Many women shy away from hormone replacement therapy because they fear the side effects. Our columnist Diana Helfrich knows that these can easily be reduced with a few tricks.
Hormone replacement therapy during menopause is a great topic for pharmacists. After all, they are the experts for the dosage form, i.e. for the way in which a drug enters the body. And there are few areas where it depends as much as in the administration of estradiol. This is the main estrogen produced in the body, but only while an egg is maturing in the ovary and getting ready to ovulate. After the last bleeding, the menopause, it is often a matter of replacing the estradiol with medication.
Unlike many other drugs, estradiol passes through the skin very well. And if it gets into the bloodstream this way, bypassing the digestive system and especially the liver, you need a lot, much less of it: A normal daily dose for an estrogen tablet is 750 to 1500 micrograms (millionths of a gram). With the patches, 100 micrograms is already a high dosage, there are also some that only release 25 micrograms per day. So we’re talking about a factor well over 10 here.
This has to do with the fact that estradiol, like all active ingredients that we swallow, first reaches the liver from the intestine via a thick bloodstream connection called the portal vein before it is even transported to the heart and from there distributed throughout the body. And in the liver, a good part of the estradiol is already metabolized and thus ineffective, or at least converted to molecules with a much weaker effect.
Hormone replacement: Estrogen tablets increase the risk of thrombosis
Another major disadvantage of this so-called first passage through the liver is that the coagulation factors that are responsible for the increased risk of thrombosis in hormone therapies are produced under estrogen (as with the pill, smokers should not take it either). This leads to an increased risk of embolism under hormones. The effect is greatest in the first few months of therapy, which is again like the pill. And it is all the greater, the higher the dose and, more commonly, the greater the basic risk of a woman – which usually means nothing other than: the older she is.
Band-aids and the like are better: According to the guideline, there is no evidence of an increased risk of thrombosis with low-dose transdermal estrogen therapy, and administration through the skin also performs better with other risks. Whether plaster, spray or gel, that isA matter of taste. Depending on the product, you only have to think about the plaster once or twice a week. It is best to apply the gel and spray at the same time every day, ideally in the morning after the shower. You only have to let them dry for a short time, then you can get dressed. Personally, I would always go for the gel.
Gels are very easy to dose
Like the spray, it’s invisible – it would bother me if someone could see my patch in the sauna or when changing at the gym (such patches usually stick to the abdomen or hips, where the skin is soft). And I would be worried about losing it in the pool. Compared to sprays, gels have the advantage that you can vary the dose greatly. This is very simple, because such gel preparations are in dosing dispensers: one stroke then contains a fixed amount of the drug. You can therefore also improvise with half strokes, but hardly with half sprays of a spray.
Incidentally, gels (they are applied as extensively as possible to the arm and shoulder, stomach or thigh) and sprays (they are usually sprayed on the inside of the forearm) also form a depot. Instead of in the patch matrix, however, it forms in the horny layer of the skin. From there, the hormone diffuses into the underlying blood vessels. According to the package insert for the spray, you can shower again an hour after applying it.
What remains, however, even with transdermal administration, is a slightly increased risk of breast cancer after a few years. This can never be avoided, because women who come into menopause late, i.e. who produce estrogen for longer themselves, have breast cancer a little more often.
The fact that the proportion of hormone users has recently increased from 6.2 (2020) to 6.4 (2021) percent should be explained by the Wiesbaden gynecologist Dr. Sheila de Liz have to do. She is a huge advocate of hormone replacement therapy and has created a real Meno wave with her bestseller “Woman on Fire”, numerous television appearances and her Instagram channel. I celebrate her for that, she was overdue! But I was also annoyed, because I left the book with the feeling that if you don’t take hormones, you’re making a huge, stupid mistake, getting old and sick prematurely and by yourself.
Why should a woman take anything if she has no symptoms?
But I ask myself: Why should a woman who has no symptoms take anything? To feel young longer? To optimize yourself? Maybe I don’t want that! There must be room for everyone who doesn’t want to or can’t take it, for example because they once had breast cancer. I’ll write about the non-prescription help available in the next column.
And then I want to get rid of something, while I’m already talking about the ways estrogens enter the body. Hormones can also be used locally, i.e. in such a way that they only work locally. Namely in the form of vaginal creams, suppositories or tablets against vaginal dryness; and estrogens used in the genital area can also achieve a lot against urinary incontinence. Such products usually contain the active ingredient estriol, which is much weaker than estradiol. And then in low doses. The idea is that unlike the gels etc. mentioned above, it doesn’t affect how estrogen is happening in the body, it really just changes things locally. So you don’t have to ask yourself all the questions about the risks. The package insert still says that the preparations should not be taken if you have breast cancer or if you have risk factors for estrogen-dependent cancers. However, it can also be handled differently if necessary.
The difference between these two types of hormone treatment is not clear to many. How generally knowledge about menopause is still modest, even among doctors. And when I recently looked again at my physiology textbook from my studies (which was also common among doctors at the time), I also realized why: It is of course about the female menstrual cycle.
Menopause is hardly a topic in medical school
But menopause is not mentioned at all. As if women on the edge and beyond fertility don’t exist. And, even worse: it’s not even mandatory in gynecology training, nor is the subject of sexual medicine. It’s hard to believe given the fact that menopause is not a rare disease, it literally affects EVERY woman at some point. But true. It is therefore not surprising when doctors do not attribute symptoms such as memory problems, joint problems, dizziness or cardiac arrhythmias to hormonal changes, when women go to medical marathons and simply cannot find anything that will make things better.
But fortunately the Meno wave is rolling, there is still a lot of catching up to do. Because one thing is for sure: no woman just has to “go through it”, which is still heard by far too many people. There is effective help.
Detailed information about menopause is also available in the podcast “Meno an mich” with consequences Hormone therapy – yes or no or Below discomfort: vaginal dryness.
Follow me on Instagram: @apothekerin_ihres_vertrauens
Note: The column cannot provide individual advice in the Pharmacy replace the package leaflet or medical diagnosis and treatment.