(1997)

You’re relieved that hormone replacement therapy (HRT) can reduce menopausal symptoms such as hot flashes and vaginal dryness. And you’re comforted by the fact that it cuts your risks linked to cardiovascular disease and osteoporosis in half. But how do you get these benefits without the side effects?

As many as two-thirds of women who start HRT stop within two years. One main reason they stop is because of side effects, particularly the irregular bleeding that can last anywhere from a few months to a few years.

So how do you reap the benefits of HRT and bypass the side effects? Customize. HRT comes in a variety of doses, regimens and preparations designed to make you more comfortable with your therapy while gaining long-term benefits.

Starting with the standard dose

If you haven’t had a hysterectomy and you’re postmenopausal, you’ll probably start with the standard dose of 0.625 milligrams (mg) of either an oral estrogen such as Premarin, Ogen or Estrace. A starting dose of 0.625 is the minimum dose of estrogen that protects against cardiovascular disease and osteoporosis, plus relieves your menopausal symptoms.

With estrogen, you’ll take 2.5 to 5 mg of progestin. Progestin protects against uterine cancer. It stops uterine cells from dividing and causes your uterus to shed its lining. By this action, however, progestin can induce monthly bleeding.

If you’ve had a hysterectomy, you’ll probably start with 0.625 mg of estrogen alone. Because you no longer have your uterus, you don’t need the protective effects of progestin.

For many women, these standard starting dosages work just fine. And many women quickly feel dramatically better as their hot flashes ease and they can get a good night’s sleep. But there’s no such thing as a one-size-fits-all HRT regimen.

Choosing a regimen

You can take oral estrogen and progestin in one of two ways. Cyclic hormone therapy, which causes monthly bleeding, involves taking oral estrogen daily plus oral progestin for 10 to 14 days each month.

With continuous combined hormone therapy, you take a combination of estrogen and progestin daily. This combination is now available in a single pill.

Estrogen can cause some bleeding and menstrual-like symptoms such as breast tenderness and mood swings. It can also aggravate existing medical conditions such as migraines, gallbladder disease and high triglycerides. Progestin can cause irregular bleeding and mood swings. It can also reduce estrogen’s effectiveness in raising high-density lipoprotein (HDL) cholesterol (the good kind).

There are many factors that go into custom designing an HRT program. If the standard starting regimen doesn’t work for you, talk with your health-care provider about adjusting your HRT program. Together, you should be able to come up with a plan that gives you the most benefits from HRT with the least number of side effects.

Here are some of the most common concerns you may have about HRT:

• Can you stop the bleeding? Probably. Many women don’t mind the bleeding caused by estrogen and progestin. For others, eliminating bleeding is a high priority. You can manage this common and bothersome side effect if you:

• Switch from a cyclic to a continuous regimen. Up to 90 percent of women who switch from a cyclic to a continuous HRT regimen stop bleeding within one year.

• Irregular bleeding. For a few women, however, irregular bleeding can continue for more than a year. If you don’t stop bleeding after a year with continuous combined HRT, you may need tests to make sure there’s no problem, such as uterine cancer. If testing reveals nothing, your health-care provider may recommend an adjustment in your progestin dose.

• Take progestin less frequently. Taking progestin every three months may increase the volume and length of bleeding. But you may bleed only four times a year instead of every month. If you’re on a cyclic program and don’t want to bleed during a special occasion such as a vacation, you can skip your monthly dosage of progestin if approved by your health-care provider. This stops bleeding without any adverse effect.

Do you have to put up with the menstrual-like symptoms?

No. To relieve breast tenderness, mood swings and bloating, you can:

• Take HRT less often. You may have the option to take continuous combined HRT Monday through Friday only.

• Alter your HRT dose. Your health-care provider may suggest you raise or lower your HRT dose to offset menstrual-like symptoms. Resuming the standard dose or switching to a different type of estrogen or progestin may also be suggested.

How will HRT affect other health problems?

If you have migraines, liver or gallbladder disease or blood clots, oral estrogen can make your problem worse. You can:

• Switch to the patch. Applying the patch to your abdomen delivers estrogen directly through your skin into your blood. Because estrogen delivered this way bypasses your liver, it reduces the aggravating effect HRT can have on liver and gallbladder disease and blood clots. Using the patch also reduces the fluctuations in estrogen levels. These fluctuations can make your migraines worse.

Don’t let the side effects of HRT stop you from getting relief from your menstrual-like symptoms and protection from cardiovascular disease and osteoporosis.

Work with your health-care provider to customize your HRT program.