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Section 10
Hormone Replacement Therapy
& Recommendations for Mental Health

Question 10 | Test | Table of Contents

Hormone Replacement Therapy
As its name describes, Hormone Replacement Therapy (HRT) involves the replacement of hormones lost, or in the process of being lost, to women experiencing all phases of menopause (Clinkingbeard et al., 1999). HRT may be useful for the alleviation of short-lived symptoms such as hot flashes and insomnia, and for long-term threats to health, including osteoporosis and heart disease (Clinkingbeard et al.; Fox-Young, Sheehan, O'Connor, Cragg, & Del Mar, 1999; Tosteson et al., 2000). Research findings from the Women's Health Initiative on the health risks of HRT published in the summer of 2002 brought fear of HRT to the forefront, leading many women to discontinue their use of HRT. The Women's Health Initiative was stopped on May 31, 2002, due to increased risks of breast cancer, heart attack, stroke and pulmonary embolism in research subjects (Yusuf & Anand, 2002). Although benefits were found in fewer hip fractures and reduced risk of colorectal cancer, the risks outweighed the benefits (Yusuf & Anand). The questions linger regarding the utility of HRT and alternative options available (Derry et al., 1997; Gannon, 1999; Huston & Lanka, 1997; Tosteson et al.).

Benefits
With regard to benefits, HRT eliminates hot flashes in the majority of women, usually within 2 weeks. In most cases, the suffering and discomfort associated with hot flashes will not return unless HRT is stopped (Cone, 1993). If the hot flashes interfere with sleep, HRT can also lead to marked improvement in sleeping patterns, thereby reducing insomnia (Coney, 1994). In addition, within weeks the replacement of estrogen counters the preliminary symptoms of vaginal atrophy, including dryness, itching, and painful sexual intercourse (Cone). Furthermore, if estrogen therapy is begun prior to the onset of vaginal atrophy symptoms, discomfort such as vaginal dryness will not occur so long as HRT continues (Huston & Lanka, 1997). Thus, HRT will improve vaginal discomfort and alleviate symptoms whether the symptoms are present or are yet to come (Cyr et al., 1994). HRT also counters the effects of urinary stress incontinence (Derry et al., 1997). Specifically, estrogen appears to strengthen muscles in the pelvic region, the urethra included. As is true of the vagina, the urethra responds positively to the replacement of estrogen by both developing a thicker mucous lining and increasing surrounding muscle strength (Cone).

In a survey of 665 women regarding knowledge of the usefulness of HRT, Clinkingbeard et al. (1999) found that the top two reasons cited for participating in HRT concerned preventing both osteoporosis (45%) and heart disease (29%). As for preventing osteoporosis, estrogen has been associated with reduction of bone loss, and in certain situations may actually counter osteoporosis by promoting increased bone density (Teaff & Wiley, 1995) and increased bone strength (Huston & Lanka, 1997). HRT is especially effective in women who have experienced abrupt estrogen loss such as that induced by surgical menopause (Cone, 1993). Estrogen replacement therapy in particular can have a major impact upon osteoporotic risk by producing a 50% to 60% decrease in arm and hip fractures. Moreover, estrogen improves calcium absorption. Estrogen receptors have been isolated in bone cells, suggesting that estrogen directly stimulates bone formation (Cyr et al., 1994). The timing of HRT and its association with combating osteoporotic symptomology is critical. Namely, studies of the impact of HRT upon bone mass assert that HRT must be initiated within the 5 years prior to menopause (Gannon, 1999). Furthermore, Gannon concluded that research is lacking regarding the link between the benefits of HRT on bone density and reduced risk of advancedage fractures.

As for combating heart disease, estrogen in particular has been shown to decrease heart disease risk by 40% to 60% (Cone, 1993; Kass-Annese, 1999). Estrogen can increase the good cholesterol (high-density lipoprotein, HDL) and decrease the harmful cholesterol (low-density lipoprotein, LDL), a result that apparently continues for as long as estrogen therapy continues. However, it is important to note that estrogen must be taken in moderation; otherwise, triglyceride levels become too high, which may lead to clotting of the blood. Concerning the combining of estrogen with natural progesterone, results may not be as favorable (Kass-Annese) and, as found in the Women's Health Initiative study, the combination could increase risks of heart attack and other cardiac concerns (Yusuf & Anand, 2002). More research is needed to understand the impact of combining estrogen with other hormones (Gannon, 1999; Matthews, Wing, Kuller, Meilahn, & Owens, 2000).

An interesting benefit of estrogen therapy concerns prevention of colorectal cancer. According to Huston and Lanka (1997) and Stevenson and Whitehead (2002), numerous research studies have linked estrogen usage with colon cancer reduction. Citing the results of approximately 18 studies, Huston and Lanka noted that the reduction in incidences of colorectal cancer ranged from 20% to 60% for participants involved with estrogen replacement therapy.

Risks
Although the benefits of HRT seem positive, there are many risks. Perhaps the most notable concern regarding HRT involves its connection with breast cancer. In general, HRT usage for less than 5 years has not been associated with increased risk of breast cancer. Nevertheless, research is indicating that HRT usage beyond 5 years increases breast cancer risk. In the Women's Health Initiative study, research on HRT was stopped after 5 years, instead of the planned 8 and one-half years, due to breast cancer diagnoses reaching and surpassing the prespecified safety limit (Stevenson & Whitehead, 2002). Furthermore, the risk of breast cancer may be increased not for those without cancer, but for those who already possess cancer cells.

Another concern associated with estrogen usage is that of endometrial cancer. However, the increased risk of endometrial cancer appears to be specifically associated with 'unopposed' (i.e., unregulated dosage or unprescribed) estrogen usage. Unopposed estrogen was the primary means of estrogen therapy decades ago. A more accessible and seemingly benign source of unopposed estrogen is herbs including ginseng, dong quai, and black cohosh. At this time, it is not clear whether herbal sources of unopposed estrogen increase risk for endometrial cancer. For women who use herbal estrogen, Huston and Lanka (1997) suggested monitoring the thickness of the endomitrium via ultrasound.

Aside from the long-term risks previously mentioned, HRT has been associated with hypertension and liver and gall bladder problems (Cone, 1993; Teaff & Wiley, 1995). As for less threatening side effects, estrogen therapy has been associated with breast enlargement and tenderness, enlargement of fibroids (benign tumors), dark patching of the skin, weight gain, and hair loss (Cone; Kass-Annese, 1999). Also, women using estrogen may experience headaches, nausea, and bloating (Teaff & Wiley). With HRT that includes progesterone, fluid retention is the most commonly reported side effect (Cyr et al., 1994), with other side effects including moodiness, breast tenderness, and headaches (Teaff & Wiley). However, the side effects associated with progesterone usage may be countered by altering the frequency or amount of dosage (Huston & Lanka, 1997).

Many researchers agree that HRT used long term "cannot be recommended as the risks associated with it are more than the benefits" (Shetty, 2002, p. 1243). According to findings from the Women's Health Initiative, women aged 65 to 69 who had used HRT for more than 11 years more than doubled their risk of breast cancer (Greiser, Steding, Giersiepen, & Janhsen, 2002). Shetty argued that HRT offers short-term relief with consequences too severe to justify its use. Shetty also encouraged general practitioners to be more honest with their patients regarding the risks of HRT. Finally, Shetty and Day (2002) both noted that arguing the benefits of HRT is unrealistic as the risks are so much larger and damaging than the possible benefits.

Numerous authors (Day, 2002; Gallant, Keita, & Royak-Schaler, 1997; Gannon, 1999; Huston & Lanka, 1997; Kass-Annese, 1999; Teaff & Wiley, 1995; Yusuf & Anand, 2002) emphasize the need for women to take care of their bodies throughout their lifetime by exercising regularly; eating a healthy, balanced diet; resting enough; and avoiding harmful habits such as smoking and excessive alcohol consumption. It is often difficult to isolate the risks specifically associated with HRT from those resulting from poor diet or a lifetime of heavy drinking, for example.

Recommendations and Resources for Mental Health Counselors
Although women are actively seeking information about their own wellness, even as they glance through popular women's magazines, Clinkingbeard et al. (1999) concluded in their study that women are not as accurately informed about menopause as they could be. Often gynecologists and other doctors offer limited information, which was the case with Amy's first medical consultation. Women, however, report that being informed about menopause results in an easier transition (Matthews et al., 2000). Mental health counselors are in a unique position to bridge the gap between a woman's need to understand her body and information available to assist with this need. Via professional resources, mental health counselors have available a wealth of information that they might disseminate to their clients. Women experiencing menopause will come in as individual clients as well as members of families seeking therapy.

Given the dramatic impact of menopause on some women's health and emotional status, it is imperative that mental health counselors recognize the impact of menopause as an invisible factor in a woman's and a family's psychological well-being. Often, it is the responsibility of the mental health counselor to provide informational resources or referrals and to be available for processing clients' understanding about the possible impact of menopause. Mental health counselors must not overstep their roles by providing medical advice; yet they ethically need to be able to separate developmental concerns from psychological issues. Providing information regarding the possible impacts of menopause can provide clients with renewed hope and understanding.

Women have many more options than suffering unassisted through the stages of menopause or choosing HRT. Openness and interest in alternative options to traditional medicine have increased dramatically over the past decade. Among the alternative medicine options for menopause are products offered by natural holistic medicine practices, flower essences, Black Cohish (Remifemin), soy foods, and homeopathy to name a few. Up-to-date, reliable information on each of these options can be found at www.alternativemedicine.com.

Homeopathy is increasingly sought as an alternative approach to medical treatment. The word homeopathy comes from the Greek word homoios, meaning similar, and pathos, meaning suffering (Homeopathy, 2002). Homeopathic "remedies are generally dilutions of natural substances like plants, minerals, and animals. Based on the principle of 'like cures like,' these remedies specifically match different symptom patterns or profiles of an illness, and act to stimulate the body's natural healing process" (Homeopathy, p. 1). Homeopathy has been utilized for nearly 200 years, and it has been effective for treating diseases that traditional medicine has been unable to heal. Over 500 million people worldwide utilize homeopathic treatment today. Homeopaths treat each woman uniquely based on each woman's needs throughout the process of menopause. Homeopaths can be found throughout the world at web sites such as www.alternativemedicine.com.

Menopausal Symptoms and their Management

- Santoro, N., Epperson, C. N., and Mathews, S. B. (2015). Menopausal Symptoms and their Management. Endocrinal Metab Cli North Am., 44(3). p. 497-515. doi:10.1016/j.ecl.2015.05.001

Personal Reflection Exercise #3
The preceding section contained information about hormone replacement therapy and recommendations for mental health.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 10
Given the dramatic impact of menopause on some women's health and emotional status, what is imperative for mental health counselors to recognize? To select and enter your answer go to Test.