Reaching this beneficial goal requires only small doses of progestins, usually doses of 5 to 10 ma. Some women need slightly higher or lower doses. Women who develop side effects such as fatigue and depression may need to drop their dose to as low as 1.25 mg per day, while others must use up to 10 mg per day to achieve the best therapeutic effects.

Progestins can be used for other aspects of menopause in addition to their normal role in preventing uterine or endometrial cancer. For example, physicians often prescribe progestins for women making the transition into menopause who have excessive bleeding due to an imbalance of female hormones. Women may produce too much estrogen without ovulating. This causes heavy periods, which can last as long as 10 to 20 days, or even longer. Progestins taken for one week each month or for 10 to 12 days are usually effective in controlling this bleeding. They are also used during the early menopausal years when a woman is no longer bleeding. Progestins are given as a "challenge test" to see if the lining of the uterus is still being stimulated. If you bleed after stopping the progestins, your body is still producing estrogen. In this case, the progestins must be used on a monthly basis, even without additional estrogen therapy. The risk of endometrial cancer is higher in women taking no hormones than those on HRT because of a woman's unopposed endogenous estrogen.

The most commonly used brand of progestins is Provera (Upjohn). Norlutate (Parke-Davis) is also frequently prescribed, but it may cause side effects similar to androgens such as oily skin and acne. A third progestin currently on the market is Amen (Carnick).

Oral Micronized Progesterone. Synthetic Progestins were used originally instead of natural progesterone because they may be taken orally. Unfortunately, natural progesterone cannot be ingested because it is destroyed during digestion and never reaches the bloodstream. In recent years, a new micronized form of progesterone is available that is protected from destruction by stomach acid and enzymes and can be absorbed and utilized by the body. Made from the natural progesterones found in yams and soybeans, oral micronized progesterone has gained wide acceptance by physicians as a treatment for premenstrual syndrome (PMS). I began to prescribe natural progesterone over a decade ago to my PMS patients, and I am very pleased by the response to this treatment. It seems to be particularly helpful in controlling the emotional symptoms of PMS such as anxiety and mood swings.

Menopausal women are beginning to use this form of progesterone more frequently because it causes fewer side effects than the synthetic progestins. While the progestins can cause depression, fatigue, bloating, breast tenderness, and also adversely affect blood cholesterol levels, the natural progesterone seems to cause fewer adverse reactions. However, natural progesterone may still cause drowsiness because of its sedative effect on the brain.

The main drawback to natural progesterone is its expense. It is more expensive than the synthetic progestins, a deterrent for women on a tight budget. In menopausal women, dosages of 200 mg daily can be effective, although the dose can vary in either direction. Like the synthetic progestins, it is used 10 to 13 days per month and appears to confer an equal amount of protection against uterine cancer. Besides the oral form, it can also be obtained as a rectal or vaginal suppository. PMS patients use this route of administration successfully, as vaginal suppositories allow excellent local intake of progesterone into the uterus. Ask your physician about natural progesterone if it seems like it might be the right form of progesterone for you.

Progesterone Skin Cream. Pro-Gest^®Cream is applied to the skin and absorbed into the general circulation. Recent research has shown that it not only elevates progesterone levels, but it also elevates DHEA levels in the body. Because it is absorbed through the skin, it bypasses the liver, thereby escaping liver metabolism. Unlike the synthetic progestins, there are few side effects reported by its use.

Pro-Gest cream is applied to the skin twice daily in one quarter to one half teaspoon amounts. It is generally used on rising and before going to bed at night. It can be applied to any area of your skin. Many women will rub it into their chest, abdomen, arms or back. If the cream is absorbed rapidly (under two minutes), it means that the body needs a higher dose and a slightly higher amount may be used. Few physicians have any experience using Pro-Gest cream to date and it is more likely to be used by physicians knowledgeable about alternative therapies. You may want to check with physicians practicing alternative therapies in your area to find one prescribing progesterone topical cream.

General Guidelines of Hormonal Use
Understand and follow these principles if you wish to obtain the best results from HRT. These relate to dosage, route of administration, regimen and frequency, choice of physician, and proper cessation.

Choose the Lowest Dose that Works
In general, use the lowest possible dosage of both estrogen and progesterone that will relieve your symptoms and prevent longterm health problems associated with hormonal deficiency such as osteoporosis and cardiovascular disease. Medical research has shown this to be 0.625 mg for the Premarin oral tablet and 0.05 mg for the estrogen transdermal patch. If you start at higher doses, you are more likely to encounter side effects such as anxiety, mood swings, fluid retention and breast tenderness. Many women who could benefit from HRT discontinue it because of unpleasant (and often unnecessary) side effects.

Some women find that even the tiniest dosage of estrogen normally prescribed, 0.3 ma, provides adequate symptom relief. However, such a low dosage may not provide sufficient protection against the development of bone loss or cardiovascular disease. Thus, women with high risk factors for developing either problem should not use this minimal dosage. To know your risk potential, have your physician perform the appropriate tests. If you feel comfortable at the smaller dosages, you may wish to combine estrogen with the alternative therapies described later in this book. At the other end of the spectrum, you may feel your best only when using estrogen in the high dose ranges. If you have experienced a surgical menopause below the age of 40, you may need more estrogen than women who go through natural menopause at a later age. Obviously, with estrogen, one dosage does not fit all women and therapy must be carefully individualized to each woman's needs.

Progesterone should also be used in the lowest possible dose to prevent side effects. This is particularly true for the synthetic progestins, which can cause the most problems. As mentioned earlier, I have had patients drop their dosages to as low as 1.25 mg to avoid common progestin-induced side effects such as fatigue, depression and bloating. I've also seen physicians increase the dosage to as high as 15 to 20 mg per day on a short term basis to stop heavy menstrual bleeding in a woman making the transition into menopause. Your physician will order the lowest dose to confer protection against uterine cancer, yet one that is comfortable for you. This may require some fine tuning and tests such as a vaginal ultrasound under the guidance of your physician.

Choose the Route of Administration that Is Most Comfortable
Some women find it difficult to remember to take one or two pills each day. They may, occasionally, miss days. This does not create the same potential problem that missing a day or two of birth control pills will, because menopausal women do not have to worry about unplanned pregnancies (unless they are in the early stages of menopause). However, if you find pill taking too challenging or unpleasant, then you are better off asking your physician about the alternative routes of administration such as the estrogen transdermal patch or progesterone cream.

Choose the HRT Regimen that Suits You Best
Traditionally, estrogen was taken only three weeks per month with one week off. Provera, a common progestin, was added during the last 10 to 13 days of the regimen to prevent the development of endometrial cancer. Taking one week off estrogen each month reduces the time during which the uterine lining is exposed to estrogen, therefore, reducing the risk.

However, some women find that menopausal symptoms, such as hot flashes, recur during this "off" week. In addition, many women dislike the bleeding, similar to a regular menstrual period, that occurs within a few days after the hormones are stopped. Even though the bleeding tends to be lighter and even diminishes or stops over time, many women find it an annoyance.

While some physicians still use the traditional three weeks on, one week off regimen with their patients, other regimens have become very popular in recent years. With one protocol, estrogen is taken every day and a progestin is added on an intermittent basis, usually during the first 12 days of the calendar month. More than two-thirds of the women on this regimen, if they have a uterus, experience bleeding when administration of progestin stops after the twelfth day. With combined continuous therapy, both estrogen and low doses of progestins are used on a daily basis without stopping. Women on this regimen may experience irregular bleeding during the first six months of treatment, which then diminishes. With both continuous and combined continuous therapy regimens, bleeding often doesn't persist indefinitely. For many women, bleeding becomes lighter and stops entirely after a few years. This occurs as the endometrium eventually becomes inactive.

Both these regimens appear to protect women against the development of uterine cancer as well as does the "on-off regimen." Also, constant daily hormonal intake protects women better from recurrence of menopausal symptoms.

Pick a Physician Who Will Tailor HRT to Your Needs
One of the most important factors in developing a successful menopause relief program is to work with a physician who is knowledgeable and dedicated to helping you achieve the best therapeutic results. How does one find such a physician? You might try asking your friends for a referral. Choose several physicians and interview them to determine if their philosophy of HRT and personality fit with you. Ask many questions and evaluate the responses. Remember, this relationship between you and your physician will be a long term one.

Attaining the goal of the best HRT regimen for you may require considerable tinkering over time with both dosages and formulations until the right results are achieved. Though some women adapt easily and effortlessly to their hormonal regimen, others need the expertise and help of an empathetic physician to achieve the results they desire. However, if you have made the decision to use HRT and believe strongly that these hormones can provide you with real benefits, it is worth the time and persistence. The benefits that HRT can provide are discussed in detail in the following chapters.

Stop Hormone Use Gradually
What if you've been on HRT for some time and now feel that it's time to stop using it? While many women stay on HRT indefinitely, other women do not feel the need to continue with HRT after using it for a short period of time. Once the initial symptoms are relieved and the body is adjusted to the postmenopausal period, they may wish to see how they feel without hormones. Others dislike the side effects that develop with HRT, so choose to discontinue it. Whatever the reason for stopping HRT, don't do it abruptly. This can cause a severe recurrence of symptoms (such as hot flashes) as your body reacts to the rapid decline in estrogen. Just as during the early postmenopausal period, the pituitary pumps out high levels of FSH in an attempt to make your body produce the estrogen that has suddenly disappeared. Hot flashes and night sweats can reappear as the pituitary-hypothalamic axis goes off balance.

Be sure to stop HRT use very slowly. I often recommend cutting the dose of estrogen by one-half each month for one or two months. Then cut back to every other day for a month, followed by twice a week for a month, and finally to once a week for a month. Continue to take your progesterone on your regular schedule until you have stopped the estrogen entirely, then discontinue it. If your symptoms recur in too uncomfortable a fashion, you can always begin HRT use again.