HRT – separating Fact from Fiction

Introduction to HRT Basics 0:00

Hi, Dave's Menopause. Let's talk about the truth about hormone replacement therapy. I get a lot of questions about HRT in my practice, whether it's appropriate for women or not, and what it can actually do for them. And you've probably actually heard a lots about Hormone Therapy online. It could make you lose weight, it could you feel like you're 25 again, It can help with hot flashes, could change your life. Well, This all might be a little bit too good to be true, but there are actually some good things about hormone therapy, so I wanted to go over the facts.

In fiction today, just you had a bit of the basics and start thinking about if it's appropriate for you or not. And also to know a litte bit about the 101 of taking hormones and some key questions to ask your prescriber, your doctor. Basically, what is hormone therapy? Hormone therapy is an umbrella term. It could describe any type of hormone, therapy or hormone replacement. This could apply to estrogen, progesterone, testosterone, but also thyroid hormone and insulin. When you're thinking about hormone-therapy for menopause, it's often termed menapausal hormone theory or MRT, or a hormone of placement therapy, HRT.

But often, you want to use bioidentical hormones. So that would be a small BHRT. So this is important just to know if you're looking at research or any articles about what hormone therapy can do for you. If it says BHT, that means they're using bioidentical hormones. Bioidentically hormones are naturally derived, usually made from plants, and they are changed in the lab to be identical to the hormones that you make. A bio identical estrogen, is usually estradiol. is exactly the same molecule that your ovaries would make.

Bioidentical progesterone, exactly same the molecule as your overage would makes. So it acts in the body the the hormones that you would on your own.

Bioidentical vs Synthetic Hormones 2:00

Hormone replacement therapy may be synthetic. That would be like a birth control pill that may have estrogens that are similar to our own estrogen or projestins that act like progesterone in some parts of our body, but not in other parts. So if it's really important to you to have hormone therapy that's identical to your own hormones, look for bioidentical hormone replacement or BHRT. Another thing to think about is with hormone, therapy, if you're going to use hormones that are systemic, meaning apply to treatment, treating the whole body and brain or localized such as a cream or a suppository that's treating just the area that it's applied to.

You also want to think about using conventional or compounded. The good thing is over the past 10 years, we have a lot more formulations that are conventional, ready to be prescribed off the shelf and appropriate for you. Compounding is less favored now just because it normally only used if you have allergies to the components in regular hormones or conventional hormone therapy like the patches or suppositories or the creams that they're in. If you're allergic to those things, you may need compounded hormones, or if we need a different dose.

But like I said, over the past 10 years, a lot more dose formulations have been available in lower strengths and higher strengths, so the need for compounding is less. Also, compounded hormones are much more expensive than the conventional options. Hormones are available in many different forms. They can be oral pills, topical patches, gels or creams, they can vaginal or vulva creams. Vaginal suppositories or pellets. The difference between these different forums does determine how your body uses the hormones and the levels of hormones.

Also some hormones such as estrogen, post-menopausal and perimenopause are not favored to be oral. That's why we have the topical options. So those are things to consider when you're thinking about hormone therapy. And you also want to think about the symptoms you are treating. If you have local symptoms, which I'll talk a little bit more about, such as urinary tract infections or an overactive bladder, you may not need systemic hormone and a local therapy may be more applicable for you. So let's look a little bit at some of the myths around hormone therapy, because that's most often what I get questions about.

Forms of Hormone Therapy 4:30

There are a lot of myths, around the safety and cancer promoting aspects of hormone, therapy. Most of this comes through the women's health study that was done. It came out in 2003, but it was actually done over the previous decades where Astrogen that was actually derived from pregnant horses was given to women as a replacement therapy for menopause. This study was halted because it found that the estrogen therapy increased risks for cardiovascular disease and stroke in older women and also increased the occurrence of uterine cancer.

And then hormone therapy was deemed unsafe. and a lot of the research on it stopped for about 20 years, which is why we don't know too much about hormone replacement therapy until recently we've had more research. The issues with this study were One, the type of estrogen they were using was from pregnant horses, which is about up to a hundred times stronger than the estrogen that women make themselves. So it was using a really high dose or potent estrogen. Another issue was they we're using this type estrogen in women of all ages, even women over 70 and 75, where it's not appropriate.

And that's where this estrogen caused more blood clots, were it caused strokes and cardiovascular conditions. They also did not balance the estrogen with progesterone. And because it wasn't balanced with the proesteroin, this high dose estrogen stimulated the uterine tissue and led to utering cancer. So now we know that we have some rules around estrogen therapy. It should not be oral because you have to use high doses if it's oral. That's why we use topical. it also should be balanced for projesteroine if you had a uterus to prevent uterin cancer and we had the research showing that that does.

prevent uterine cancer if you're balancing it with progesterone and using bioidentical estrogen at doses that are appropriate for what your body would

Myths and Safety Concerns 6:30

normally be making and also not introducing hormone therapy over the age of 60. So now that we have these guidelines, it's much safer. There's also a myth that once you run hormones, you need them for the rest of your life. Again, not true. They're best used to handle symptoms and manage symptoms as you are transitioning through menopause. or to prevent some conditions such as dementia or osteoporosis. But they should not be used for the rest of your life. It's more to use during the transition period.

There's also a myth that estrogen is the only hormone replacement therapy that there is. And that's not necessarily true. Like I already mentioned, we use progesterone. We can use DHEA, testosterone, other types of hormones. So even if a woman has concert indications to using estrogen, there may be some hormone therapies that could help with hot flashes, night sweats, and vaginal symptoms of menopause. And then there's a myth that I think is promoted by the media now, in social media in particular, that every woman needs hormone replacement and menoppause to feel like a woman or to feeling good.

That's not necessarily true either. It's natural phase of life. Some women don't have any hotflashes, so they don' have night's sweats. They don have trouble sleeping. and their weight is stable. So they may not even look at hormone replacement therapy and not every woman needs it. The key is to find out if it's appropriate for you, for your symptoms. Let's look some of the facts around hormone therapy. Research does show us that hormone replacement therapy in the form of estrogen and progesterone does reduce hot flashes, does improve sleep quality by reducing hot flash, but also progesterone is calming and does help with sleep.

It helps with mood, reduces irritability, increases energy, and can help joint aches that can accompany menopause. This research is all centered around using systemic estrogen and progesterone. So either estrogen cream or patch combined with a oral proesteroin or projustin. A lot of the research does use projestins, which are synthetic, but projustins do have a long history of use in women in birth control pills. That's what's used in research. However, pro jestins don't act the same as pro gestero in your body and they don t actually help the brain.

in research haven't helped mood and sleep as much as oral bioidentical progesterone. I should also mention because it's becoming a little popular online, no research has shown that testosterone or pellets of even estrogen or testosterone has helped with these symptoms. And that's actually a question we talked about in the discussion portion of the menopon meeting was, the pellets versus other forms and why pellet seem

Benefits for Symptoms and Prevention 9:30

to be more promoted by med spas and lifestyle aspects versus medically. And doctors aren't necessarily talking about pellettes as much, mostly because we don't have the research on the pallets. There's one study that show studying estrogen and testosterone in pallettes in women, and it showed that the palette form of insertion increased estrogen and testosterone levels a lot higher than using patches or creams, which could be an advantage or disadvantage, but the pellets actually caused higher rates of side effects from the hormones in women.

I think 57% to 58% of women using the pallets had side-effects versus less than 15% percent of woman using other forms, the topical estrogen, and topical testosterone had side effects. So you do run the risk with the pallets of having a higher rate of side-effects. And again, we don't have much research on this form of hormones in women medically. That's why it's being promoted more for cosmetic uses and not in the medical arena. Besides those symptoms, if you're having hot flashes, mood changes, sleep changes you may want to consider hormone therapy.

If you don't have those symptoms and you're thinking about preventative health or long-term health, there is some data showing systemic estrogen and progesterone hormone replacement therapy can improve heart health in women. One of the reasons that women have lower rates of heart disease in their 50s versus men is because of our estrogen, it does help our heart. So by replacing some of the estrogen you prolong the protective factors of estrogen in your heart, so if you have a risk of heart disease in you family, particularly for women having heart attacks or strokes under the age of 65, you may want to consider hormone replacement therapy for heart health.

A very specific study showed that hormone replacement therapy drastically reduces the risk for dementia by about 88%. But that was only for women who had a first degree relative diagnosed with dementia. So they had to have a parent or a sibling that already was diagnosed for Alzheimer's or dementia to show that adding in estrogen and progesterone and menopause decreased the So I'm sure we'll be doing more research on dementia prevention. But again, if you're in that case of having a first degree relative with dementia, you may want to consider hormone therapy.

Also, estrogen does preserve bone density. So for women entering menopause, the first three years of menoppause is where we lose the most bone-density, at the fastest rate. And from there, we're losing bone intensity because of ongoing age, but on par with men. We're loosing it parallel with them. It's really this drop in estrogen that's drastic. Our bone stops presenting those estrogen receptors, which trigger the bone to remodel and build. So adding in estrogen during this time can help preserve bone density.

If you have a family risk of osteoporosis or osteopenia, or if you know you're at personal risk, some of the things that increase your personal risks would be being under 127 pounds, being small framed, Asian or Caucasian. Those are some things to think about when you are thinking about hormone replacement therapy. Again, this is all on systemic estrogen and progesterone replacement therapy, not on testosterone or pellets. When you're thinking about local symptoms, so not systemically treating your whole body and brain, there are some ways that you can use hormone replacement.

Because postmenopause changes in estrogen levels, it does change our vaginal tissue and our pelvic floor and a urogenital tissue. Some women experience vagina dryness that causes irritation and tearing. frequent urinary tract infections, and overactive bladder symptoms. There is research showing that local estrogen in the form of a suppository or topical cream helps decrease these symptoms and rejuvenate the tissue. there's also research that showing DHEA, which is not estrogen, hormone suppositories can help these systems as well.

So even if estrogen is contraindicated for you, you may want to think about DHA. Research has shown that systemic HRT, so using estrogen and progesterone systemically, we don't use doses high enough to really help with these symptoms

Local Therapy for Vaginal and Urinary Symptoms 14:00

in the pelvic floor. So if your symptoms are mostly physical in this nature, in your pelvic and urinary tract, you want to think about local therapy. Besides these facts, things to keep in mind about the key points from the research. Most of the research now is done on systemic bioidentical hormones. So using that bio identical estrogen and progesterone that are exactly like the hormones that we make, or at least using bio-idental estrogen with those synthetic projustins that mimic pro testosterone in most places, but not everywhere in the body.

The first three years of menopause is the most important when you're thinking about starting hormone therapy, because that's when your still presenting estrogen receptors on most of your tissues. and you can get the most benefit out of the hormone replacement. We try to use the lowest dose necessary to reach physiological and therapeutic levels, meaning not what they were doing last century, I should say, in the 1900s, with horse urine and really high doses of estrogen. They're trying to lower doses for symptom management and to mimic what you naturally would produce.

Again, this comes up the issue with the pellets. They still haven't formulated those correctly to be able to get lower doses into women. So that's where you have that higher rate of side effects. If you had local symptoms, try to think about local treatment. It would be more applicable, you'll get better relief, and there's lower risk with using those local treatments too. And then when it's time to stop the hormones, try to wean off them slowly and not go cold turkey, because then if you're going cold Turkey off some of the hormone, especially if they're a little bit higher dose, you just mimicking menopause just at a later date in your life.

So you'll still have that drop off in bone density. and potentially hot flashes and night sweats. So if you're weaning them off, your body has a chance to adapt to it, produce less receptors.

Key Rules for Starting and Stopping HRT 16:00

Your body doesn't feel like it's such an abrupt cliff and you'll have less symptoms. Hormone therapy rule is just to keep in mind, bioidentical is better because it is made from natural sources and it's identical to what your body makes, so it acts the same way in your own body. Your body processes it the way as your hormones and responds to it. It is helpful to have lab testing to know what doses to start at. We'll talk about lab-testing next month. In my practice, I always do annual lab testing and reassessing, especially as women are in perimenopause and then moving into menopaus, their own hormone production changes and their needs for hormone replacement would change.

If you have a uterus and you're thinking about using systemic hormone therapy, you HAVE to use progesterone with the estrogen. If you don't have a uterus, if you've had a hysterectomy, even if still retain your ovaries, you do not need to use the progesterone if your on estrogen therapy. You may want to using oral bioidentical progeterones. If your main goals are helping with sleep and mood, the Progesteron can cross the blood-brain barrier and help with those symptoms. But if just thinking about hot flashes and night sweats, then estrogen would be appropriate.

Even though those first three years of menopause is the most important symptom-wise, if you're going to use hormone replacement therapy, you do want to start it by age 60 and end within the first 10 years menoppause. Again, after that 10-years, we don't have the hormone receptors present anymore, so you'll get less effect from it or even no effect, and it may be dangerous for you to do hormone replacements. After age 60, you have increased risk for blood clots, so it's best to not begin after age sixty.

It's actually recommended to do that at all anymore. You want to start within the first 10 years of menopause and by age of 60. If you go into menoppause at age 48, then you'd want start hormone therapy before the age 58, if you're going to use it. So next month in the menopause, menopod for the dames, we are talking about hormone lab testing, a little bit more specifics of why you might want to get your hormones tested, when you may want get them tested pre or post menopus or what time of your cycle and the types of tests available and types information you get from the different types tests because not all testing is the same.

So I hope you enjoyed this recap and I will see you next