Understanding Hormone Replacement Therapy for Menopause & clarifying misleading/harmful terms in Women’s Health

Okay so the decision has been made, it’s time to start hormone replacement therapy. Now what? What kind of estrogen do I need? I don’t want horse-urine estrogen! I want something natural, like from a plant. It’s definitely safer. It’s for sure the animal hormones that gave everyone cancer and blood clots and liver failure!

The fearmongering is SO real.

When it comes to hormone replacement therapy- here is what you need to know:

Compounded bioidentical hormone therapy:

What is a bioidentical hormone?

A hormone with the same molecular structure as one that your body naturally makes. In case you’re wondering it’s 17-beta estradiol (that’s the most potent one, though we have 3 forms in our body, well technically 4, but E4 is only produced during pregnancy)

The term is incorrectly being used to describe the use of custom compounded, multihormone regimens, including estrogen, progesterone, testosterone and DHEA. In this case doses are adjusted based on repeat hormone measurements.

Sounds great, right? A customized hormone cocktail? It sounds safer too! Except that it isn’t, it isn’t safer, and it certainly isn’t more effective.

The experts: The Menopause Society, American College of Obstetricians and Gynecologists and the Endocrine Society all advise against the use of custom-compounded hormones.

Bioidentical hormones are made from soy and plant extracts, they are subsequently modified to have the same structure as our own, naturally produced hormones.

This is the exact same approach that is used for most of the hormones that are prescribed in your doctor’s office- that are both FDA approved and commercially available.

The difference?

1. The quality of compounded products cannot be verified and may, in some cases, be substandard. Compounded bioidentical hormones are not subject to regulatory oversight.
2. The potency can range wildly, one study showed efficacy ranging from 67.5% to 268% of the amount specified on the label.
3. There are no randomized trials that demonstrate the safety or efficacy of bioidentical hormone therapy in treating menopausal symptoms.
4. There is no shortage of approved and effective estrogen/progesterone formulations to aid in the management of menopausal symptoms
5. Compounded bioidentical products do not come with the standard warnings/package inserts that all approved hormone products provide. Not because they are without side effects, but rather because they are not withheld to the same standards as FDA approved medications.

But what about the natural hormones, aren’t the ones prescribed by my doctor synthetic? I’d prefer plant-based hormones, with no modification.

Apart from conjugated equine estrogen (the one derived from horse urine), all other estrogens that are prescribed for menopausal hormone replacement therapy are natural and come from plant sources! The process of extracting a plant hormone and then chemically modifying it to make a bioidentical hormone is what makes the process somewhat “synthetic.” However, this is the exact same process that is used in the production of compounded bioidentical hormones. Both processes take plant precursors and modify them to create bioidentical hormones that are both “natural” and “synthetic” at the same time.  The real difference is that one system is highly regulated to ensure efficacy and patient safety, the other, not so much.

Why won’t my doctor check my hormone levels? The med spa checks them every 3 months and adjusts my doses based on my levels.

When we prescribe HRT, we do not routinely check hormone levels, and it’s because (in most cases) they don’t actually matter or change our management. Perimenopause and menopause are clinical diagnosis and hormone levels do not always correlate with patient symptoms. Your levels may be normal, but you have had a relative decline in your estrogen levels, and it is causing symptoms that are altering the quality of your life. What I’m saying is your symptoms and the clinical history you share with us are the MOST important part of initiating and managing your hormone replacement therapy. There are no “perfect” or “target” hormone levels.

When you come in with the crushing symptoms of menopause/perimenopause what should follow is a discussion about the risks and benefits of treatment, and if appropriate, the initiation of hormone replacement therapy at a low dose with subsequent adjustments based on your individual response to treatment.

There is absolutely a role for checking hormone levels, when we suspect something else may be going on, or when periods have stopped in a patient under 45 etc- but when it comes to the routine hormonal management of perimenopause and menopause, hormones do not guide therapy. Repeatedly checking hormones and looking for an “optimal” level is not an individualized treatment plan. It is a waste of your time and resources, not to mention it may actually delay treatment in people with “normal” levels.

Now that we’ve touched on what to avoid, let’s talk about what’s available through your doctor:

There are 3-4 main types of estrogen formulations in the US

1. Oral (pill formulation)
2. Topical (lotions, gels)
3. Transdermal (patches)
4. Intravaginal (ring, cream)
5. Depot (long-acting injections)- this one is not recommended or available in the US

Which one is right for you will depend on the indication, your personal risk factors (oral has the highest risk for adverse effects), cost, preference etc.

I won’t go through it all today but can in the future. If you’re interested, leave a comment below.

If you have a uterus, you will require some form of progesterone in addition to estrogen. This is to prevent unopposed estrogen which can cause proliferation (growth) in your endometrial lining which can lead to endometrial cancer.

There are 2-3 main progesterone formulations and dosing options in the US

1. Oral (MPA-and micronized progesterone)
2. Progesterone containing IUD (this is an off-label usage, but studies thus far have demonstrated safety and efficacy- you might consider this option if you do not tolerate oral progesterone)

Dosing frequency:

1. continuous (low dose daily)
2. cyclical (12 days monthly at a higher dose)

There are 2 main combination formulations in the US

1. Oral formulation (pill formulation)
2. Transdermal (patches)

At the end of the day, this isn’t a post to demonize bioidentical hormones. But it is a chance to remind us of a few things.

1. Hormone replacement therapy isn’t the root of all evil, when used in the right patient, it is a safe and effective tool to manage menopausal symptoms.
2. “Natural” and “bioidentical” do not necessarily mean safer or more effective
3. You must ask questions and do your research! You are your own biggest advocate. (Unless you are my patient, then I will do the research and be your biggest advocate)

I hope this information helps you make an informed decision about what you decide to put into your body.

Sincerely,
Corsano MD- Your friendly neighborhood PCP

Resources:
Preparations for Menopausal Hormone Therapy- UpToDate
Treatment of Menopausal Symptoms with Hormone Therapy- UpToDate