The Pros and Cons of Hormone Therapy

Are you suffering with symptoms of menopause and don't know whether you should take hormones or not?

The symptoms of menopause can be overwhelming and hormonal treatments are very efficient, especially in relieving hot flashes, memory fog, mood swings, fatigue, and lack of sleep.

However, there is a lot of controversy about hormone therapy and I wanted to help you see through this to the best of my knowledge and experience of treating women in menopause for many years.

The way I treat women and use hormones is different from most medical providers because I combine traditional and holistic approaches, therefore minimizing the potential risks of hormone therapy.

When it comes to Menopause, it is not just about replacing hormones. It is a "whole patient approach" and women can benefit from holistic treatments that are as important as hormone therapy.

Let’s talk about the myths, and the pros and cons of hormone therapy.

HORMONE REPLACEMENT

First, we have to evaluate if you need hormones, and whether hormone replacement is safe for you.

Who is it NOT for?

• Women who don't have symptoms and still produce enough hormones after menopause. 
• Women who have a strong medical or family history of breast or gyn cancer and for which the risks of hormone therapy outweighs the benefits.
• Women who have a predisposition to process hormones in a harmful way. There are specific tests that can assess this risk .

Women who cannot take hormones can use other approaches to maintain their health throughout menopause. This includes replacing other things to slow down the aging process, and preventing certain functions in the body to decline.

HRT (Hormone Replacement Therapy vs BHRT (Bioidentical Hormone Therapy)

Most studies on hormone replacement have been using HRT which includes oral estrogens and progestins, both “synthetic hormones”.

So what is the difference between synthetic and bioidentical hormones?

Where do they come from?

• Synthetic hormones are derived from the urine of mares (female horses) and they are purified through many processes to extract the estrogens and progesterone that are put into a pill.
• Bioidentical hormones are derived from yams which contain a substance called Diosgenin that is converted to estrogens and progesterone, made more identical to the ones produced by the body.

Which form do they come in?

• Synthetic hormones are usually given by mouth and need to go through the digestive system.
• Bioidentical estrogen is given in a transdermal form, meaning that it goes through the skin directly into the blood. Progesterone can be given transdermally or in a micronized (more absorbable) form in a slow release oral capsule. 

What kind of Estrogens do they contain?

• There are 4 forms of estrogens: Estradiol, Estriol, Estrone, and the newly discovered "Estetrol" which only used in contraceptives.
• Estradiol is the most potent and most used form of estrogens; Estriol is considered a safe, but weak estrogen; Estrone, the form of estrogen that the body makes in menopause, but has shown to be unsafe when taken as HRT.
• HRT uses “CONJUGATED ESTROGENS” including Estrone.
• Bioidentical estrogens are made of Estradiol or Estriol.  

What kind of Progesterone do they contain?

• HRT uses Progestins extracted from equine urine.
• BHRT uses micronized Progesterone derived from Diosgenin in yams.

DOSAGE OF HORMONES

The main issue with hormone therapy!

Today, we have several bioidentical products in the pharmacies but dosage hasn't been addressed properly.

The doses of systemic hormones approved by the FDA are “supraphysiological”, meaning that they are higher than what the body needs. This is especially true for progesterone which only comes in a 100 mg pill.

High doses of hormones cause the common unwanted side effects such as water retention, weight gain, and breast discomfort. They also increase the risk of blood clots and cancer.

NOT ALL BHRT IS GOOD!

• Many women are offered BHRT in the form of compounded creams and it is difficult to evaluate how much estrogens and progesterone they are actually absorbing. Many of these creams are sold over the internet without adequate pharmaceutical supervision and cause many issues.
• Pellets which are inserted under the skin (and cannot be removed) tend to have higher doses of estrogens. They also contain testosterone which can cause adverse effects in women.
• Lately, testosterone injections have been suggested for women to avoid estrogen therapy, not understanding that testosterone itself can turn into estrogens. In addition, high testosterone is detrimental to the female body and can deplete the adrenals.

THE BIG CONTROVERSY: Hormones and cancer

When it comes to the link between hormone therapy and breast cancer, we have a lot of data on HRT with synthetic estrogens and progestins, not much on BHRT.

The conclusion from all these studies is that the relationship between hormone replacement therapy (HRT) and breast cancer is much more complex that we previously thought.

What do studies show?

• The Women's Health Initiative (WHI) study conducted in 1991 had found that women who used combined HRT had a higher risk of developing breast cancer and blood clots.
• Since then, the menopausal society has evolved in favor of BHRT for women without contraindications, such as a previous, genetic,  or family history of breast cancer. 
• Interestingly, the most recent conclusion from all the studies is that estrogen-only HRT doesn’t increase breast cancer.

What role does progesterone play in Breast Cancer?

• The doses used in the WHI study where particularly high, especially the dose of 2.5 mg pf progestins, roughly equivalent to 100 to 200 mg of bioidentical progesterone.
• We know that high doses of progesterone cause side effects, such as weight gain and an increase in blood sugars. They also increase breast density which has been considered as a risk for breast cancer.

Important: Women on estrogens who didn’t have a hysterectomy have to take progesterone to avoid thickening of the uterus, which can increase the risk of uterine cancer. However, the lowest dose of progesterone should be used.

Estrogens and breast cancer

• The dose of conjugated estrogens of 0.625 mg used in the WHI study was actually reasonable, but contained estrone, which is considered to be harmful when taken in hormone replacement.
• Although BHRT that doesn't contain Estrone is safer, we still have monitor the safety of BHRT through regular tests because Estradiol can be converted to the harmful estrone when the body is not balanced or stress resilience is low.
• BHRT with Estradiol is still not recommended for women with risk of breast cancer for the same above reasons. 

        In conclusion, we can say that there has been a lot of confusion in hormone therapy. I have been prescribing hormones for over 10 years and my priority is to keep women safe when treating their symptoms. I believe in minimal therapeutic doses to rebalance the body. 

BHRT is becoming the treatment of choice for hormone replacement. However, BHRT is not recommended for every woman and a thorough medical evaluation is needed to rule out potential risks.

If you are on BHRT, make sure you have regular follow ups and are tested for specific makers that assess the way your body processes hormones.

Don't buy creams over the internet, or go to a quick fix hormone station. BHRT needs skilled medical supervision.

Even with BHRT, you still need additional support to maintain an active metabolism, and good levels of energy. You also need to  build stress resilience which protects the body from illness and the effects of aging.

In Vibrant Health,

Dr. Evee

Evelyne Leone, DO, FAARFM, ABBARM