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Estrogen Replacement Therapy

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Updated July 19, 2009

Is ERT Right For You?

Estrogen replacement therapy is the medical administration of estrogen; it may sometimes also include the use of progestins. ERT replaces hormones which the ovaries no longer produce, either through natural or surgical menopause, and provides relief from the unpleasant symptoms of menopause such as hot flashes and night sweats.

According to a Journal of American Medicine report released February 19, 1997, estrogen use begun in the early menopausal period and continued late into life is associated with the highest protection of bone density, although beginning ERT after age 60 does appear to offer nearly equally bone protection.

The most common form of estrogen prescribed in the United States is conjugated estrogen, sold under the brand name of Premarin and not currently available in a generic form. Other types of estrogen available include the patch and estrogens made of singular estrogens rather than the triple estrogen of conjugated estrogens. Some women are finding relief from menopausal symptoms with herbal remedies such as Black Cohosh, widely thought to help reduce the symptoms of menopause.

Although much controversy exists regarding the use of conjugated estrogens, their use is associated with significant reduction in the occurrence of heart disease and osteoporosis, including a reduction of approximately 10% in the occurrence of heart disease and stroke, over non estrogen users.

Conjugated estrogen, either alone or combined with progestins, has been found to reduce levels PA-1 by approximately 50%. PA-1 is an essential inhibitor of fibrinolysis which increases in women after menopause and may contribute to the risk of cardiovascular disease. This may help to explain the protective effect estrogen has in the reduction of heart disease in postmenopausal women. (NEJM 1997; 336:683-90)

An estimated 15- 20% of post- menopausal women currently use ERT. Many women have heard the risks of estrogens and are unaware that many of the substantial increases in risks occurred at much higher doses of conjugated estrogens than are recommended today.

In the past, conjugated estrogen was routinely prescribed doses of 1.25 mg to 2.5 mg per day; at todays recommended daily dose of .625 mg which is required to achieve the osteoporosis reduction benefit of estrogen, most of these risks are fairly small, although you must weigh the benefits against the risks of ERT and choose on an individual basis weather conjugated estrogen is for you.

Some women reject the use of conjugated estrogens because they are obtained from the urine of pregnant mares and they object to the practice of keeping the mares pregnant only to retrieve their urine for the making of estrogens.

Many women reject the use of ERT on principle, disliking the idea of using a synthetic hormone which disrupts the natural development of the body and fearing past disasters such as occurred with DES.

Because of the potential risk factors involved with estrogen replacement therapy, a study was conducted to examine the relation of ERT and mortality. The study conducted between 1976 and 1994, included participants who were part of the Nurses' Health Study; the women were between the age of 30 and 55 when the study began.

After adjusting the results for variables the study concluded, women who used estrogen replacement therapy had a lower mortality rate than the non- users; however the survival benefit of ERT decreased with long- term use and is lower for women already at risk for heart disease. (NEJM 1997; 336: 1769- 75)

Another study reported in The New England Journal of Medicine to determine the effect of ERT on life expectancy in postmenopausal women with different risk factors for heart disease, breast cancer and hip fracture, concluded that the benefit of ERT in reducing the chance of heart disease appears to outweigh the risk of breast cancer for almost all women and supports the wide- spread use of estrogen replacement therapy.

A new report, released March 4, 1998, by the Journal of American Medicine concludes that plausible biological mechanisms exist by which ERT may lead to improved cognition, reduced risk of dementia, or improvement in the severity of dementia; however studies of women have produced conflicting results and larger placebo controlled studies are required to address the use of estrogen in the prevention of Alzheimers and other dementia related symptoms. Given the risks associated with estrogen, at this time estrogen use, solely to prevent dementia is not advised until adequate trials are completed.

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