The newer, safer estrogen therapy can reduce your risk of cancer, heart disease, osteoporosis–even improve your looks and your sex life.

BY LILA NACHTIGALL, M.D., AND JOAN RATTNER HEILMAN

You’ve heard of it, and heard too that someday you may need it. But you’ve probably also heard reports that estrogen replacement therapy (estrogen replacement therapy) is not safe. That’s simply not true –not anymore. The latest research shows that it’s even better than safe: When administered correctly, it can protect your health, your looks and your ability to enjoy sex. It has other valuable benefits as well. Here, a well-known doctor and estrogen specialist answers some important questions regarding a vital treatment that every woman should know about. Someday estrogen replacement thereapy could change your life. 

Click on a question below, or scroll down to read through all the Q&A regarding estrogen.

• How has estrogen replacement therapy been made safe?
• What were the worries about estrogen and breast cancer?
• How does estrogen affect the heart?
• How can taking estrogen prevent brittle bones? Isn’t calcium enough?
• What influence does estrogen have on your sex life?
• Is hair growth altered by estrogen?
• What causes hot flashes and other uncomfortable menopausal symptoms? How can estrogen help?
• How long must estrogen be taken?
• Does estrogen replacement therapy have any side effects?
• Why have women been afraid to take estrogen?

• Rx for younger skin
• Who needs estrogen replacement therapy?
• Three ways for estrogen replacement therapy
• The Healing Hormone

Q. How has estrogen replacement therapy been made safe?

A. The new therapy prevents the excessive buildup of the uterine lining in three major ways; First, estrogen is prescribed only after menopause, when the body’s natural supply of this hormone is reduced.

Second, the hormone is given in low doses-1.25 milligrams or less a day of conjugated estrogen (made from natural sources) or the equivalent amount of other types of estrogen. In exceptional circumstances, higher dosages might be administered.

Third, progesterone-the other major female hormone-must always be prescribed along with the estrogen for women who still have a uterus. Progesterone causes the uterine lining to be shed, so no excessive buildup is allowed to occur.

Doses of these hormones must be tailored to an individual’s needs, because everyone’s sensitivity is different. And regular gynecological examinations every six months are imperative.

Many major studies, including my own-which followed women on estrogen replacement therapy for ten years-have confirmed the safety of estrogen used this way. In fact, women who take it correctly are less likely to develop uterine or breast cancer than those who have never hone near a hormone pill.

Estrogen would never knowingly be given to a woman who already has uterine cancer, however, because the hormone can accelerate the cancer’s growth. And for the same reason, estrogen is withheld after the cancer has been removed.
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Q. What were the worries about estrogen and breast cancer?

A. Because estrogen influences breast tissue, there has always been a concern that it could initiate malignacies. But results of many scientific studies show no link between estrogen replacement therapy and breast cancer. Others present clear evidence that low-dose estrogen combined with progesterone actually helps to prevent this disease.

However, estrogen replacement therapy must never be given to a woman who has an existing estrogen-dependent cancer because, although the hormone did not initiate the cancer, it can make this type of tumor grow more rapidly. For the same reason, it is best to avoid estrogen-except on a very short-term basis-if you have a strong family history of this disease.

On the other hand, breast cancer that is non-estrogen-dependent will often shrink with estrogen replacement therapy, so women are frequently treated with it after surgery to help prevent a recurrence. Breast cancer that develops before menopause is almost always estrogen-dependent, while cancer that develops after menopause, especially five to more years later, is almost always non-estrogen-dependent. 
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Q. How does estrogen affect the heart?

A. At least seven major studies strongly support evidence of a beneficial effect. The one most widely reported was done in the early eighties by Trudy L. Bush, Ph.D., and colleagues for the National Heart, Lung and Blood Institute of the National Institutes of Health. This research showed that the death rate for estrogen users after menopause was only one-third as high as for nonusers.

It’s not yet known how estrogen protects the heart, but the benefit probably comes from an increased blood level of high-density lipoproteins (HDLs). The HDLs carry plaque formed by cholesterol and triglycerides away from artery walls, while HDLs do the opposite. Estrogen is also thought to help maintain the elasticity of the arteries, making them more efficient at pumping blood to and from the heart.
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Q. How can taking estrogen prevent brittle bones? Isn’t calcium enough?

A. You do require calcium-and exercise- to build strong bones. But these alone won’t prevent osteoporosis, the cause of the high incidence of broken hips, fractures wrists, and dowager’s humps among older women.

Estrogen, though it isn’t directly responsible for bone strength, controls the absorption of calcium into the bones. It also stimulates production of calcitonin, a hormone that protects them. When your body no longer makes much estrogen, the bones can’t absorb and retain calcium, and they quickly start losing more bulk than they gain-no matter how much calcium you consume. Bone loss is especially rapid in the first seven years or so after menopause-if you are not on estrogen replacement therapy.

This, then, is the bottom line; If you have kept your bones at full strength by eating and exercising properly before menopause, and have inherited a sturdy skeleton, you’re ahead in the game. A calcium-rich diet and moderate exercise may be all the protection you need after menopause. (Postmenopausal women are advised to consume at least 1,500 milligrams of calcium a day if they’re not on estrogen replacement therapy, and 1,000 a day if they are.)

But if you are at high risk for osteoporosis (see "Who needs estrogen replacement therapy?"), you must seriously consider estrogen replacement therapy to stem the unrelenting loss of bone as you get older. Conjugated estrogen, in minimum daily doses of 0.625 milligrams (or the equivalent amount of other estrogen), will prevent bone loss before it begins if therapy is started immediately after menopause. Regardless of when therapy is started, however, it will prevent further bone loss.
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Q. What influence does estrogen have on your sex life?

A. Taking estrogen doesn’t guarantee a fantastic sex life at all! Estrogen is responsible for maintaining the size, shape and flexibility of your vagina as well as the thickness and lubrication of its lining. After menopause, the vaginal lining becomes thinner and drier, less pliable and expandable. The vagina may even become shorter and narrower. These changes, which occur over a period of years after menopause, can make sex uncomfortable, downright painful or even impossible.

But this is one problem that is easily and rapidly resolved with estrogen replacement therapy and has become the primary reason why women start taking it. Estrogen restores vaginal tissues to a more youthful state-thicker, moister and more flexible-in only a few weeks.
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Q. Is hair growth altered by estrogen?

A. One of estrogen’s functions is to encourage the growth of hair on the head, pubic area and under the arms, and to discourage it on the rest of the body. With the advent of menopause, that pattern tends to change. Some women notice that the hair on their heads gets thinner, coarser and drier, while the secondary hair-in the armpits and pubic area- is straighter and less luxuriant.

At the same time, usually five or more years after menopause, hair may start growing on the face and body where it never grew before and where it cestrogen replacement therapyainly in most unwelcome. Adding to the problem, the hairs already present often become darker, thicker, and tougher. All this happens because the androgens, the malelike hormones that every woman produces, are activated as the estrogen level drops. Estrogen no longer can block their action at the hair follicle receptors, and so the hair tends to grow in a more malelike pattern.

Estrogen therapy won’t have an enormous effect on the hair on your head, though the hormone may make your hair a little thicker. But it definitely will have a beneficial effect on unwanted facial and body hair. When you start estrogen replacement therapy, hair growth in these areas stops.
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Q. What causes hot flashes and other uncomfortable menopausal symptoms? How can estrogen help?

A. The most common menopausal symptom is the hot flash, a feeling of intense heat that envelops the body, usually from the waist up and affecting especially the face and neck. The blood vessels on the skin’s surface dilate, causing a rosy flush. The flash is almost always accompanied by profuse sweating and is often followed by chills.

Hot flashes are the result of changes prompted by the decreasing level of estrogen: The pituitary gland starts to produce other hormones in a desperate effort to stimulate the ovaries to get going again. The heightened amounts of these pituitary hormones, plus increased activity in the brain’s hypothalamus, make the body’s heat-regulating mechanisms go haywire. These hormonal shifts can also produce cold sweats, palpitations, dizziness, faintness and tingling sensations, as well as insomnia, anxiety, irritability, fatigue and joint pains.

For the majority of women, hot flashes and other symptoms last only a year or two-although some women have them for many years, and others, till the day they die. estrogen replacement therapy usually eliminates these problems in less than two weeks.
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Q. How long must estrogen be taken?

A. If you’re on estrogen replacement therapy just to relieve transient symptoms, you will need it for only a few months to a few years, until your body adjusts to its new low estrogen level. Never quit estrogen abruptly or your symptoms may return, perhaps worse than ever. Taper off gradually, with your doctor’s guidance.

If you are using estrogen replacement therapy to prevent osteoporosis or sexual and urinary problems, you must take it long-term, maybe for life.
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Q. Does estrogen replacement therapy have any side effects?

A. You may have a light, short progesterone-induced period starting a day or two after you stop taking this hormone each month. The pattern should be consistent; if it is not, inform your doctor.

Other possible side effects, usually minor and transient, include fluid retention, weight gain, tender breasts, nausea, headaches and vaginal discharge. Sometimes a woman may have an allergic reaction; switching to a different brand of estrogen or to another form of therapy may solve the problem.
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Q. Why have women been afraid to take estrogen?

A. In the 1960’s estrogen was hailed as a miracle medication that could keep you young forever, and many doctors prescribed huge daily doses of it for any woman who asked. The therapy was often started before menopause, with recommendations that it be continued for life. Then, in 1975, researchers reported that women who took the hormone were four to eight times more likely to develop uterine cancer that women who did not. When the bad news hit the headlines, the use of estrogen sharply declined.

But now we know that estrogen itself does not cause cancer-it is not a carcinogen. One of this hormone’s jobs, however, is to thicken the lining of the uterus; if used incorrectly, it can cause an excessive buildup of this lining. Although such a condition (called endometrial hyperplasia) is not cancer, it can go on to become cancer among susceptible women if it is neglected.
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Rx for younger skin

Estrogen is not the fountain of youth, but it can help your skin look better. This hormone is largely responsible for maintaining the layer of fat just beneath your skin, as well as for keeping the skin supplied with moisture, oil and collagen-the connective tissue that makes skin thick and firm. After menopause, when estrogen levels slack off, the skin loses its natural padding and becomes drier, thinner and more likely to wrinkle.

Although estrogen can’t totally reverse any damage already caused by a deficiency of this hormone, nor alter the effects of normal aging and overexposure to the sun, it can help hod off further changes due specifically to estrogen loss. It can also improve the skin by adding fat, moisture and collagen, which will result in a smoother, firmer look. Estrogen is not recommended as a beauty aid to be taken solely for this reason, however. Remember that estrogen is a drug, not a cosmetic, and should always be treated as one-with caution and respect.
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Who needs estrogen replacement therapy?

Not every woman needs to take estrogen after menopause. Some women stop producing this female hormone so gradually that they experience few or no uncomfortable symptoms, while others continue to produce a small amount of estrogen for the rest of their lives. But many women are not so fortunate. While alternative measures may help alleviate some of the problems outlined below, you should consider estrogen replacement therapy if you and your doctor have not found them to be effective.

• Severe menopausal symptoms. About 75 percent of women have hot flashes and other discomforts after menopause. If these are severe enough to affect the way you live your life, you are an excellent candidate for estrogen replacement therapy.
• Brittle bones. estrogen replacement therapy is essential if you are one of the four out of every ten women who are de3stined to develop symptomatic osteoporosis. The more of the following characteristics you have, the higher your risk: You are thin, fair-skinned and small-framed; you reach menopause before age 40; your mother or grandmother grew shorter with age; you smoke; you have gone on a lot of diets, consume more than two alcoholic beverages a day and have always hated milk and other calcium-rich foods; your family comes from the British Isles or Northern Europe; you have rarely exercise.
• Sexual difficulties. Because of the degenerative changes that take place in vaginal tissues, many women find sex extremely uncomfortable after menopause. Special lubricants or suppositories may help for a while, but, if you’re like most women, you’ll need more help than that. Estrogen replacement therapy is the only way to rejuvenate delicate vaginal tissues.
• Recurring urinary or vaginal infections. When vaginal tissues become thin and dry, they are more susceptible to irritation and infection. The tissues lining the urethra-the tube that drains urine from the bladder-also gradually shrink and dry out, a condition that may lead to urinary infections. estrogen replacement therapy restores all these tissues to a less vulnerable state.
• Early menopause. If you reach menopause in your thirties or early forties, you should definitely consider estrogen replacement therapy unless there is a very good reason for you not to have this treatment. Because you will be living without a good supply of estrogen for 10 – 15 years longer than the average woman, you’ll get an unfortunate head start on the long-term consequences of estrogen deficiency-osteoporosis, sexual and urinary problems, and a higher risk of cardiovascular disease as well.
• Instant menopause. Should you have instantaneous menopause because your ovaries are damaged or surgically removed before their time, you will probably have the most severe menopausal symptoms because of the sudden withdrawal of estrogen. That’s why your doctor will almost invariably prescribe estrogen replacement therapy for at least five years or so, unless you’ve had an estrogen-dependent malignancy.

There are now three major ways to replace the estrogen your body no longer makes. Available by prescription only, these must be supplemented with progesterone if you still have a uterus. Have a discussion with your doctor to determine which method is best for you.

• ORAL ESTROGEN comes in tablet form. Premarin-which is conjugated estrogen made from natural sources-is the most commonly prescribed. There are also generic conjugated estrogens, and several synthetic or semisynthetic compounds, any one of which your doctor may prescribe for you instead.
   

  
   
   

  The usual dose is 0.625 milligrams of conjugated estrogen (or the equivalent). It is generally taken every day of the month, along with seven to thirteen days of progesterone. Sometimes, however, oral estrogen is prescribed for three weeks of the month, along with an appropriate schedule of progesterone.

• VAGINAL ESTROGEN CREAM is insestrogen replacement therapyed into the vagina with a measured applicator. Though the hormone is absorbed into the bloodstream and affects other parts of the body, its major influence is on the tissues of the vagina and urethra, where it reverses the degenerative changes causes by an estrogen deficit. For this reason, you should rely on vaginal estrogen cream only if your menopausal discomforts are limited to vaginal-urinary problems. Otherwise, choose oral estrogen or the transdermal patch. 
   

  
   
   

  The usual dose of vaginal estrogen cream is one gram twice a week. But, because absorption varies from woman to woman, you and your doctor should work out a dose that is right for your needs. The absorption, which is very rapid at first, slows down once the vaginal lining has become thicker and more resistant.

  Vaginal estrogen does not pass through the digestive system, as does oral estrogen. Therefore, it doesn’t aggravate such medical conditions as liver dysfunction, hypestrogen replacement therapyension, gallbladder disease and thrombophlebitis (blood clots).

• TRANSDERMAL ESTROGEN is the newest form of estrogen replacement-so new that few woman have even heard of it. A small, round patch with adhesive is pasted on the skin and changed twice a week. Each patch contains a reservoir of estrogen encased in a special membrane that allows a controlled amount of the hormone to be absorbed through the skin into the bloodstream. Like vaginal cream, estrogen that is delivered this way does not go through the digestive system, and so will not aggravate other medical conditions.

The patch has been shown to be as safe and effective as oral estrogen in reducing hot flashes and other menopausal symptoms and in reversing vaginal and urethral changes. The final answers as to its effects on calcium absorption and blood-fat levels are not yet in, but all studies so far indicate that these are almost identical to those of oral estrogen.

Patches are currently available in two doses: 0.5 milligrams and 0.625 milligrams (equivalent to approximately 1.25 milligrams of conjugated estrogen). The only apparent side effect of transdermal estrogen replacement therapy is an occasional skin irritation or rash under the patch. If this problem should occur, discuss it with your doctor.
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