Hormone Replacement Therapy

Terms

Hormone Replacement Therapy (HRT) is a medical treatment used to relieve symptoms associated with hormonal imbalances, most commonly during menopause in women. The term Hormone Therapy (HT) is also used. Menopausal Hormone Therapy (MHT) is yet another term. They all refer to the same thing.

In women going through perimenopause and menopause, the ovaries produce less estrogen and progesterone. Hormone therapy helps by adding some of these hormones back, with estrogen and progesterone.

Who should not take hormone therapy?

HRT is not recommended if you have ever had:

• Breast cancer

• Endometrial cancer

• Stroke

• Heart attack

• Blood clots

• Liver disease

• High levels of triglycerides

• Gallbladder disease

  
  

How long should I take menopausal hormone therapy? 

The FDA recommends that women take hormone therapy at the lowest dose that works for the shortest time needed.

Types of Hormone Replacement Therapy

• Estrogen: Primarily used for women who have had a hysterectomy.

• Estrogen+Progestin: Recommended for women with an intact uterus to reduce the risk of endometrial cancer.

• Estrogen+SERM: Duavee is the only brand on the market. Combination of estrogens and bazedoxifene, a selective estrogen receptor modulator (SERM). Option for women experiencing menopausal symptoms and at increased risk of breast cancer. Or for women who have side effects from the progesterones in HRT, such as breast tenderness, headaches, nausea, and mood swings.

Benefits of HRT

• less hot flashes & night sweats

• better sleep

• less anxiety and depression

• less vaginal dryness

• improved bone health

• better sex, less painful sex, improved orgasms

• improved urinary symptoms

• reduced risk of dementia and brain fog

• improved heart health when started early in menopause.

• maintained muscle strength

• Possible reduced risk of colon cancer.

"Estrogen contributes to heart health through its helpful effects on cholesterol and because it increases blood flow by relaxing and dilating blood vessels." 

- Dr. Yoav Arnson, Cedars-Sinai, Pasadena, CA.

-You should find that your symptoms improve after a few days or weeks of taking HRT.

Risks of HRT

• Increased risk of blood clots and stroke.

• Possible increased risk of breast cancer with long-term use.

• Potential for gallbladder disease.

  
  

The benefits of hormone replacement therapy (HRT) usually outweigh the risks. Recent evidence suggests that the risks of serious side effects from HRT are very low.

Older studies found potential risks of HRT and made many people reluctant to take or prescribe it. However, this view is now seen as out of date because it does not take into account many of the benefits of hormone therapy.

The benefits and risks of taking HRT depend on your age, your menopause symptoms, and any risk factors you have. It also depends on when you start hormone therapy. Benefits are maximized when starting HRT within 10 years of menopause.

If you're under 60 years old, have menopause symptoms, and are not at high risk of breast cancer or blood clots, the benefits of HRT are likely to outweigh the risks.

Breast cancer

HRT can slightly increase the risk of breast cancer. If you've had breast cancer, you'll usually be advised not to take HRT.

The increased risk is low: there are around 5 extra cases of breast cancer in every 1,000 women who take combined HRT for 5 years.

There is no increase in the risk of breast cancer from estrogen-only therapy, which you can take if you've had a hysterectomy.

Blood clots

HRT tablets can increase the risk of blood clots, but the risk is still very low.

HRT patches, sprays, and gels do not increase the risk of blood clots. This is because estrogen is safer when it's absorbed into your body through your skin.

Stroke

HRT tablets (but not patches, gel, or spray) slightly increase the risk of stroke. But the risk is still very low, particularly if you're under 60 years old.

Heart Attack

Small increased risk of heart attack for older women. This risk may be related to age, existing medical conditions, and when a woman starts taking hormone therapy.

Some research suggests that combined hormone therapy may protect against heart attacks in women who start combined therapy within 10 years of menopause and who are younger than 60 years. This benefit may be even greater for women taking estrogen alone.

More research is needed on this topic. At this time, combined hormone therapy should not be used solely to protect against heart disease.

Alternatives

How is hormone therapy given?

Estrogen can be given in pills, patches, sprays, and gels. Pellets are another option that some doctors provide.

If progestin is prescribed, it can be given separately or combined with estrogen in the same pill or a patch. With systemic therapy, estrogen is released into the bloodstream and travels to the organs and tissues where it is needed.

Women who only have vaginal dryness may be prescribed “local” estrogen therapy in the form of a vaginal ring, tablet, or cream. These forms release small doses of estrogen into the vaginal tissue.

HRT Patches

Downsides of Using Hormone Patches

• Skin Irritation: Hormone patches can cause local skin reactions, including redness, itching, or rash at the site of application. This is less common with oral pills.

• Insurance Coverage: Hormone patches may not always be covered by insurance, leading to higher out-of-pocket costs compared to hormone pills, which are more commonly covered.

• Patch Adhesion: Hormone patches can come loose, which may reduce their effectiveness and require more frequent replacements or adjustments.

HRT Pills

Oral HRT is a popular choice for many women looking for systemic hormone replacement therapy (HRT), especially if they prefer not to use patches or don’t have insurance for those options.

When you take estrogen in pill form, it goes through your stomach and intestines before getting processed by the liver. This liver processing brings along some unique risks that are specific to oral HRT, such as:

• Increased risk of gallstones

• Higher risk of heart disease

• Elevated triglyceride levels, which can increase the risk of blood clots, including stroke, pulmonary embolism, and deep vein thrombosis (DVT)

The likelihood of developing a blood clot from postmenopausal estrogen is quite low, significantly lower than the risk linked to birth control pills, which many women use routinely during their younger years.

HRT Gels and Sprays

Types of HRT Gels

• Transdermal Gels: These are applied directly to the skin, allowing hormones to be absorbed into the bloodstream. They are often used for estrogen replacement.

• Combination Gels: Some gels contain both estrogen and progesterone, providing a balanced approach to hormone therapy.

Types of HRT Sprays

• Nasal Sprays: These sprays deliver hormones directly through the nasal membranes and are often used for quick absorption.

• Transdermal Sprays: Similar to gels, these are sprayed onto the skin and absorbed into the bloodstream.

Benefits of HRT Gels and Sprays

• Ease of Use: Gels and sprays can be easier to apply compared to pills.

• Reduced Gastrointestinal Side Effects: These methods bypass the digestive system, potentially reducing side effects.

• Adjustable Dosing: Gels and sprays can allow for more flexible dosing compared to other forms of HRT.

Considerations

• Skin Reactions: Some users may experience irritation at the application site.

• Dosage Accuracy: It is important to follow dosage instructions carefully to avoid under- or overdosing.

• Cost: They may be more expensive and less likely to be covered by insurance

• They can be transferred to others from your body. Estrogen gels and sprays pose a risk of transferring estrogen to someone who touches you before the product is completely absorbed.

What Are Bioidentical Hormones?

Bioidentical hormones have the exact chemical structure as the hormones the body makes.

When discussing bioidentical hormones, we mean:

• Estrogen – Primarily estradiol (E2), but you may also see estriol (E3), and estrone (E1)

• Progesterone

• Testosterone

• DHEA

Conversely, "traditional" or non-bioidentical hormones exhibit hormonal effects in the body, yet their structure is not identical to that of human hormones.

FDA-Approved Options for Women

The good and often surprising news is that there are many FDA-approved bioidentical hormone preparations. These medications tend to be covered by insurance and are more affordable.

Bioidentical progesterone is available as micronized progesterone under the brand name Prometrium as a 100 mg or 200 mg oral capsule.

Bioidentical estradiol, the primary estrogen during the reproductive years, is available as 17-beta estradiol in various capsules, patches, creams, and gels. Transdermal delivery as a patch, cream, or gel is the preferred mode of administration as it carries fewer risks than oral options. Brand names for patches include Alora, Climara, Menostar, and Vivelle. Estrace is a brand name for vaginal estradiol cream.

BHRT Myths

Let’s review some myths and truths about bioidentical hormone replacement therapy (BHRT).

Myth: Bioidentical hormones are natural.

Truth: Bioidentical refers to the hormone structure, which requires manipulation to match the human hormone, even when coming from a natural source like soy or yams.

Myth: Bioidentical hormones are compounded hormones.

Truth: Bioidentical hormones are available as standard, FDA-approved prescriptions or compounded formulas.

Myth: Bioidentical hormones are alternative medicine.

Truth: Bioidentical hormones bridge conventional, integrative, and functional medicine. They are widely available and offered by many types of prescribing practitioners.

Myth: Bioidentical hormones are safe.

Truth: Overall, HRT is much safer than we were led to believe from the Women’s Health Initiative. Still, bioidentical hormones may cause side effects just like non-bioidentical hormones.

Compounded HRT

Compounded drugs are not regulated by the FDA. Customized compounded hormones pose more risk because they vary in strength and purity. That means you can take too little or too much of a hormone without knowing it.

There are also safety concerns about a kind of compounded drug known as pellet therapy.

There is no scientific evidence that compounded hormones are safer or more effective than standard hormone therapy. The American College of Obstetricians and Gynecologists (ACOG) recommends FDA-approved hormone therapy over compounded hormone therapy.

Hormone Therapy Checklist

If you are ready to start or are starting BHRT, here are some tips:

• Start sooner vs. later. Perimenopause is the time to begin discussing BHRT with your provider. Starting hormones closer to menopause may offer more benefits than further into the post-menopause years.

• Start low and slow. It may take your body some time to adjust to the hormones. Starting at a low dose and slowly increasing may help mitigate any side effects. If you stop hormones, weaning off slowly may also be helpful.

• Monitor labs. Depending on your health goals, you may want to achieve specific hormone levels in the body. Monitor blood labs to see how you respond to BHRT and adjust as necessary.

• Don’t skip the foundations. While BHRT might be a game changer for menopausal symptoms and support long-term health, it doesn’t replace the need for solid nutrition, exercise, sleep, stress management, and self-care.