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Hormone Help Desk: ET, EPT, and More

Before you have your annual checkup, the Hormone Help Desk offers a refresher course on menopause terminology including ovarian hormones (estrogens, progesterone, and androgens) and the various hormone therapies (HT) to relieve menopause-related symptoms and/or to decrease long-term risks for diseases such as osteoporosis. This checkup can help determine whether or what kind of hormones might be appropriate for you.

Estrogen -- This is the “female hormone” that promotes the development and maintenance of female sex characteristics for purposes of reproduction. The 3 main estrogen types called estrone, 17beta-estradiol (most biologically active), and estriol (highest in pregnancy) all decrease at menopause, and that decrease can result in menopause symptoms such as hot flashes and vaginal dryness.

Progesterone -- Often called the “nurturing hormone,” progesterone signals the uterus to prepare a lining of tissue for a fertilized egg. It also acts to maintain pregnancy and promote development of mammary glands (breasts). In women having periods, progesterone is produced by the ovary only after ovulation (or the release of an egg). If the egg is not fertilized, levels of progesterone fall and menstruation results. The end of ovulation at menopause means the end of progesterone production as well.

Androgens -- Often called “male hormones,” androgens are also produced in the female body as testosterone and dehydroepiandrosterone (DHEA), among others, but in much lower quantities than in men. Insufficient androgen levels at any age are thought to contribute to fatigue, mood changes, and lowered sex drive. There is no dramatic change in androgen levels at menopause; androgen production seems to be affected more by aging, although women who have their ovaries removed (surgical menopause) sometimes experience a sharper drop in their levels of testosterone. Interestingly, testosterone has been found to increase again in older women.

Estrogen therapy (ET) -- Various estrogens can be used by women in different ways (pills; skin patches and gels; vaginal creams, rings, and tablets) for the treatment of distressing menopause-related conditions. Therapy with estrogen alone is generally appropriate only for women who have had a hysterectomy and do not need any uterine protection in the form of progestogens (either as natural progesterone or synthetic progestin) to prevent uterine cancer. (See more below)

"Systemic" (meaning throughout the body) oral and skin preparations of ET  are government approved in the United States and Canada for the treatment of moderate to severe hot flashes and vaginal atrophy. Most of these products are also approved for lowering the risk of osteoporosis if used long term. "Local" low-dose vaginal ET is effective (and approved) for vaginal atrophy only.

ET has been widely studied and used for more than 50 years by millions of women. Systemic ET is associated with side effects, such as an increased risk of stroke, blood clots, and possibly breast cancer if used long term. ET should be used at the lowest effective dose consistent with a woman’s treatment goals.

Progestogen therapy -- Progestogen therapy is an umbrella term used to describe therapy that aims to mimic the effects of the hormone progesterone. Natural progesterone and synthetic progestins with progesterone-like activity are all progestogens. These hormones have sometimes been used alone during perimenopause to treat symptoms such as hot flashes when a woman cannot use estrogen, but their most common use is to protect against uterine cancer associated with ET.

Estrogen-progestogen therapy (EPT) -- Women with a uterus who wish to use estrogen for symptom relief should combine it with a progestogen to protect the lining of the uterus (endometrium). Estrogen stimulates the uterine lining and causes it to thicken, increasing risk for endometrial cancer (cancer of the lining of the uterus). Progestogen is used to decrease the risk caused from ET, but does not protect against the type of uterine cancer that that is unrelated to estrogen. EPT is associated with side effects similar to ET and should be used at the lowest effective dose consistent with treatment goals. The risk of breast cancer appears to be higher with EPT, especially when used long-term (more than 5 yrs).

Hormone therapy (HT) -- HT is another umbrella term your healthcare provider might use that refers to either ET or EPT. The term “hormone replacement therapy” is no longer used by the Food and Drug Administration (FDA) or The North American Menopause Society because the goal of HT is to provide the amount of hormones required to relieve symptoms, not “replace” the amount produced before menopause. It is considered normal to have low estrogen and progesterone after menopause. Menopause is not a deficiency disease.

Androgen therapy -- Some studies have shown a beneficial effect of androgen therapy on women's sex drive. There are no government-approved androgen products available for women in the US or Canada although a number of testosterone products for women are currently under development and study. Some testosterone products approved for men are prescribed for women (called “off-label” use) but in much lower doses than used for men. DHEA is available over the counter in the US but not Canada where a prescription is required. Custom-compounded androgen products are also available through prescription. There are many uncertainties about the role of androgens in female health,  and while the risks and side effects are rare if the level is kept within the female normal range, high doses may cause side effects and may not improve sex drive., Further study is needed to determine the effectiveness and safety of long-term androgen use by women.

Bioidentical hormone therapy (BHT) -- There is a lot of discussion in the media about “bioidentical” hormones, a term coined to refer to hormones that are chemically identical to those made by the human female. Some people use the term to mean compounded hormones, but there are so-called bioidentical preparations of estrogens and progesterone that are government approved in the US and Canada, even though the FDA does not recognize the term as an acceptable scientific term and will not use that term in their drug labeling. Despite many marketing claims, there is no scientific evidence that custom-compounded BHT is safer or more effective than the many government-approved therapies mentioned above.  Studies indicate that compounded products are not supervised as closely as FDA-approved hormone products.

Now you should be well prepared to discuss menopause symptoms and ovarian hormones with confidence during appointment with your healthcare provider! 

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