Introduction Menopause is a natural phase in a woman's life, but it often comes with a variety of challenging symptoms, such as hot flashes, mood swings, and sleep disturbances. Bioidentical Hormone Replacement Therapy (BHRT) is one option that has gained popularity in recent years for managing these symptoms. In this blog post, we'll review the benefits and risks of BHRT, the different forms of hormones, and the importance of safely monitoring hormone use based on the July 2023 American Family Physician's article on "Managing Menopausal Symptoms."
What is Bioidentical Hormone Replacement Therapy BHRT means using hormones that are molecularly identical to the forms we naturally make in our ovaries before menopause. This is in comparison to conventional hormone replacement therapy that used conjugated equine estrogens that are molecularly identical to pregnant horse hormones and progestin, which is a synthetic but binds somewhat effectively in our naturally occurring progesterone receptors. The bioidentical hormones are estradiol, estriol, progesterone, DHEA and testosterone.
Benefits of Bioidentical Hormone Replacement Therapy BHRT involves the use of hormones that are structurally identical to those produced naturally by the body. This fundamental similarity makes BHRT an appealing option for many women experiencing menopausal symptoms. Some of the potential benefits of BHRT include: 1. Relief from Hot Flashes and Night Sweats: Bioidentical hormones can effectively alleviate these bothersome symptoms, improving sleep and overall comfort. 2. Mood Stabilization: BHRT may help regulate mood swings and reduce irritability, anxiety, and sleep disorders commonly associated with menopause. 3. Bone Health: Hormone therapy can help maintain bone density and reduce the risk of osteoporosis. 4. Improved Vaginal Health: BHRT can alleviate vaginal dryness and discomfort, making sexual intercourse more enjoyable. It also protects against urinary incontinence and overall genitourinary symptoms. Libido often improves as well.
5. Enhanced Cognitive Function: Some studies suggest that BHRT may have a positive impact on cognitive function and memory. 6. Enhanced Vitality: BHRT users report higher quality of life, feeling younger and stronger, and enjoying overall anti-aging benefits. 7. Improved Skin Integrity, collagen production, and facial tone and prevention of muscle laxity. 8. Prevention of chronic diseases including diabetes, colorectal cancer, and cardiovascular disease. In fact, all-cause mortality is lower among women using BHRT, and premature menopause/hypogonadism is a known risk factor for early mortality due to the increase risk women with low lifetime hormone exposure have of these conditions, as well as frailty, and fractures.
Risks of Bioidentical Hormone Replacement Therapy While BHRT offers many potential benefits, it's essential to consider the associated risks and limitations: 1. Blood Clot Risk: Hormone therapy may elevate the risk of blood clots, thromboembolism, which can lead to serious health complications. 2. Increased Risk of Gall Bladder Disease: It’s unclear why, and there are many ways to improve and manage gall bladder health with diet and lifestyle strategies. 3. Uterine Cancer Risk: Women who have not had a hysterectomy and take estrogen without progesterone may face an increased risk of uterine cancer. 4. Increased Risk of Breast Cancer: Hormone replacement therapy has been linked to a slightly increased risk of breast cancer, although the extent of this risk remains a subject of debate. A recent review of 25 clinical trials that looked for associations between breast cancer and hormone replacement therapy found that only 1 of those 25 trials found an increased rate of breast cancer recurrence in women who had previously had breast cancer and used HRT. The subgroup analysis demonstrated that this was true for women with hormone receptor positive (HR+) cancers, but not for HR- ones Another trial has shown a lower rate of breast cancer among women taking estrogen-only HRT (women who have had hysterectomies and don’t need progesterone for endometrial protection). (references at the end of this blog). It is also important to put the degree of risk in context with other risk factors. For example, obesity incurs a 60% increased risk of breast cancer which is much greater than BHRT.
5. Individual Variability: The effectiveness and safety of BHRT can vary from person to person, making personalized treatment plans crucial.
Forms of Bioidentical Hormones Bioidentical hormones can be administered in several forms, tailored to individual preferences and needs. These forms include: 1. Oral: Pills or capsules are a common method, but suboptimal option. Because of gastric metabolism, taking hormones orally requires very high doses to get a small percentage of what is taken into circulation. Further, the liver has to process and detoxify all the excess and some of the metabolites created by the liver are considered more toxic and higher risk than estradiol alone. I rarely use oral estradiol for these reasons. While the same holds true for progesterone, some of the metabolites of progesterone are actually beneficial for improved sleep and relaxation. 2. Transdermal: Patches, gels, creams, and oils, applied to the skin offer a steady release of hormones into the bloodstream. Transdermals are the best method to allow for fine-tuning of doses by the prescriber and patient. And because we can control the base cream, gel, or oil, we can control exposure to unwanted additives like parabens or phthalates and chemicals that are common in low-quality personal care products. There is an organic oil base that most prescribers are unfamiliar with. If you care about chemical exposures, this option is the cleanest one available. 3. Pellets: Tiny hormone pellets implanted under the skin release hormones gradually over several months. Convenient, but if the dose isn't right, there's no way to take them out! 4. Injections: Intramuscular or subcutaneous injections provide rapid delivery of hormones but require weekly appointments.
Monitoring Hormone Use Monitoring BHRT is crucial for ensuring safety and efficacy. This involves regular check-ups and various tests, including: 1. Lab Testing: Hormone levels should be regularly assessed to ensure they are within the desired range, not excessively high, and that hormone metabolites are being appropriately processed and metabolized. Blood tests can only give a glimpse of circulating hormone levels at the moment of testing. Urinary hormone testing is superior and is the only way to accurately measure metabolites. Read more in the references at the bottom. 2. Mammograms: Regular breast cancer screening through mammograms is vital for early detection and treatment. In March of 2023, guidelines for reporting mammograms changed and now comment on the density of the tissue. Dense tissue can obscure small masses and may also increase the risk of breast cancer. If you have dense breasts, it is probably wise to use a
more sensitive method of screening. While there is no consensus on this, 3D mammography (digital breast tomosyntesis), ultrasounds, and MRIs can show things that are not visible on mammogram. But those may not be covered by insurance. 3. Pelvic Ultrasounds: If unusual bleeding or spotting occurs, a pelvic ultrasound can help identify any abnormalities in the uterine or ovarian tissues. 4. Hormone Metabolite Testing: Tests such as the DUTCH urinary hormone panel or similar panels provide a comprehensive view of hormone metabolites. This data helps understand how well the body is metabolizing or processing the hormones, aiding in treatment adjustments.
Non-hormonal Strategies for Menopausal Symptoms There are other options beside BHRT for women who for whatever reason prefer to try non- hormonal methods to manage symptoms and address prevention and healthy aging. In fact, in most of my patients, I employee some of these strategies along with BHRT. For vasomotor symptoms, some women find relief with high dose vitamin E and soy isoflavones. Isoflavones are particularly useful because they also reduce the risk of cardiovascular disease, breast & uterine cancer, dementia, osteoporosis, and many of the same conditions we seek to address with BHRT. Urogenital symptoms often respond to non-hormonal therapies like hyaluronic acid and homeopathic suppositories that can moisturize vaginal tissue and maintain pH balance. For more information on lifestyle factors, see my previous blog post on Hormone Harmony (link below).
Conclusion Bioidentical Hormone Replacement Therapy can be a valuable tool in managing menopausal symptoms and planning for a healthy, vital second half of a woman’s life, but it is essential to weigh the benefits and risks carefully and tailor treatment to individual needs. Regular monitoring, using methods like hormone level testing and advanced metabolite analysis, ensures the safety and efficacy of BHRT. Choosing the right dose and right delivery method are also critical. As one of California’s only doctors certified by the Institute of Bioidentical Medicine and Dr. Rosensweet’s Menopause Method, you will find no one more experienced in BHRT than Dr. Oberg. If you are curious of hormones might provide relief from menopausal symptoms and enhance your quality of life during this significant life transition, consider scheduling a complimentary 15 minute exploratory call with Dr. Oberg to see if working with her would be a good fit.
AAFP menopause management: https://www.aafp.org/pubs/afp/issues/2023/0700/menopausal-symptoms.html
Soy isoflavones: https://pubmed.ncbi.nlm.nih.gov/33809928/
HRT and all-cause mortality/CVD: https://pubmed.ncbi.nlm.nih.gov/35594469/
BHRT and osteoporosis blog: https://www.drericaoberg.com/post/hormones-osteoporosis-are-bioidentical-hormones-right-for-me
Hormone Harmony blog: https://www.drericaoberg.com/post/hormone-balance