Your Menopause Questions Answered

Salivary hormone testing is often used by compounding pharmacies to tailor the prescription of bioidentical hormones – hormones derived from natural sources, such as plants, that have a chemical structure identical to the body's own natural hormones – to a patient. However, the American College of Obstetricians and Gynecologists stresses that salivary testing of a woman's hormone levels is not useful because these levels vary within each woman depending on her diet, the time of day, and the specific hormone being tested.

According to the FDA, some compounding pharmacies claim that estrogen levels in a person's saliva can be tested by practitioners to help them estimate the hormone dosage a person needs and then to customize the therapy for her. "There is no scientific basis for using saliva testing to adjust hormone levels," notes the FDA. "Instead, practitioners should adjust hormone therapy dosages based on a patient's symptoms."

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Prescription estrogen therapy (ET)—as an oral tablet, skin patch, gel, mousse, spray, or lotion—remains the most effective treatment for hot flashes. When this type of "systemic" (circulated through the body) ET is chosen, women with a uterus must also use another prescription hormone, progestogen, to protect the
uterus. This combined estrogen-progestogen therapy is called EPT. If hot flash relief from hormone therapy is the goal, systemic ET or EPT is best.

ET in all dosage forms (oral tablets, skin products, and vaginal products) is also the most effective treatment for moderate to severe vaginal dryness. Vaginal forms of ET provide estrogen "locally" (not circulated through the body); in this case, progestogen may not be required. If vaginal symptoms are the only reason to consider hormone therapy, local vaginal ET is the most appropriate choice. Choices include vaginal creams (Estrace Vaginal Cream, Premarin Vaginal Cream), a vaginal ring (Estring), and a vaginal tablet (Vagifem). The newer vaginal ring (Femring) has both local and systemic effects.

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In the past, most women who started hormone therapy for relief of symptoms such as hot flashes and vaginal dryness stayed on hormone therapy for life. Although the time of symptoms may have passed, women liked the fact that using estrogen reduced their risk of fractures from osteoporosis. Newer research has resulted in a different practice for most women. Hormone therapy, even at the lowest dose, should always be used for the shortest duration possible consistent with treatment goals.

A woman should eventually attempt to reduce or stop hormone therapy when appropriate for her, and always in consultation with her healthcare provider. If bothersome symptoms persist, hormone therapy can be resumed or other strategies can be tried. For the majority of women, a point will be reached when symptoms are gone for good, and hormone therapy can be stopped.

Importantly, however, hormone therapy is an effective option for some women to use long-term to keep bones strong. Some women may decide to continue long-term hormone therapy for other potential or perceived benefits. The decision should be revisited regularly to reassess the risk/benefit ratio for each individual in light of her health and research advances.

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Each woman experiences their menopausal transition in a unique way, and therapy needs can vary. Several factors to consider include the kind of therapy as well as the dose. These decisions will be based on finding a treatment that works while minimizing any associated risks.

One way to lower potential risk with any type of drug treatment, including hormone therapy, is to use the lowest effective dose. Some clinicians start with a standard dose and adjust up or down as needed for symptom relief. Other clinicians start very low and go up when required. Today's hormone therapies are available in very low doses to help with this approach. Research has shown that "lower than standard" doses of estrogen are almost as effective for symptom relief as standard doses.

It is important to remember that one milligram of one type of estrogen doesn't always equal one milligram of another in its effects on the body. More oral estrogen is required, because much of it is lost as it passes through the gastrointestinal system and is broken down in the liver before it reaches the blood stream. Transdermal estrogen goes through the skin and right into the bloodstream. The best thing is to listen to your body and have your clinician monitor you and continuously reassess your options.

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