Localized vs. Systemic Hormonal Replacement Therapy
Beth Safarian, PT, MSc. PT, BSc
Hormone replacement therapy (HRT) is a common topic of discussion at our clinic for patients who are peri and post-menopausal. However, there is still a lot of confusion and uncertainty when it comes to understanding if HRT would be the right treatment for them. As pelvic physiotherapists, we can educate our clients on how these medications work, and what benefits/risks are involved. These conversations can prompt our clients to ask their family doctor or gynaecologist about HRT and have further discussions to determine if it’s appropriate for them.
What is HRT?
Hormone replacement therapy is the use of medication that contains estrogen, progesterone, or a combination of both. One of the most common reasons it is prescribed is for people who are peri or post menopausal, and need supplementation of the hormones that their body is no longer producing.
Systemic Hormone Therapy
This type of medication is called systemic because it travels through the bloodstream to all parts of the body. This version of HRT usually contains higher doses of hormones and comes in multiple forms that include oral tablet, skin patches, creams, gels, spray or injection. These medications are typically prescribed for symptoms like hot flashes and night sweats. There is more risk associated with taking systemic HRT versus localized. Estrogen-only HRT can increase the risk of uterine cancer, so it is only recommended for people without a uterus (eg. post-hysterectomy). Combined HRT (estrogen and progesterone) is more commonly used for people who have a uterus. However, long term use (5 years or more) of combined HRT has been associated with increased risk of breast cancer, uterine cancer and cardiovascular risks. Because of this, it is important that the lowest dose possible is prescribed and a specific benefit/risk analysis is discussed with each individual patient. It also means that systemic HRT is not recommended for patients with a history of breast or uterine cancer.
Localized Hormone Therapy
This type of medication is called localized because it is more specific to a particular area of the body that the hormones are affecting rather than traveling through the bloodstream. This option typically contains lower doses of hormones and is usually estrogen only. It works by increasing the thickness and lubrication of the vaginal tissues. It comes in the form of suppositories, creams and rings. Common brand names that you may have heard of include Vagifem, Premarin and Estragyn. The product is inserted into the vagina with the goal of impacting the genitourinary tissues (vuvla, vagina and lower urinary tract), and are not as readily absorbed into the bloodstream, if at all. These medications are prescribed for symptoms specific to the vagina like dryness, irritation, atrophy and pain with sex. There are more recent studies being done that indicate that vaginal estrogen may also positively impact persistent urinary tract infections and urinary incontinence. Overall, the research shows that vaginal estrogen can improve genitourinary symptoms of menopause with no increased risk of breast cancer.
Taking any medication is a very personal choice and many factors should be considered when making a decision about HRT. It is important to do your research and talk to your doctor to determine if it this treatment is right for you.
Sources:
https://cancer.ca/en/cancer-information/reduce-your-risk/understand-hormones/all- about-hormone-replacement-therapy-hrt
https://www.menopause.org/for-women/menopauseflashes/menopause-symptoms-and- treatments/hormone-therapy-benefits-risks
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252029/