Considering hormone replacement therapy

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In recent years, medical experts have gone from recommending hormone replacement therapy (HRT) to all postmenopausal women, to condemning it as a source of all kinds of problems like heart attacks, to a more subtle reconsideration that's currently taking place, so I don't blame you if you're confused about this subject. Because these hormones have a definite effect on your blood glucose control, you need to understand what they do and whether they're for you.

The purpose of HRT

With the onset of menopause, you're at risk for some or all of the following symptoms:

¡^ Hot flashes ¡^ Vaginal dryness ¡^ Sleeplessness ¡^ Irritability

Some of these symptoms mimic hypoglycemia, and unless you test your blood glucose, you may eat extra calories, thinking that you're treating that condition.

Having T1DM along with menopause adds several other problems that make your blood glucose even more difficult to control; they include:

¡ Bacterial and yeast infections ¡^ Urinary tract infections

Because all these symptoms seem to arise from a lack of the hormones estrogen and progesterone, it seems logical to replace them to reverse the problems. Hormone replacement therapy was the standard treatment for all these conditions up until 2002. It also was thought to protect women against osteoporosis and heart disease.

Controversies about HRT

In July 2002, a key study was published in The Journal of the American Medical Association under the title "Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women's Health Initiative Randomized Controlled Trial." The report provided the following conclusions about postmenopausal women who took HRT compared to those who did not. The users had



increase in cases of breast cancer



excess of heart attacks



excess of strokes



excess of blood clots in veins



decrease in bone fractures



decrease in cancer of the large intestine

The study had an immediate and enormous effect. Millions of women taking HRT stopped taking it. A typical study in The Archives of Gynecology and Obstetrics in August 2007 showed that the number of prescriptions for HRT dropped from 1,272 per month in July 2002 to 493 per month in July 2005 at one medical center.

Since these studies and findings, there has been some reconsideration of the rush to stop using HRT. Much of it has to do with problems in the 2002 study, especially the fact that most of the women using HRT began taking it years after they went into menopause rather than the usual custom of starting it at menopause. By age 60, women have had time to develop many of the conditions that were found in excess in that study; it's possible that HRT wasn't responsible for the increases because it was given later than it should have been.

However, there has been a significant decrease in the incidence of breast cancer since HRT usage declined in the U.S., and many experts believe that the reduction in use of HRT is the explanation. The decline was noted in 2003. It's difficult to believe that a disease that takes decades to develop like breast cancer can decline after just a year of decreased use of HRT, but the experts believe that the decline was in the cancers that depended on estrogen in HRT for growth. Given that the incidence of breast cancer increased in every year for 20 years up to 2002, it's hard to argue with the findings.

Deciding whether to use HRT

HRT can be used short term, for five years or less, without being clearly associated with the abnormalities described in the previous section. The people who can benefit from short-term use of HRT are

¡^ Women with debilitating hot flashes, especially if they disturb sleep

¡^ Women with vaginal dryness and hot flashes

HRT manages both these conditions. If vaginal dryness is present but not hot flashes, local estrogen preparations can be given.

The women who shouldn't take HRT at this time are

^ Women with any history of breast cancer ^ Women with any history of heart attacks or strokes ^ Women with a history of deep vein thrombosis

Should the woman with T1DM take HRT? My answer is if she does not fall into the second group or has debilitating hot flashes making control of her diabetes difficult, this could be a short-term consideration. If the HRT allows her to achieve good control of the diabetes with hemoglobin A1c levels under 7 percent, the benefits of short-term therapy outweigh the risks. If you're at all considering whether to use HRT, be sure to talk to your doctor.

If a woman with T1DM goes on HRT, she must continue regular mammograms and checks of her cervix. Any irregular bleeding should be reported to the doctor.

Many other treatments can be used if osteoporosis is the only reason for considering HRT. Among the safe treatments for women with T1DM are

^ Reloxifine, a selective estrogen receptor modulator that preserves bone. Side effects include hot flashes and blood clots.

^ Alendronate and risindronate, both belonging to a chemical group called bisphosphonates that prevent fractures and slow bone loss.

^ Calcitonin, a naturally occurring hormone that increases bone mass and prevents bone loss. It's used for people who have definite osteoporosis at least five years after menopause.

^ Teriparatide, a form of parathyroid hormone that may reverse bone loss.

^ Vitamin D and calcium, necessary for bone formation.

If you're considering HRT only to protect yourself again heart disease associated with T1DM, you may want to reconsider. There are a number of things you can do instead, such as the following:

^ Stop smoking or any use of tobacco.

^ Control your blood pressure (less than 120/80 for diabetic patients). ^ Lose weight through diet and exercise.

^ Control your cholesterol (LDL cholesterol less than 100 mg/dl and a ratio of total to HDL or good cholesterol less than 4.5).

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