Menopause is the end of menstruation; in other words, it is the end of a woman’s reproductive life. It usually occurs when a woman reaches the age of 45 to 55. A severe drop in follicular activity in the ovaries usually brings about menopause. Also, a decrease in the production, as well as secretion of progesterone and estrogen, can contribute to the onset of the condition. It is often a challenging experience for most women and can negatively impact a woman’s quality of life. Hormonal therapy is one of the treatments approved by the government for relief of symptoms of menopause. The common symptoms of menopause are changes in mood, vasomotor symptoms, vagina dryness, concentration loss, libido loss, and osteopenia, pain in the muscles, secondary sexual characteristics atrophy, osteoporosis, and many others. As such, hormonal therapy was established to treat all the mentioned chronic and acute menopause symptoms. Because menopause is a difficult transition for women, hormonal therapy is the most effective therapy to treat menopausal symptoms, henceforth, improving life quality beyond menopause.
The Replacement Hormones
Hormone Replacement Therapy (HRT) replaces the hormones that the body of a woman fails to produce because of the onset of menopause. The two primary hormones employed are estrogen as well as progestogen (Dodampahala, 2015) . In hormonal therapy, a woman can either take both estrogen and progestogen hormones or take one, estrogen. According to Bozkurt (2010), Natural estrogens maintain a low level of estrogen (200-300 pmol/L). In most cases, this amount of estrogen is usually adequate to overcome menopausal issues. When it comes to progestins, the most commonly preferred are C-21 derivatives (Bozkurt, 2010). Because progestins can lead to cyclical bleeding, most menopausal women who are uncomfortable with bleeding prefer a combination of daily estrogen and progestin. Even though spotting can occur at the beginning of therapy, a non-bleeding state can be achieved eventually, in most cases. In the mid-1975, utilizing both estrogens and progesterone became popular. This was to prevent getting endometrial carcinoma while using estrogen therapy alone (Kamrava, 2017) .
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Benefits of Menopausal Hormone Therapy
As stated earlier, a decrease in follicular activity results in a reduction of estrogen and progesterone in the body. Consequently, there is an increase in negative feedback in the secretion of LH and FSH. This , thus, leads to an increased level of serum of the two hormones. The escalated release of hypothalamic hormones and the reduced estrogen levels are linked with multiple menopausal symptoms. Estrogens, in general, play a pivotal role in thermoregulation. They do so by modulating the brain neurotransmitters. During menopause, the symptoms of reduced estrogens include sweating at night, hot flashes, pain during sexual intercourse, vaginal dryness, osteopenia, as well as changes in urine such as urgency and frequency (Kamrava, 2017) . Estrogen replacement has been typically employed to treat these signs. They can be prescribed as cream, oral, gel, patch, dermal, or implant as well.
The risks and benefits of hormonal therapy vary depending on a couple of factors. Ordinarily, the time since menopause as well as a woman’s age are the most significant factors. As such, younger women usually under the age of sixty benefits from a substantial decrease in cardiovascular conditions, type 2 diabetes, osteoporotic fractures, and colorectal cancer. Their overall mortality also improves as well. The menopause hormonal therapy type further modulates risk. This is because using estrogen alone typically reduces breast cancer risk, whereas, using both progestogen and estrogen raises this risk after about three to five years of utilization. Additionally , the delivery mode of estrogen is critical. This is because contrary to oral estrogen, there is a lower cholecystitis risk if low-dose transdermal estrogen is used (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Further, there is a small risk of deep venous thromboembolism as well as stroke. Therefore, intently assessing estrogen delivery mode is essential.
Osteoporosis
Markedly, hormonal therapy during menopause prevents problems such as bone loss issues and minimizes fractures as well. Estrogen therapy protects the bones even in low doses, thus, improving or preserving the density of the bone. For women at risk of osteoporotic fracture, it is recommended that they use hormonal therapy. This is especially beneficial when other treatment options pose several health risks. Therefore, hormonal therapy, more specifically estrogen therapy, is a useful treatment option for menopause as it alleviates osteoporosis symptoms.
Mortality and Cardiovascular Conditions
Numerous studies and clinical trials provide evidence that hormone therapy, particularly estrogen therapy may reduce coronary heart conditions as well as mortality. This is especially the case for women younger than sixty years and within ten years of menopause. As such, menopausal hormone therapy can be utilized by younger menopausal women . In addition , some evidence demonstrates that estrogen therapy reduces calcified atherosclerotic plaque development (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Even though there is enough evidence suggesting that hormonal therapy is associated with mortality benefit for the cardiovascular condition, this form of treatment is not presently indicated for coronary heart illness prevention. Contrarily, women who are distant from menopause face a risk for coronary heart disease.
Diabetes
Hormonal therapy significantly reduces type 2 diabetes development. This is facilitated by the utilization of oral CEE plus progestin or conjugated equine estrogens (CEE) (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Nonetheless, there is conflicting information regarding the protective advantage of MHT. Some studies have realized that MHT has severe impacts on the sensitivity of insulin, while others have recognized protection. Some studies further indicate that hormonal therapy for menopausal women minimizes fat mass and weight accumulation, especially central fat mass.
Stroke
Notably, controversies surround the impact of MHT on stroke. However, it is clear that oral estrogen alone does not heighten ischemic stroke risk in women between fifty and fifty-nine years of age. In other words, hormonal therapy safeguards against stroke especially for women with estrogen deficiency. This deficiency is usually brought about by the premature menopause onset. Early deprivation of estrogen increases the risk of stroke, hence, using estrogen therapy is pivotal to minimize this risk. In addition to the age issue, the impact of hormonal therapy on the risk of stroke differs by dose, administration route, MHT type, as well as risk factors, present such as hypertension. Sood, Faubion, Kuhle, Thielen & Shuster 92014) found that a low dose of estrogen use does not raise the risk of stroke, whereas, a high dosage slightly increases the risk. Hypertensive women have an increased risk of stroking when they use hormonal therapy, especially using a combination of progestogen and estrogen. Nonetheless, the risk reduces slightly when they use estrogen alone.
Breast Cancer
Studies demonstrate that taking estrogen along with progestogen for more than five years can increase breast cancer risk. Sood, Faubion, Kuhle, Thielen & Shuster (2014) notes that the risk varies with the use duration, initiation time pertinent to final menses, breast cancer family history, the mass of the body, as well as the progestogen type employed. There is less risk when sequential progestogen is adopted compared to continuous utilization of the hormone. Further, there is less risk with particular progestogens – micronized progesterone (Sood et al., 2014) According to Sood et al. (2014), perhaps, there is an increased risk of cancer with using hormonal therapy because the therapy may facilitate the growth of pre-existing cancers . In most cases, otherwise, these cancers may not have developed or have remained small to be diagnosed. Markedly, using estrogen alone is linked with no reduction or increase in breast cancer risk. However, the Million Women Study found a heightened cancer risk among women who started estrogen-only therapy within five years of menopause onset (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Additionally , the Nurses’ Health Study found an escalated risk with longer-term utilization of estrogen-only (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Also, studies demonstrate that breast tumor in women using hormonal therapy is likely to be less aggressive as well more localized . This , indeed, minimizes mortality from breast cancer (Bozkurt, 2010) . Therefore, because of breast cancer concerns, it is recommended that hormonal therapy be used for a short period mainly for symptom relief.
Cognition
When younger menopausal women use hormonal therapy, there is a decreased risk of decline in cognitive functions and a decrease in Alzheimer’s risk by 0.29% to 0.44% (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Also, research in premature menopausal women found menopause hormonal therapy prevents cognitive reduction as well as dementia. However, for older menopausal women, there is an increased risk of Alzheimer’s, especially in women above sixty-five years. Therefore, it is recommended for women who are later in menopause not to use hormonal therapy. This is because the cognitive impairment risk markedly outweighs the benefits. On the other hand, for women with premature menopause, utilizing hormonal therapy until the average menopause age may protect against the decline of cognitive functions. Thus, hormonal treatment can be used by women with premature menopause.
Side Effects and Risk of Hormonal Therapy
According to Kamrava (2017), the common side effects of using estrogen breast soreness. Often, this can be reduced by utilizing lower doses. Additionally, women using progestin therapy may experience bloating and mood symptoms. Also, almost all women using estrogen-progestin regimens experience vaginal bleeding in the initial stages of treatment . Other effects consist of changes in mood, headaches, as well as nausea. These effects usually resolve by three months. Nonetheless, persistent severe impacts of progestogen can be addressed by modifying the progestogen or by utilizing an intrauterine system (Akter & Shirin, 2018). As a result, there will be endometrial protection and a decrease in periods with continuous use of estrogen.
Bozkurt (2010) also argues that venous thromboembolism is a significant concern. Although few hormonal therapy users have venous thrombosis, screening for congenital thrombophilia is imperative prior to prescribing the replacement of oestrogen. Examining the family history of embolic illness is essential. Obesity also heightens the risk of venous thrombo-embolism (Bozkurt, 2010; Akter & Shirin, 2018). However, the benefits gotten from arterial infections overshadows the risk . Similarly , the presence of varicose veins is a contra-indication to the hormone, oestrogen . For this reason , oestrogen should be avoided unless explicitly demonstrated. Additionally, oestrogen replacement may precipitate seizure or migraine disorders. As a result, close observation is needed in women for whom menopausal hormone therapy is contemplated .
Prescribing Hormonal Replacement Therapy
On the one hand, estrogen therapy is utilized by women who have gone through a hysterectomy . On the other hand, estrogen along with progestogen is used by women with an intact uterus. Estrogen together with progestogen is recommended for women who have gone through endometrial ablation (Sood, Faubion, Kuhle, Thielen & Shuster, 2014) . Initiation of estrogen therapy needs a review of the regimens and types of the readily available preparations. Individual preferences, as well as health concerns, guide the decision for the preferred hormonal regimen. Also, there are women in whom using hormonal therapy is a contraindication. Majority of women are concerned about the risk of breast cancer. Therefore, it is recommended that there be a three months trial of the treatment. This would, hence, enable women to examine their life quality, whether hormonal therapy is advantageous or not. Afterwards , they can choose the duration since they are already aware that the risk of breast cancer significantly depends on the treatment duration. A complete history will bring to light any existing medical issues or the history of the family, cancer, or cardiovascular disease. This information will guide the clinician to provide the appropriate regimen, administration route, and dose. Blood pressure, as well as body mass index, can indicate whether more investigation is required. Once a woman starts hormonal therapy, the therapy should not be stopped abruptly. However, one should discontinue the therapy gradually. Usually, restarting or continuing on hormonal treatment is a choice based on life quality. Menopausal symptoms can generally start in the state of perimenopausal. Such women require cyclical hormonal therapy for twelve to fourteen days per months (Akter & Shirin, 2018) . This is fundamental to avoid unscheduled bleeds or additional investigation. It is imperative to note that once a woman starts hormonal therapy, all that is required is an annual examination.
Conclusion
Menopause is a difficult transition for women. As such, hormonal therapy is the most effective therapy to treat menopausal symptoms. Contraindications to using hormonal therapy are mostly family or personal history, and cardiovascular diseases. This treatment form, therefore, can be given to menopausal women to minimize troublesome symptoms of menopause, for prevention of vaginal dryness, and hip fracture. Because the benefits of hormonal therapy tremendously outweigh the risks, it would be best for menopause women to start the regimen as quickly as possible. Thus, their life quality beyond menopause will significantly improve.
References
Akter, M., & Shirin, E. (2018). Latest evidence on using hormone replacement therapy in the menopause. Journal of Bangladesh College of Physicians and Surgeons , 36 (1), 26-32. doi: 10.3329/jbcps. v36i1.35508
Bozkurt, B. (2010). Where do we currently stand with advice on hormone replacement therapy for women? Methodist Debakey Cardiovascular Journal , 6 (4), 21-25. doi: 10.14797/mdcj-6-4-21
Dodampahala, S. (2015). Menopause and HRT then and now. Austin Journal of Obstetrics and Gynecology , 2 (3), 1-3. Retrieved from https://www.researchgate.net/publication/301692803_Review_Article_Menopause_and_HRT_Then_and_Now_Austin_Journal_of_Obstetrics_and_Gynecology
Kamrava, M. (2017). Menopausal hormone replacement therapy. Journal of Gynecology and Women's Health , 5 (2), 1-3. doi: 10.19080/JGWH.2017.05.555659
Sood, R., Faubion, S., Kuhle, C., Thielen, J., & Shuster, L. (2014). Prescribing menopausal hormone therapy: an evidence-based approach. International Journal of Women's Health , 47. doi: 10.2147/ijwh. s38342
