Hormone Replacement Therapy (HRT) is a medical treatment used to relieve symptoms associated with hormonal imbalances, most commonly during menopause in women.
Who should not take hormone therapy?
HRT is not recommended if you have ever had:
Breast or endometrial cancer
Stroke
Heart attack
Blood clots
Liver disease
Types of Hormone Replacement Therapy
Estrogen Therapy: Primarily used for women who have had a hysterectomy.
Estrogen-Progestin Therapy: Recommended for women with an intact uterus to reduce the risk of endometrial cancer.
How is hormone therapy given?
Estrogen can be given in several forms. Systemic forms include pills, skin patches, and gels and sprays that are applied to the skin.
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.
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 like non-bioidentical hormones and pose risks for certain populations. It’s necessary to discuss the benefits and risks with your healthcare provider.
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 also are 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.
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.
maintaining 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 and Considerations
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
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.