Hormone Replacement Therapy (HRT) – Is it for me?

What’s in your hormone therapy? (The facts about bioidentical hormones)

As your gynecologists, we know you are interested in bioidentical hormones.  We can prescribe such hormones and we are interested in talking to you about your menopausal symptoms.

Prior to 2002, HRT (hormone replacement therapy) was widely prescribed to treat menopausal symptoms and was once prescribed for prevention.  The WHI, or Women’s Health Initiative, was started to study HRT’s effectiveness in lowering the risk of heart disease and other medical conditions in women ages 50-79.  In 2002, the Women’s Health Initiative study was paused because of the increased risk of breast cancer, heart attack, stroke and blood clots seen in women on estrogen and progesterone.  In turn, there was an abrupt decrease in prescriptions for HRT.

Since then, women’s health providers have been able to make better sense of this data and can have a meaningful discussion with our patients about the many benefits of HRT as well as the risks.

There are many women who benefit from HRT and there are many forms of HRT.  Over the last few years I have seen more and more women come to their annual or for a consultation other than for menopausal symptoms, after having seen another provider to obtain compounded bioidentical HRT.

A bioidentical treatment is a plant derived compound that is chemically similar or structurally identical to those produced by the body.  There are bioidentical hormones approved by the FDA.  I get it that my patients are not excited to use hormones that are sourced from the urine of pregnant horses found in a commonly prescribed form of estrogen.  There are options for bioidentical micronized estrogen and progesterone that are monitored by the FDA.

As the compounded forms of hormone therapy are not regulated, a patient is ultimately unaware of the purity, potency or quality of the product used.  I also see many women having their hormone levels checked which is not necessary.  Let me discuss each issue further.

Many compounded hormones use combinations of the 3 types of estrogen produced by our bodies: estriol, estradiol and estrone.  Estriol is the weakest of the estrogens and is often used in the highest amount in compounded hormones.  However, estriol is less bioactive so to get the improvement in symptoms, there is the risk of overdosing on this estrogen.   Estradiol is more bioactive, is bioidentical, and is included in the options approved by the FDA.  Such options have doses that are stable and well-studied.  High doses of any estrogen can lead to the risk of cancer of the uterus and blood clots. For women with a uterus on estrogen in doses high enough to treat hot flashes, progesterone is needed to protect a woman from the risk of cancer of the uterus.  Compounded progesterone that comes from certain wild yams may not be bioavailable, so a woman may not be receiving the protection the uterus needs.

As far as hormone testing, steroid hormones do not meet the criteria for requiring individualized testing.  Steroid hormones have a large range of levels that lead to a desired effect.  These hormones are not directly eliminated by the kidneys in our urine and they are metabolized by our GI tract.  There are no known therapeutic and toxic concentrations base on large studies of blood levels.  Furthermore, checking salivary levels do not provide a representation of blood levels.  Salivary levels depend on a patient’s diet, time of day and the specific estrogen being tested. When I prescribe HRT, I do not check hormone levels.

When a patient needs HRT I discuss the FDA approved options that make sense for her individualized history.  I prescribe the lowest dose that provides benefit.

Thanks for your time and I encourage you to talk to your provider if you are interested in learning more about HRT.