left of the two front teeth. Applied twice a day, it continuously releases testosterone into the blood through the oral tissues.
Injections and implants: Testosterone can also be injected directly into the muscles, or implanted as pellets in the soft tissues. Your body slowly absorbs the testosterone into the bloodstream.
Why not a simple testosterone pill?
Oral testosterone is available. However, some experts believe oral testosterone can have negative effects on the liver. Using other methods, such as skin patches, gels, orally disintegrating tablets, or injections, bypasses the liver and gets testosterone into the blood directly.
Menopause is the time in a woman’s life when her period stops. It is a normal part of aging. In the years before and during menopause, the levels of female hormones can go up and down. This can cause symptoms such as hot flashes and vaginal dryness. Some women take hormone replacement therapy (HRT), also called menopausal hormone therapy, to relieve these symptoms.
HRT MAY ALSO PROTECT AGAINST OSTEOPOROSIS.
However, HRT also has risks. It can increase your risk of breast cancer, heart disease, and stroke. Certain types of HRT have a higher risk, and each woman’s own risks can vary depending upon her health history and lifestyle. You and your health care provider need to discuss the risks and benefits for you. If you do decide to take HRT, it should be the lowest dose that helps and for the shortest time needed.
TAKING HORMONES SHOULD BE RE-EVALUATED EVERY SIX MONTHS.
Hormone replacement therapy (HRT) is a treatment used to relieve symptoms of the menopause. It replaces female hormones that are at a lower level as you approach the menopause.
The menopause, sometimes referred to as the “change of life”, is when a woman’s ovaries stop producing an egg every four weeks. This means she will no longer have monthly periods or be able to have children naturally.
The menopause usually occurs when a woman is in her 50s (the average age is 51 in the UK), but some women experience the menopause in their 30s or 40s.
Hormone replacement therapy (HRT) is given to some women whose estrogen and progesterone levels drop significantly because of the menopause. Estrogen and progesterone are hormones. HRT tops up a woman’s levels of essential hormones. HRT may also refer to male hormonal treatment, as well as for individuals who undergo a sex change.
This article focuses entirely on HRT for women whose problem is caused by the menopause.
When estrogen and progesterone levels drop, as they do when the menopause approaches, some women may benefit from artificially boosting their hormone levels to reduce certain menopausal symptoms.
The hormone estrogen stimulates the release of eggs. As soon as a woman’s supply of eggs has ended, estrogen levels start to go down.
OESTROGEN & PROGESTERONE:
Oestrogen and progesterone (see below) are female hormones that play important roles in a woman’s body. Falling levels cause a range of physical and emotional symptoms, including hot flushes, mood swings and vaginal dryness.
The aim of HRT is to restore female hormone levels, allowing the body to function normally again.
What are the signs and symptoms of a drop in estrogen levels? Estrogen helps maintain good bone density, skin temperature and regulating moisture of the vagina.
A DROP IN ESTROGEN LEVELS CAN CAUSE:
• Vaginal dryness
• Urinary problems
• Thinning hair
• Sleep problems
• Night sweats
• Lower fertility
• Irregular periods
• Hot flashes (UK: hot flushes)
• Concentration and memory difficulties
• Breasts get smaller
• Accumulation of fat in the abdomen
These sometimes unpleasant symptoms usually go away within two to five years, except for vaginal dryness.
Symptoms may sometimes occur before the menopause starts (peri-menopause). In this case the woman’s supply of eggs has not finished, they have just dropped significantly, which can trigger a fall in hormone levels. So, the patient may still have regular periods as well as menopausal symptoms.
HRT estrogen comes from pregnant horse urine or plants.
Progesterone’s main function is to prepare the woman’s womb for possible pregnancies. This hormone also helps protect the endometrium (the lining of the uterus).
Lower progesterone levels do not really cause the woman any immediate discomfort. Experts say her risk of developing endometrial cancer may be higher.
Oestrogen helps to release eggs from the ovaries. It also regulates a woman’s periods and helps her to conceive.
Oestrogen also plays a part in controlling other functions, including bone density, skin temperature and keeping the vagina moist. It is a reduction in oestrogen that causes most symptoms associated with the menopause, including:
• hot flushes
• night sweats
• vaginal dryness
• loss of libido (sex drive)
• stress incontinence (leaking urine when you cough or sneeze)
• bone thinning – which can lead to osteoporosis and fractures
Most symptoms will pass within two to five years, although vaginal dryness is likely to get worse if not treated. Stress incontinence may also persist and the risk of osteoporosis will increase with age.
The main role of progesterone is to prepare the womb for pregnancy. It also helps to protect the lining of the womb, known as the endometrium.
A decrease in the level of progesterone does not affect your body in the same way as falling levels of oestrogen. However, taking oestrogen as HRT on its own when you have a womb increases the risk of womb (uterus) cancer, sometimes called endometrial cancer.
A synthetic form of progesterone, called progestogen, is usually used in combination with oestrogen in HRT.
However, if you have had a hysterectomy (an operation to remove your womb), you do not need progesterone and can take oestrogen-only HRT.
HOW SYSTEMIC HRT IS TAKEN
Tablets, patches or implants are only needed if you have menopausal symptoms, such as hot flushes, and have weighed up the benefits and risks of treatment.
There are many different combinations of HRT, so deciding which type to use can be difficult. Your GP will be able to advise you.
LOCAL OESTROGEN FOR VAGINAL DRYNESS
If you are only experiencing vaginal dryness, you will probably be recommended oestrogen preparations that can be applied directly to your vagina.
As the dose of oestrogen is so low, you do not require the protective effect of the progestogen. Local oestrogens do not carry the same risks associated with systemic combined HRT.
FORMS OF HRT:
Local oestrogens can be in the form of:
• pessaries placed directly into the vagina
• a vaginal ring
• vaginal creams
There are several ways HRT can be taken, including:
• Tablets – which can be taken by mouth
• a patch that you stick on your skin
• an implant – under local anaesthetic, small pellets of oestrogen are inserted under the skin of your tummy, buttock or thigh
• oestrogen gel – which isapplied to the skin and absorbed
WHEN TO STOP TAKING HRT
Most women are able to stop taking HRT after their menopausal symptoms finish, which is usually two to five years after they start.
Gradually decreasing your HRT dose is usually recommended, rather than stopping suddenly. You may have a relapse of menopausal symptoms after you stop HRT, but these should pass within a few months.
If you have symptoms that persist for several months after you stop HRT, or if you have particularly severe symptoms, contact your GP because treatment may need to be restarted, usually at a lower dose.
After you have stopped HRT, you may need additional treatment for vaginal dryness and to prevent osteoporosis (brittle bones). Read about the best ways to prevent osteoporosis.
Creams and lubricants are available for vaginal dryness, as are local oestrogen preparations.
WHO CAN USE HRT?
You can start HRT as soon as you begin to experience menopausal symptoms. However, HRT may not be suitable if you are pregnant or have:
• a history of breast cancer, ovarian cancer or womb cancer
• a history of blood clots
• a history of heart disease or stroke
• untreated high blood pressure – your blood pressure will need to be controlled before you can start HRT
• liver disease
If you have irregular periods, this will also need to be diagnosed before HRT is used.
If you are unable to have HRT, different medication may be prescribed to help control your menopausal symptoms.
SIDE EFFECTS OF HRT
Hormones used in HRT can have associated side effects, including:
• fluid retention
• breast tenderness or swelling
BENEFITS AND RISKS
Over the years, many studies examining the benefits and risks of HRT have been carried out.
The main benefit is that it is a very effective method of controlling menopausal symptoms, and it can make a significant difference to a woman’s quality of life and wellbeing.
HRT can also reduce a woman’s risk of developing osteoporosis and cancer of the colon and rectum. However, long-term use is rarely recommended, and bone density will decrease rapidly after HRT is stopped.
Combined HRT slightly increases the risk of developing breast cancer, womb cancer, ovarian cancer and stroke. Systemic HRT also increases your risks of deep vein thrombosis (DVT) and pulmonary embolism (blockage in the pulmonary artery). Other medicines are available to treat osteoporosis that do not carry the same level of associated risk.
Most experts agree that if HRT is used on a short-term basis (no more than five years), the benefits outweigh the risks.
If HRT is taken for longer, particularly for more than 10 years, you should discuss your individual risks with your GP and review them on an annual basis.