Hormone Replacement Therapy in Women

I have been following posts about hormone replacement therapy in various Facebook groups, and have seen some unsettling comments.

As a doctor, I have seen so many cases of women being put on what I believe to be the wrong hormones, at the wrong dosages, and for the wrong reasons. And Facebook just corroborates this.

Mismanagement by other providers has allowed me to see the effects of these therapies, and their laboratory and clinical consequences.

This post is to offer some clarity to the topic. I hope that this will help you (and your doctor) to make the best decisions about your hormonal health.

Hormone replacement therapy: An expert’s perspective

For starters, here is my experience. I was formally trained as an OB/GYN and have been using bio identical hormones with my patients now for 20 years. The understanding of HRT has changed over this time frame, and so too has my practice.

In this post I will review what I feel to be the most important considerations across a woman’s reproductive life.

Hormone replacement therapy can be life enhancing and life extending. If not managed well, it can be potentially life shortening. I believe that women can enjoy the benefits of hormone replacement with proper management.

Bio identical hormones defined

Bio identical hormone replacement therapy (BHRT) generally uses estrogen (estradiol, oestrogen), progesterone, and less frequently testosterone to achieve hormonal balance. These are identical molecules to the hormones produced in by our bodies.

In this text, the word progestin refers to a synthetic progesterone-like molecule. A progestin is not a bio identical hormone. All birth control pills contain progestins, along with a synthetic estrogen known as ethinyl estradiol.

To this day most providers continue to recommend synthetic hormones to their menopausal patients as well. Add this to years of oral contraceptive use, and a woman could conceivably be exposed to synthetic hormones for a majority of her life.

For clarity, the terms estrogen and progesterone used here refer to the bio identical molecules only.

The best way to understand hormone replacement over a woman’s lifespan is in respect to her relative reproductive age.

Prime reproductive years ages 18-35

This group generally has predictable monthly cycles. This implies normal progesterone and estrogen cycling. Normal estrogen levels are common. There is generally no need for a younger woman to be using estrogen.

The one hormone that I might recommend in this age group is progesterone. It can balance out a woman’s estrogen dominance. In women with recurrent miscarriages, it has been shown to help maintain a pregnancy.

I have seen some athletes who have benefitted by augmenting their testosterone a bit in this age group. But this represents the vast minority of women in my care.

Of course, stress strongly influences ovulation and sex hormone levels.

Hormone replacement in the perimenopausal years: ages 35-50

No, I’m not saying that you are on the brink of menopause if you are 36. But declining fertility characterizes this age group. Lower fertility is associated with lower levels of progesterone while estrogen levels remain unchanged.

Normal estrogen with low progesterone creates a state of estrogen dominance.

In many women the perimenopause spans a decade or more, with slow, progressive hormonal and biological changes.

Common symptoms of estrogen dominance are weight gain, menstrual changes, mood changes, headaches, sleep disturbances… the list goes on. Most women in this category don’t need estrogen; they generally have enough.

The most common abnormality is a state of estrogen dominance from progesterone deficiency.

Progesterone replacement at the second half of the cycle can be lifesaving to some. I usually prescribe use oral progesterone to be taken at night. It balances the estrogen, and its metabolite pregnanediol promotes sleep. This can be a winning combo!

Hormone replacement therapy in the menopausal years

No menstrual cycles for 6 months, with a FSH greater than about 60 generally defines menopause. The average age for menopause in the USA is about 51.

Why are there so many women whose docs prescribe only progesterone in the menopausal years, or nothing at all?? I imagine that there is an unfounded fear in using estrogen based on outdated literature.

Here’s my view of menopausal HRT painted in broad strokes. For starters, HRT is not for everybody. Some women don’t want to use it, and I respect personal autonomy to make health decisions above all.

But the flip side is that we are living longer. If a woman lives to 100, about half of her life could potentially be spent without this important hormone.

Estrogen benefits

• Maintains bone density and decrease fracture risk
• Improves mood, memory and decrease cognitive decline
• Decreases colon cancer risk
• Decreases cardiovascular risk
• And most women feel so much better without the night sweats and vaginal dryness. Better sleep and better sex; what’s not to like?

Does hormone replacement therapy with estrogen increase the risk of breast cancer?

Not if it is appropriately balanced with progesterone. Check out the study by Fournier at the bottom of the post. He looked at 80,000 menopausal women on estrogen with different kinds of progesterone.

Bio identical progesterone and estrogen showed a breast cancer relative risk of 1. This means that the woman had the same risk of breast cancer as a woman who was not using the hormones.

However…. The use of estrogen with a synthetic progesterone increased breast cancer risk by upwards of 70%! So which would you choose?

You can guess what I have used with my patients.

Does hormone replacement therapy increase the risk of blood clots and strokes?

The literature on birth control pills (recall: synthetic estrogens and synthetic progesterone) has shown an infrequent but real increase in blood clots. The cause may be two-fold.

The first may be in the use of the synthetic hormones. Recall the Fournier study? Breast cancer was associated with the use of synthetic progestins. The extensive Nurse’s Health Study (2007) also showed the use of progestins to increase breast cancer.

The second reason is that estrogen (and ethinyl estradiol) is known to promote the liver’s production of clotting proteins if taken orally. But when the hormone is applied to the skin (to include vaginal application for women with severe dryness) it bypasses the liver. Problem solved.

Does Hormone Replacement therapy increase the risk of uterine cancer?

Estrogen well balanced with progesterone is unlikely to increase the risk of uterine cancer. The uterine lining is estrogen sensitive and grows with excessive estrogen. All bleeding in the menopausal years must be evaluated with an ultrasound, and if indicated, a tissue biopsy.

Management of HRT is an art. It involves a careful history and exam, a review of family history and consideration of an individual’s risk factors, beliefs and needs. Not everyone needs HRT, but in carefully managed patients it can be transformative.

This review was intended to give a general framework for the use of hormone therapy at different times in a woman’s reproductive life. It is based on my experience and practices over two decades. Here are my closing thoughts.

Hormone Replacement Therapy: Summary

• Hormone therapy is a safe alternative for many women if applied and followed correctly.
• All HRT management should involve reviewing clinical symptoms in addition to laboratory testing.
• I do not use hormone pellets in my patients. This requires a frequent surgical procedure, is 10x more expensive than dermal hormones, and causes hormonal chaos over time. Avoid if possible.
• I generally would recommend using estrogen and testosterone dermally. I recommend that progesterone is used orally due to its calming effects.
• Finally, I follow hormone levels with bloodspot or salivary tests. I believe these best hormone activity at the cellular level. Of the two, I prefer the blood spot testing.
• I don’t use the DUTCH test. It is expensive, and I don’t want to know the hormonal metabolites. I want to know the actual hormone values at the tissue level. But that’s my personal bias, and it seems to make good sense scientifically.

Here’s the Fournier study. Check it out.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2211383/