In all my years of conventional medical training, I honestly cannot remember a single dedicated lecture on prescribing hormone replacement for women. I do recall hearing a two second spiel during a birth control lecture that there was an increased of breast cancer and blood clots with hormone replacement, and, should I ever be bold enough to offer treatment to a woman for her debilitating hot flashes, there was this medication called Prempro (conjugated equine estrogen and medroxyprogesterone) I could try. However, prescribe at your own risk! Fast forward to residency- While soaking up education at various integrative and functional medicine conferences, I was introduced to bioidentical hormone replacement therapy. Alas! A safer, yet still effective, alternative to Prempro! With an interest in women’s health, (and countless suffering women searching for relief) I knew this was something I wanted to learn more about and offer to my patients.
In order to understand the rationale behind the scare with hormone replacement therapy (HRT), you need to know a little about the research that has been done. Right now, if you pull up PubMed on your browser and search the words “hormone replacement therapy”, you will get tens of thousands of articles. There are a plethora of articles discussing HRT using various types of hormones, various formulations (oral, transdermal, vaginal, etc.), cyclical vs continuous dosing, treatment durations, as well as their effects on breast and endometrial tissue, the cardiovascular system, bone health, etc.….but the most frustrating part of the research though, is that many of the studies are conflicting. How to make sense of it all?
The most famous study on HRT was the Women’s Health Initiative (WHI). The WHI was a large, multi-center study that followed women either in observation only, or in randomized controlled trials, looking for benefits from diet, hormone replacement, and various nutrients on cancer, bone health and heart disease prevention. One of the most significant outcomes noted was that women who received a combination of conjugated equine estrogen and medroxyprogesterone HRT were found to have a significant increased risk of breast cancer. Another notable outcome from the research included an increased risk of venous thromboembolism (blood clots in the legs that can potentially travel to the lungs) from estrogen therapy. It was this (and other similar research) that rocked the world of hormone replacement. In the blink of an eye, all those providers who were giving out Prempro samples like Halloween candy pulled back the reins on prescribing HRT, and instead, recommend alternatives like layering clothing, using a fan, and praying to the hormone gods that your hot flashes quickly cease and dismiss.
Thankfully, more recent research is showing that bioidentical hormone replacement behaves differently than the medications used in WHI. Micronized progesterone (bioidentical progesterone) does not seem to have the same increased risk of breast cancer that medroxyprogesterone acetate does. In fact, many studies show no increased risk of breast cancer with micronized progesterone. And other studies are showing that transdermal estradiol has a lower risk (though risk is still present) of venous thromboembolism than oral estrogen. Although integrative medicine providers had already been prescribing bioidentical hormone replacement therapy for decades, with this new research (and much to the dismay of handheld fan and wicking camisole companies!), even conventional providers now started to reopen their HRT prescription pads.
Although our HRT knowledge is continuously evolving, some of the potential benefits of hormone replacement therapy include: Decreased menopausal hot flashes and night sweats, improved sleep, increased bone density, improved lipid profile, decreased risk of metabolic syndrome, better skin moisture and elasticity, mitigating stress response effects on working memory, and potentially cardiovascular benefits when treatment is started within a few years of menopause onset.
With the considerable amount of resources being pooled into hormone research, I am hopeful that HRT will continue to evolve into safer, more personalized therapy, not only for treatment, but for disease prevention as well.
*Lastly, please remember that HRT is just one treatment option for perimenopausal/menopausal symptoms. There are several lifestyle modifications, as well as botanical therapies, that can be trialed prior to advancing to prescription medications.
If you or someone you know is interested in finding out more about menopausal symptom treatment, please consult a qualified provider. And, if you have tried any treatments for your menopausal symptoms, I would love to hear about your experience!
