Scenario # 1: The Medical Assistant is preparing to perform a venipuncture on a patient who has come into the office for their annual physical exam. To prevent exposure to blood you must wear personal protective equipment (PPE). When a medical assistant is performing or assisting with a venipuncture, the expected PPE to be used is gloves.

According to Delmar’s Clinical Medical Assisting, “Gloves will be worn when drawing blood and/or handling biomedical specimens.” Blood drawing is common sense, but biomedical specimens consist of urinalysis as well as fecal analysis. That means throughout the venipuncture and collection process you must wear gloves to protect yourself from any blood borne pathogen or contamination.

Gloves should be worn from the point prior to venipuncture until the blood tube is placed in the biohazard transport container. You want to wash your hands before and after every procedure and make sure that nothing is going to put you at risk for the barrier (the gloves) being broken, and if you think there is a risk to this, you want to double your gloves (long nails, wedding rings and things of that nature can put you at risk)

PPE is to be utilized at all times in situations that involve potential exposure to blood or other body fluids. Your skin can have microscopic cuts and abrasions that can provide an avenue for transmission if exposed to blood or other infectious body fluid which is why it is of such an importance to wear gloves when coming in contact with any blood borne pathogen or bodily fluid such as saliva and semen.

Gloves are typically effective for protection from splashes but do not protect from penetrating injuries caused by needles or other sharp objects. If any such injury is to occur, you are to report it to your supervisor immediately so prompt action is taken to prevent further consequences such as a patient contracting HIV/AIDS or even worst, yourself.

Scenario # 2: Patient Sonny Jones is here for symptoms that include fever, sweating, lots of nasal congestion, and a cough that is productive in nature. This patient has been in contact with family members who just tested positive for the flu.

During a flu outbreak, governmental agencies such as the Center for Disease Controls, Health and Human Services and the Occupational Safety Health Administration may recommend that you protect yourself from infection by using a face mask, N95 respirator, or other type of equipment.

For this sort of outbreak, according to Delmar’s Clinical Medical Assisting and the Florida Department of Health and Human Services, employees who work in the medical field and are in constant contact with patients and those who handle the clinical aspect of medical assisting and healthcare as well as collect or transport clinical specimens should consistently adhere to recommended infection control precautions to minimize their exposure.

The Center for Disease Controls states that potentially infectious specimens should be placed in leak-proof specimen bags for transport, labeled or color coded for transport and handled by personnel who are familiar with safe handling practices, have been trained in the area of infection control as well as spill cleanup procedures. They also state that workers who collect specimens from pandemic-influenza infected patients should wear PPE as described for employees in the manual that is located on-site at the work environment while performing direct patient care.

PPE in this scenario would consist of gloves made of latex(if the patient has no latex allergy), vinyl, nitrile, or other synthetic materials as appropriate, when there is contact with blood and other bodily fluids, including respiratory secretions.

Common sense would be to wash your hands before and after seeing every patient, do not double glove unless your needed to for a specific reason, do not re-use the gloves previously used, properly dispose and discard the gloves after usage, and proper usage of hand hygiene should also be adhered to as well to prevent chance of infection.

Gowns may also be needed with the chance of heavily soiled clothing due to performing an intubation or where constant secretions might occur, but it is not required by OSHA or the CDC.

Goggles or Face Shields are not needed in this case, however, if sprays or splatters of infectious material are likely, it states that goggles or a face shield should be worn as recommended for standard precautions. If you are around a patient who is consistently coughing or hacking, you would want to ensure the patient has a face shield to prevent the spread of infection, and you would also want to protect yourself from getting that as well.

Scenario # 3: The Medical Assistant is assisting Dr. Jacobs with a cyst removal (a surgical procedure) in the office setting.

For removal of a cyst on a patient, the medical assistant would assist the doctor with whatever he needed. The book did not really go too much into detail so I decided to watch a few YouTube videos of the incision, draining and removal of a cyst to see what actually occurs during this. After watching these few videos on YouTube, because you’re dealing with bodily fluids like blood and pus, you would want to wear Gloves.

First you would want to wash your hands before placing the gloves on. Of course because this is surgery you would want to ensure your sterile field is maintained. To maintain a sterile field, you would want to open your sterile dressing kit and set it up on a tray. You want to make sure the tray is above waist height because anything below the waist is considered to be contaminated or not sterile. You would then want to open the sterile kit making sure you do not touch anything inside as you do not have your gloves on yet, and everything is sterile.

You would then want to put on your first set of PPE for the removal of the cyst, which would be your mask. You would want to wear a mask because this is a sterile procedure, and your mouth has germs. This way you’re not breathing on or around, talking, coughing or sneezing around the sterile field. You would then hand the doctor his or her mask, and any other assistants theirs.

The next thing you would want to do is put on your sterile gloves. Because this is a surgery procedure, putting on sterile gloves is important because you do not want to cause the patient to be at risk of any sort of infectious diseases. Our skin carries and comes in contact with several billion bacteria during each hour of the day, and you would not want to be the cause of a patient catching MRSA or VRE or a super bug because they got sick and then developed a resistance and could not be treated, so it is important you follow each step about putting on sterile gloves. How you would do this is by opening the glove wrapper with the palm facing up.

You then would want to pick up the first glove by the cuff making sure you are only touching the inside portion of the cuff. While you’re holding the cuff with one of your hands, you want to slide your other hand into the glove this way your sterile hand is the first to go into the sterile gloves. While you are doing this you want to be careful that you are not touching anything, as everything else is again considered to be contaminated. The second glove is the hardest part of placing sterile gloves but the most important step to maintain sterility in the sterile field and environment. You want to slide your gloved hand under the cuff of the second glove and slide your hand inside the glove until you’re able to adjust both gloves to fit comfortably.

The next step would be to proceed to assist the doctor with the removal of the cyst by applying sterile dressings from the sterile field, as well as making sure he does not need your help with anything. Before the doctor enters the room you would want to make sure the tray for the removal of the cyst is ready in the sterile field, this way the doctor does not need to leave the room for any reason at all and the sterile field is maintained until the removal of the cyst is completed.

The doctor might also ask the medical assistant to assist by giving an injection to numb the area of the cyst removal on the patient. The medical assistant would be responsible for explaining the procedure, and then giving the injection at the site of the cyst removal. Because you might come into close contact with bloods, pus and other bodily fluids, I would recommend wearing a gown. Gowns are worn to protect against bodily fluids from soiling clothing, and depending on the location of the cyst and how large it is, you might want to wear this.

Scenario # 4: The Medical Assistant is assisting Mrs. Johnson to the exam table in the patient room. Mrs. Johnson has Stage 2 lung cancer and is undergoing chemotherapy and radiation treatments – she tells the Medical Assistant that the oncologist called and told her that her WBC count is 2.1 and that she cannot be around anyone who is ill, etc.

The first thing to note with this patient is that she does have stage two lung cancer. I as the medical assistant would first verify in the patients chart that she has this condition and check what her white blood cell count is. If confirmed that she indeed does have this low of a WBC, than I would immediately prepare for isolation of the patient so she is not around any possible contamination to where she would get ill. She would be moved from the exam table into an isolation unit exam room. I would then make sure the patient is in a comfortable position for examination and proceed with the check up and assisting the doctor.

As with any other procedure or PPE usage, you will want to begin with first washing your hands. The next thing you will want to do is put on a special gown called an isolation gown which is either cloth or paper. You want to make sure you tie your isolation gown at both points which is usually behind the neck and at the waist. You do this so that when you’re treating a patient in the isolation unit, in this case Mrs. Johnson, you do not contaminate your uniform or the patient for that matter.

The next thing you will want to do is apply your face mask or shield. Usually these have a clear protective eye shield. You again want to ensure that the mask and shield are on your face properly and fit this way you do not risk contamination to the extremely ill patient by breathing on them, and you do not risk contamination to yourself either.

The next item of PPE you will want to apply is your examination gloves. It is important that you pull the cuff over the sleeve of the gown this way you are not exposing your skin to the ill patient or any toxins that could make you ill as well. You want to avoid exposure of your skin in the isolation room.

After you are done with the examination of the patient in the isolation unit, you want to be sure that the door to the unit is closed securely so no pathogens can come into the room, and then you want to remove your PPE the same way you put it on. Be sure to wash your hands after any visit with a patient.

Scenario # 5: The Medical Assistant is assisting her co-worker in cleaning up a blood spill in the office laboratory.

Blood spills or other human body fluids that occur inside or in the outside environment need to be decontaminated to prevent the potential transmission of communicable disease.

The circumstances associated with blood spills can obviously vary greatly depending on the volume and type of contact surface. A small amount of blood, if splashed, can cover a large surface area. A large volume, if undisturbed on a flat surface, can pool in a relatively small area. A good example of blood or bodily fluids is a pregnant woman’s water breaking.

Prior to beginning the cleanup, you would want to notify your supervisor of the spill and ask where the spill cleanup kit was located.

Per OSHA and CDC Standards, a typical spill kit consists of the following: 10% bleach solution (or Lysol, virex or other EPA reg. Tuberculocidal), gloves, clear plastic bags, biohazard labels (available from OSEH HazMat), leak-proof sharps containers, brush & dustpan, or tongs or forceps for picking up sharps and disinfectant wipes.

You would want to put on a pair of rubber, latex, PVC or similar type gloves. For small blood spills no other PPE should be required. For larger spills where there is a possibility of contaminating your face or other parts of your body, call HazMat to assist in the cleanup, and then put on a mask and face shield along with a gown.

The next thing you will want to do is to cover the spill area with a paper towel and then pour a fresh mix of the bleach solution together. You will want to allow the solution to soak into the contaminated material to ensure that it is completely disinfected. You want to also treat this similar to treating a wound in the sense that you want to work from the outside in. Next you will wipe the area with paper towels. The last and final step is that you would want to dispose of the contamination into the biohazard waste bag and dispose in the proper bio hazardous area.

To complete the cleanup, you will want to finally remove your gloves and wash your hands to avoid the risk of contamination to yourself and other patients.

Scenario # 6: The Medical Assistant is working with the autoclave machine today in the office laboratory.

The autoclave that most medical offices use is the ones that are dry heat autoclaves. These get extremely hot so it is important that the medical assistant who is using these is able to understand the proper usage along with the PPE that he or she would need to prevent any potential injury.

Some personal protective equipment you would consider to use would be eye equipment, a button lab coat to prevent burns, closed toed shoes to again prevent possible burns and injuries in the case that something is dropped, and heat resistant gloves as you will be removing the items from the autoclave.

Potential hazards that could occur without the use of PPE are burns and pressure releases Hazards may be general or specific, depending on the design of the autoclave or pressure cooker. They can include Physical injury to persons in the vicinity from the rapid release of stored energy resulting from autoclave failure (e.g. failure of doors/lids) Physical injury from exploding vessels that have become pressurized during processing (e.g. glass containers) Scalding / burns from steam or the hot contents of items being processed Risk of infection from pathogenic micro-organisms due to inefficient deactivation of the waste Inadvertent release of genetically modified organisms to the environment  Manual handling issues during loading/unloading heavier items, Electrocution (e.g. damaged/wet electrical components) and Fire hazard (e.g. human error – leaving manually operated autoclave equipment unattended).

It is utterly important that the medical assistant knows how to operate the autoclave from what the manufacturers manual says, as every autoclave is different. The reason for this is to prevent injury from occurring in the work place.

Sources:

http://extranet.fhcrc.org/EN/sections/ehs/hamm/chap3/section6.html

http://webcache.googleusercontent.com/search?q=cache:Uw7lf6KE1osJ:www.cardiff.ac.uk/osheu/resources/Autoclave%2520Guidelines%2520draft%2520document.doc+ppe+for+autoclaves&cd=10&hl=en&ct=clnk&gl=us

http://www.sterilizers.com/aboutsterilizers.asp

http://webcache.googleusercontent.com/search?q=cache:C8l9I41OLkYJ:roundtable.healthsafe.uab.edu/pages/resources/Autoclave%2520Training%2520Final.ppt+autoclave+and+ppe&cd=1&hl=en&ct=clnk&gl=us

http://docs.google.com/viewer?a=v&q=cache:uYDSE-dYDbQJ:www.oseh.umich.edu/pdf/sop/blood_spill_SOP.pdf+blood+spills+and+ppe&hl=en&gl=us&pid=bl&srcid=ADGEEShRsZJO5EZW5mXd4823i2EM5UzlmRZRHdzPyo-JH_KnURDhFeWzkeaUJMxTJUU0F38knieNnixNUzbWnd3Iy2XYFN9lq6f_FGFN4CU569u3ezegbDf_w0iu_D6aK-FEyJivIXIe&sig=AHIEtbRO4Jxq83SAZdUaqxqEyyhFdP4bbw

http://webcache.googleusercontent.com/search?q=cache:FkfgBq95zbEJ:www.nyc.gov/html/doh/downloads/ppt/bhpp/bhpp-train-don-PPE.ppt+ppe+for+isolation&cd=3&hl=en&ct=clnk&gl=us

http://www.youtube.com/watch?v=y53k3eQgb20

http://www.youtube.com/watch?v=kmWS5jGnKjE

http://www.osha.gov/SLTC/pandemicinfluenza/pandemic_health.html

http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/PersonalProtectiveEquipment/default.htm

http://www.doh.state.fl.us/disease_ctrl/std/prevent/MODULE_2_V2.1.pdf

http://www.cdc.gov/niosh/topics/bbp/

Delmars Clinical Medical Assisting, 4th Edition, Lindh, Dahl, Delmar Cingage Learning, Copyright 2010

Hormone replacement therapy, or HRT, is a type of therapy that may have major benefits such as relieving menopausal symptoms, which may include vasomotor instability, osteoporosis and fracture risk, urogenital and vaginal atrophy, low mood, and memory problems. However, research leading to conflicting results has been conducted over the course of over seventy years which shows that HRT also has primary risks. These include diseases such as breast cancer, endometrial hyperplasia, endometrial cancer, cardiovascular disease, venous thromboembolism, and stroke (Rhymer, J., 2003). This paper will focus on the various biological components used in hormone replacement therapy for menopausal and postmenopausal women, different examples of its benefits and the risks, and what the biological data implies in terms of indication or contraindication of HRT on a societal level.

Since HRT is primarily used to treat menopausal symptoms, the biological understanding of menopause should first be explained to grasp HRT’s therapeutic benefits. Menopause is the natural cessation of the menstrual cycle that occurs in women at an average of 51.4 years of age (Bakour, S. H., & Williamson, J., 2014). There is a wide arrange of menopausal symptoms depending on sociological factors such as social class, ethnicity, and culture, that cause women to seek relief by means of HRT (Rymer, J., 2003). Menopausal symptoms tend to have a negative effect on overall quality of life (Bakour, S. H., & Williamson, J., 2014). For example, the most common, discomforting menopausal symptoms are vasomotor ones, which affect approximately 70% of women for an average of 5.2 years while 10% of women may experience them for many more years (Bakour, S. H., & Williamson, J., 2014). About 20% of women experience more severe symptoms (Bakour, S. H., & Williamson, J., 2014). Another one of the main menopausal symptoms is the decrease of bone density in women, an effect that is accelerated by estrogen deficiency, which halts or slows bone loss, resulting in osteoporosis (Barrett-Connor, E., & Stuenkel, C. A., 2001).

Prescribing HRT is considered the most effective solution for relieving menopausal symptoms, which can effectively be resolved by HRT’s replacement doses of estrogen (Bakour, S. H., & Williamson, J., 2014). The presence of disturbing vasomotor symptoms may result in sleep disruptions and contribute to the main indication for the administering of HRT (Hickey, M., Elliott, J., & Davison, S. L., 2012). Hormone replacement therapy consists of estrogen for relieving menopausal symptoms, and estrogen can also be mixed with progestogen, which binds to the progesterone receptor, for endometrial protection in affected women (Hickey, M., Elliott, J., & Davison, S. L., 2012). The most common way to take HRT is as an oral medication, which is usually administered in a pill form (Rymer, J., 2003). However, an important distinction for women to know is that the ethinyl estradiol used in HRT’s oral contraception is a synthesized form of estrogen, not the natural form of estrogen produced in ovarian production. Other forms estrogen include 17 beta-estradiol, estrone, or conjugated equine estrogen (Hickey, M., Elliott, J., & Davison, S. L., 2012). If a woman still has a uterus, it is essential for progestogen or micronized progestogen to be included for prevention of endometrial hyperplasia and cancer (Rymer, J., 2003). Progestogen is usually also administered orally (Rymer, J., 2003). During regimens of HRT, estrogen is taken daily, while progestogen may be added in combination with estradiol either in a sequential cyclical regimen or daily as a continued combined therapy (CCT) if it is required (Rymer, J., 2003). While testosterone can also be added to HRT as a supplement, it will not be covered in the information disclosed here (Bakour, S. H., & Williamson, J., 2014). Alternatively, these forms of estrogen and progestogen, as well as others, can also be taken intravaginally or transdermally (Hickey, M., Elliott, J., & Davison, S. L., 2012).

About 38% of postmenopausal women in the United States were administered HRT in 2003. For example, 46 million prescriptions of Premarin were administered in 2000, a form of HRT consisting of conjugated equine estrogens (Rymer, J., 2003). This made this form of HRT the second most frequently prescribed drug in the United States (Rymer, J., 2003). British studies that were conducted in 2003 have shown that 60% of women between 51-57 years of age have taken HRT (Rymer, J., 2003). According to these studies, 45% of women were reported to have tried HRT by the time they are 50.2 years of age (Rymer, J., 2003).

The controversial aspect of HRT primarily exists because of the many benefits and risks that are associated with taking it (Rymer, J., 2003). However, there is a large amount of complexity and uncertainty about the evidence taken from various controlled trials for HRT that have found conflicting results (Rymer, J., 2003). For example, both a multitude of beneficial effects and adverse side effects were found in the publication of the heart and estrogen-progestin replacement study (HERS) and a Women’s Health Initiative (WHI) study (Rymer, J., 2003). Some of the benefits and risks are correlated with contexts such as age, duration of treatment, and pre-existing conditions (Rymer, J., 2003).

Furthermore, there is a variety of benefits associated with taking HRT. HRT for symptom relief should be administered within the early phase of menopausal symptoms for treatment benefits (Bakour, S. H., & Williamson, J., 2014). However, for women with premature menopause (younger than 40 years of age) or early menopause (younger than 45 years of age) it is recommended that women delay until age 50 to receive HRT for vasomotor systems and bone preservation (Hickey, M., Elliott, J., & Davison, S. L., 2012). The reason for this is that women between 50 to 59 years of age tend to respond with more of the benefits from HRT and less of the risks based on data collected from the Women’s Health Initiative study the prospective observational Nurse’s Health Study (Hickey, M., Elliott, J., & Davison, S. L., 2012). Conversely, HRT is generally not recommended for women over 60 years of age because the probability of HRT’s risks are increased this late after menopause begins (Hickey, M., Elliott, J., & Davison, S. L., 2012). Thus, the current guidelines for HRT recommend treatment for most symptomatic women between 50-59 years of age, but taking HRT for more than five years is not recommended (Hickey, M., Elliott, J., & Davison, S. L., 2012).

Vasomotor symptoms include often uncomfortable hot flushes and night sweats in menopause, and HRT is the most effective treatment relieving them (Hickey, M., Elliott, J., & Davison, S. L., 2012). The Women’s Health Initiative and prospective observational Nurses’ Health Study conducted some of the largest randomized and controlled trials of HRT versus placebo in American women ages 50-59 years (less than 10 years after menopause). Based on their results, there was a major reduction in the frequency of hot flushes by approximately 18 per week with the severity of hot flushes decreased by 87% in contrast with placebo (Hickey, M., Elliott, J., & Davison, S. L., 2012). Therefore, the forms of HRT, both estrogen and estrogen combined with progestogen, have shown remarkable benefits for the treatment of vasomotor symptoms from menopause (Hickey, M., Elliott, J., & Davison, S. L., 2012). HRT has been approved and labelled by the FDA for its application in treating vasomotor symptoms based on substantial evidence of these resulting benefits (Biscup, P., 2003). According to thirteen randomized clinical trials, hormone replacement therapy may also induce a causal effect in that its treatment of vasomotor and urogenital symptoms may improve various other menopausal symptoms (Rymer, J., 2003). By relieving hot flushes, one of the vasomotor symptoms listed in menopause, sleep quality and low mood may subsequently be improved (Rymer, J., 2003). Overall, the estrogen used in HRT has proven to temporarily enhance the quality of life in women with menopausal symptoms (Rymer, J., 2003).

Some other methods of treatment include tibolone, a non-hormonal alternative to HRT for treating menopausal symptoms (Rymer, J., 2003). Tibolone is an oral steroid that is synthesized with estrogenic, androgenic, and progestogenic ingredients that can be substituted as another form of HRT (Bakour, S. H., & Williamson, J., 2014). There has not been as much verification of effectiveness from the studies of tibolone as there has been of the typical HRT, which contains some combination of estrogen and progestogen (Hickey, M., Elliott, J., & Davison, S. L., 2012). However, one large, multicenter, randomized, double blind, and controlled trial has demonstrated some effectiveness of tibolone when as much as 1 mg of oral estradiol was used to reduce occurrences of hot flushes in postmenopausal women between 45-65 years of age (Hickey, M., Elliott, J., & Davison, S. L., 2012). Also, tibolone reduced bleeding within the first three months of treatment, reduced breast tenderness, and improved sexual function (Hickey, M., Elliott, J., & Davison, S. L., 2012). Gabapentin is a non-hormonal alternative to HRT that has proven to be equally as effective as low dose estrogen for treating vasomotor symptoms, whereas Clonidine is mildly effective (Hickey, M., Elliott, J., & Davison, S. L., 2012). The levonorgestrel-releasing intrauterine system Mirena has been licensed and available for four years in the United Kingdom, along with estrogen replacement therapy, since the time this article was published in 2003 (Rymer, J., 2003).

Aside from relieving vasomotor symptoms, the other main reason for administering hormone replacement therapy is the prevention or management of osteoporosis (Rymer, J., 2003). After 35 years of age, bone mass in men and women is reduced by about 1% each year (Rymer, J., 2003). The decrease of bone density is accelerated in women within the first three to four years after menopause, and a third of these women are at a larger risk of osteopenia, a form of decreased bone density that could lead to a higher risk of fracture (Rymer, J., 2003). According to data collected from randomized controlled trials, HRT has been shown to reduce fracture risk as well as bone loss in the vertebral spine by 50% and in the femur neck by 30% (Rymer, J., 2003). However, the prevention of bone loss may also apply at lower percentages in women older than 60 years of age. According to the Women’s Health Initiative (WHI) study on the reduction of a hip fracture using HRT, bone loss resumes within a year after stopping hormone replacement therapy, and bone turnover occurs at the same level seen in untreated women between three to six months after receiving therapy (Rymer, J., 2003). Furthermore, reduction of fracture risk alone may not be an appropriate indication for administering of HRT (Hickey, M., Elliott, J., & Davison, S. L., 2012). Alternatives for preventing fracture risks in women with low bone mineral density may include non-hormonal therapies that are equally as effective as HRT (Rymer, J., 2003). Some examples of non-hormonal therapies for reduction of fracture risks include bisphosphonates and selective estrogen receptor modulators (Rymer, J., 2003).

Another beneficial set of data drawn from thirty observational studies of HRT, is that estrogen lowers the risk of heart disease in postmenopausal women (Barrett-Connor, E., & Stuenkel, C. A., 2001). These studies demonstrated that estrogen caused a 40-50% reduction in the risk of coronary heart disease (CHD) in women, whereas estrogen has been shown to reduce disease and death from coronary heart disease by 30-50%, which would consist of a greater benefit if progestogens were not added to prevent women from developing endometrial disease (Rymer, J., 2003). Since cardiovascular disease is highly improbable in women before menopause, estrogen deficiency is a strongly implied cause for heart disease (Rymer, J., 2003).

As previously stated, the positive effect of HRT on heart disease has been correlated with other variables such as lipids and vascular reactivity (Barrett-Connor, E., & Stuenkel, C. A., 2001). Some of the main cardiovascular benefits of estrogen are achieved through the following influences: reduction of atherosclerosis, increase of HDL-cholesterol (high-density lipoprotein-cholesterol), decrease of LDL-cholesterol (low-density lipoprotein-cholesterol), promotion of coronary artery vasodilation, prevention of platelet aggregation, decrease of lipoprotein-a, and inhibition of low-density lipoprotein-cholesterol oxidation (Bakour, S. H., & Williamson, J., 2014). It should be noted that these observational studies were conducted on healthy women taking HRT rather than women with pre-existing conditions or diseases, a crucial factor that critics claim may have affected the results of these studies (Bakour, S. H., & Williamson, J., 2014). However, despite this fact, a large number of clinicians have advertised and administered HRT as a preventative therapy because of the decreased cases of heart disease found with its usage (Bakour, S. H., & Williamson, J., 2014).

The remaining benefits of HRT include reduction of urogenital atrophy or atrophic vaginitis, reduced risk of colon or colorectal cancer, protection against loss of connective tissue, improvement of low mood, prevention of memory loss, delay in the onset of Alzheimer’s disease, and improved cognitive functioning (Rymer, J., 2003). The type of HRT used in the treatment of atrophic vaginitis, i.e. thinning, drying, and inflammation of the vaginal walls, is topical estrogen, which initiates cornification, developing tough protective layers from squamous epithelial cells, and regenerates the vaginal epithelium without the need for progestogens (Bakour, S. H., & Williamson, J., 2014). Thus, moderate to high doses of topical estrogen improve lubrication and sexual functioning of the vagina, which can then reduce symptoms such as urgent urinating and recurring urinary tract infections (Bakour, S. H., & Williamson, J., 2014). Vaginal symptoms such as the ones mentioned can persist despite the application of adequate systemic HRT, and in this case, topical and systemic HRT are mandated for treatment (Bakour, S. H., & Williamson, J., 2014). Large randomized controlled trials have also confirmed that HRT remarkably improves upon vaginal dryness and sexual function, which can consequently improve sleep, alleviate muscle aches and pains, and improve overall quality of life in women who carry these symptoms (Hickey, M., Elliott, J., & Davison, S. L., 2012).

Although hormone replacement therapy may help in improving libido, vaginal symptoms alone do not warrant the prescription of HRT, as these symptoms can be treated using local estrogens (Biscup, P., 2003). Alternatively, non-hormonal options for atrophic vaginitis include vaginal lubricants and moisturizers, but studies have not offered sufficient evidence that these alternatives offer the prolonged benefits found with the usage of vaginal estrogen (Hickey, M., Elliott, J., & Davison, S. L., 2012). In regards to the main risks involved with the usage of topical estrogen, the benefits to the genitourinary tract as well as improved sexual intimacy may be greater than any risk of breast cancer (Rymer, J., 2003).

In a Women’s Health Initiative randomized control trial of 10,000 women taking HRT in contrast with the placebo group, HRT was confirmed to reduce the risk of colorectal, or colon, cancer (Rymer, J., 2003). The results indicated six fewer colorectal cancers per year out of the 10,000 women taking HRT (Rymer, J., 2003). Also, more than ten observational studies have shown a decreased risk of colorectal cancer in women taking HRT (Barrett-Connor, E., & Stuenkel, C. A., 2001). However, the reduction of colorectal cancer is not considered to be an indication for administering HRT as a preventative for this disease because there isn’t enough data to verify this beneficial side effect of HRT (Barrett-Connor, E., & Stuenkel, C. A., 2001).

Furthermore, HRT has also been observed to provide neuroprotective benefits such as sustained cognitive functioning, improvement upon low mood, prevention of memory loss, and reduction or delay of Alzheimer’s disease (Rymer, J., 2003). According to more than half of observational studies from two large randomized trials, women who take estrogen maintain or improve cognitive functioning more than women who do not (Rymer, J., 2003). Risk of Parkinson’s disease may also be prevented by HRT, but this benefit was seen in young, healthy menopausal women, so more studies are also needed on neuroprotective factors, especially on menopausal women without the healthy disposition found in women in these studies to contrast results (Rymer, J., 2003).

In opposition to the various benefits of HRT, there are also important risks that have been found to be associated with its treatment, such as breast cancer, endometrial hyperplasia, and endometrial cancer. In 1997, the Collaborative Group from Oxford reanalyzed 51 observational studies of HRT and breast cancer, including 52,705 women with breast cancer, to discover that women who had been taking HRT for five years or more had a greater risk of developing breast cancer (Barrett-Connor, E., & Stuenkel, C. A., 2001). Four or five years of a woman using HRT was found to increase risk of breast cancer, and this risk was heightened in women who used estrogen mixed with progestogen rather than using estrogen alone (Barrett-Connor, E., & Stuenkel, C. A., 2001). By using this large meta-analysis of data, the risk of breast cancer was found to increase by 2.3% per year of using HRT (Rymer, J., 2003). According to a Women’s Health Initiative study, there was a 15% increase in invasive breast cancer in women taking estrogen with progestogen for less than five years and a 53% increase in those taking it for more than five years (Rymer, J., 2003). However, duration of usage combined with potentially recurrent symptoms, which up to 50% of women experience after discontinuation of HRT, tend to have the greatest influences on risk (Hickey, M., Elliott, J., & Davison, S. L., 2012).

The controversy associated with the increased risk of breast cancer due to HRT exists because different studies have found opposing information. While some observational studies have shown an increased risk of breast cancer in women who took HRT, other observational studies, including ones conducted on women with a family history of breast cancer, show no increased risk of breast cancer, and many researchers currently tend to dismiss studies that display conclusions of an increased risk, despite evidence such as Nurses’ Health Study (Bluming, A. Z., & Tavris, C., 2009). Risk of breast cancer has been found to be insignificant because using data found from a worst-case analysis, researchers have concluded that a 50-year-old woman taking estrogen and progestin for ten years had a 4% risk of breast cancer while using HRT, while her breast cancer risk without taking HRT was only 2% (Bluming, A. Z., & Tavris, C., 2009). This evidence may have been exaggeratedly stated by data-reporters as a “doubling” of risk of breast cancer due to HRT (Bluming, A. Z., & Tavris, C., 2009). Other observational studies have shown increased survival rates of women who take estrogen replacement therapy (ERT), including decreased death rates from breast cancer (Bluming, A. Z., & Tavris, C., 2009).

Furthermore, there is a large volume of other results that have found that if six million women in the United States have used HRT for five years, then over 24,000 additional cases of breast cancer would develop every year, and thus, it is essential that every woman’s individual risk as well as a family history of breast cancer is assessed before administering HRT (Biscup, P., 2003). Some studies have shown that women who use HRT for more than five years are at a much higher risk of breast cancer, and further HRT is contraindicated in this case (Biscup, P., 2003). Results have shown that other health factors may also apply to this such as diet, exercise, dyslipidemia or diabetes, or smoking (Biscup, P., 2003).

Another correlation has been made between women with an intact uterus taking HRT and risk of endometrial hyperplasia and endometrial cancer (Hickey, M., Elliott, J., & Davison, S. L., 2012). This relationship has been established since the 1970s (Barrett-Connor, E., & Stuenkel, C. A., 2001). According to results taken from a PEPI trial, estrogen alone was found to increase endometrial hyperplasia at a rate of 10% per year and increased the risk of cancer in some women (Barrett-Connor, E., & Stuenkel, C. A., 2001). Endometrial cancer was increased by 4-5 times for five years and by ten times for ten years of using unopposed estrogen (Barrett-Connor, E., & Stuenkel, C. A., 2001). However, usage of progestogen with HRT or the alternative prescription tibolone does not increase the risk of endometrial hyperplasia or endometrial cancer, but progestogen’s protection diminishes with long-term usage of sequential regimens, especially after five years of use (Hickey, M., Elliott, J., & Davison, S. L., 2012). Furthermore, continuous progestogen regimens can also assist in correcting complex hyperplasia that may occur within sequential therapy, keeping the endometrium suppressed in the longer term (Rymer, J., 2003).

The correlation between HRT and cardiovascular disease is controversial and largely based on timing, duration, and preceding heart conditions (Barrett-Connor, E., & Stuenkel, C. A., 2001). Increased risk of cardiovascular disease has been found with routine acceptance of use of HRT when the largest HRT randomized clinical trial was conducted in 2002 which considered long term usage of estrogen and progestin (Krieger, N. et. al, 2005). In the year 2000, Women’s Health Initiative investigators conducted a trial on 27,348 women, finding small increased risk of cardiovascular disease within the first year of administering HRT, especially in women over 60 years of age since they are more likely to show signs of cardiovascular disease, although the cardiovascular systems in younger postmenopausal women may be benefited by taking HRT (Barrett-Connor, E., & Stuenkel, C. A., 2001). Reanalysis of the Women’s Health Initiative study in 2007 found that the taking of HRT by women within ten years of menopause was correlated with less risks as well as an overall reduction in cardiovascular events, whereas women who took HRT for more than twenty years after menopause were found to become more susceptible to cardiovascular risk (Bakour, S. H., & Williamson, J., 2014). Although it has not been proven, it is strongly implied that estrogen deficiency may increase the risk of cardiovascular disease in women because cardiovascular disease rarely affects women before menopause (Rymer, J., 2003). The correlation between estrogen levels and heart disease in postmenopausal women has been suggested by more than 30 observational studies, which have found that estrogen has multiple health benefits for preventing heart disease in correlation to lipids and vascular reactivity (Barrett-Connor, E., & Stuenkel, C. A., 2001).

Risks of deep vein thrombosis and pulmonary embolus have also been shown to increase in women who take HRT (Rymer, J., 2003). Thrombosis risk from HRT is usually recorded as having occurred within the first year of usage. However, dosage size, type, route of application, and the usage of progestogen combination may also contribute to this risk of HRT (Bakour, S. H., & Williamson, J., 2014). Lower doses of HRT as well as replacing oral treatment with transdermal treatment, which is the primary treatment method in medical conditions, may reduce the risk of venous thromboembolism (VTE) (Bakour, S. H., & Williamson, J., 2014). However, women who are sedentary, overweight, and smokers have an increased risk of VTE before receiving HRT (Bakour, S. H., & Williamson, J., 2014).

Statistics based on 1,000 European women between 50-59 years of age show that five were at risk for VTE, seven were at risk for VTE when having taken five years of estrogen only, and twelve were at risk for VTE after having taken estrogen and progestogen for five years (Bakour, S. H., & Williamson, J., 2014). Other studies show that women taking HRT, especially for five years or more, increases the risk of VTE two-fold in contrast with those who weren’t prescribed HRT, but family history of thromboembolic disease, severe varicose veins, obesity, surgery, and trauma, as well as prolonged bed rest and age are all factors that put women at a greater risk (Bakour, S. H., & Williamson, J., 2014). Further observational studies on VTE have determined that postmenopausal women who took HRT may have a 2-4 fold increase in VTE, which was found in a trial of 1,000 women (Barrett-Connor, E., & Stuenkel, C. A., 2001). About 1 in 250 women who had received HRT developed VTE, and this risk was heightened in women with a lower-extremity fracture, cancer, and 90 days after inpatient surgery or non-surgical hospitalization (Barrett-Connor, E., & Stuenkel, C. A., 2001). Finally, observational studies have also shown that estrogen therapy increased other risks such as blood clots, strokes, and gallbladder disease (Biscup, P., 2003). Furthermore, the risk of stroke increases with age and usually occurs in women over 60 years of age when using tibolone or HRT (Hickey, M., Elliott, J., & Davison, S. L., 2012). Transdermal HRT at doses of 50 μg or less may reduce the risk of stroke (Hickey, M., Elliott, J., & Davison, S. L., 2012).

Education on the results taken from trials done on women using HRT has been shown to affect women’s decision on continuing or discontinuing HRT, demonstrating the influential effects of conducting more studies and publicly posting their conclusions (Ness, J., Aronow, W. S., Newkirk, E., & Mcdanel, D., 2005). Women’s Health Initiative conducted and publicized trial results from a study on 1,000 postmenopausal women with an average range of 57-73 years of age to find the aftereffects of having published results from a trial in July of 2002 to record how prescriptions and applications of HRT may have changed due to updated information on the risks of HRT (Ness, J., Aronow, W. S., Newkirk, E., & Mcdanel, D., 2005). The data showed that 445 (45%) of the women had used or were still using HRT at the time of conducting this review. 159 (36%) of the 445 women using HRT were still using it, and 286 (64%) of the 445 women using HRT had decided to discontinue usage of HRT (Ness, J., Aronow, W. S., Newkirk, E., & Mcdanel, D., 2005). Although 181 (63%) of the women had ceased usage of HRT after the Women’s Health Initiative publication, 136 (48%) of the women listed the 2002 study as the main reason for discontinuation (Ness, J., Aronow, W. S., Newkirk, E., & Mcdanel, D., 2005). The 159 women still using HRT after these studies listed their mains reasons as follows: relief from severe menopausal symptoms in 39 women (25%), osteoporosis or osteopenia in 31 women (20%), and patient preference in 20 women (13%) (Ness, J., Aronow, W. S., Newkirk, E., & Mcdanel, D., 2005).

In conclusion, although there are many benefits and risks to hormone replacement therapy, there is still much study needed to be done to publicize more certain answers on HRT. Results have shown that duration, i.e. about five years, is a primary factor in taking HRT in that most serious risks have been shown to occur after this time. During up to five years of taking HRT are when most of the benefits start to show, such as reduction of vasomotor symptoms, reduction of osteoporosis, vaginal atrophy, and boost of cognitive functioning. However, within and especially after five years of taking HRT increases the probability of its risks, such as breast cancer, cardiovascular disease, deep vein thrombosis, stroke, etc. HRT’s risks outweigh its benefits, there is plenty of empirical evidence from various studies that suggest the contrary. Overall, individual risk, family history, and age, i.e. time of and after having started menopause are all crucial factors in considering whether HRT is indicated or contraindicated. Thus, more data and studies should be investigated to educate women and circulate information about the many benefits and potentially harmful effects to this complex form of treatment. Previous controlled trial results from the Women’s Health Initiative have been proven to influence women’s decisions on whether or not they should take hormone replacement therapy. Thus, it may be beneficial for WHI to receive financial investments if needed so that more randomized controlled studies can be conducted with published results on HRT since this has been proven to assist women in making their decisions regarding HRT.

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