What Every Woman Needs to Know About Hormone Replacement Therapy

Illustration by Justin Renninger

If you conduct an internet search for Hormone Replacement Therapy (HRT), you’ll see reams of information that is supposedly intended to help women determine if HRT is “right” for them. From medical journals and health care institutions, to the government and even Oprah, everyone seems to have an opinion on HRT. But there are so many inconsistencies and biased statements that it is a challenge for the average woman to make an informed decision. The answers to the following five questions are what I think every woman should know prior to discussing the matter further with her physician.

1) What is Hormone Replacement Therapy (HRT) and what does it treat?

Let’s start with the basics. First, although there are numerous hormones in the body, HRT generally refers to replenishing the ones made by the sex glands (ovaries for women; testes for men), which include estrogen, progesterone, and testosterone. The production of these hormones declines with age, which can create symptoms. The decline starts around age 40 and can continue for up to a couple of decades, culminating in menopause. Not every woman struggles with menopausal or perimenopausal symptoms, but those who do often complain of the following:

• Hot flashes
• Poor sleep patterns
• Diminished Libido
• Mood fluctuations
• Low energy

HRT has been shown to dramatically improve these symptoms. In addition, women can notice diminished bone density – osteopenia and osteoporosis – which also can be improved with HRT.

2) Why is there controversy about HRT?

By the year 2000, over 10 million U.S. women were taking synthetic estrogen – most often Premarin, or Premarin in combination with progestin (a synthetic form of progesterone), under the brand name PREMPRO.

In 2002, the first large-scale study of HRT, called the “Women’s Health Initiative (WHI)”, found that women who were taking PREMPRO had an increased risk for heart disease, blood clots, breast cancer and stroke. The results were so overwhelming that the study was prematurely terminated. A second study, the Heart Estrogen Progestin Replacement Study (HERS Study), showed that women who had a previous cardiovascular event had increased risk of having a second one if they were taking synthetic HRT.

Results of these two studies threw the HRT industry into a tailspin, causing millions of women to be taken abruptly off of Premarin and PREMPRO with nowhere to turn. Fortunately, there are now several other options available for the informed patient.

3) What are the current options for HRT and which are BEST?

Under the HRT umbrella, there are two very different types, though some of the available information mistakenly lumps them in the same category:

Bio-identical (or “bio-equivalent”) hormones – this is the exact chemical formula found in the human body. For example, the most common form of estrogen in the body is estradiol, and that is what is in most bio-identical preparations.

Synthetically derived, proprietary chemical formulas that have “hormone-like” effects. For example, the estrogen-like compound in the common pharmaceutical drug Premarin (meaning “pregnant mare urine”- yes, that is where the drug comes from) is Equilin, which is not part of human biology.

Both the WHI and HERS research studies evaluated synthetic hormones, not bio-identical hormones. For decades, the synthetic ones were widely prescribed, largely because pharmaceutical companies could patent them. While more research is needed on all types of HRT, bio-identical makes the most sense scientifically, and it is the only form of HRT I recommend. That is not to say that bio-identical HRT is risk free; it is a medical treatment and the risk-benefit ratio should be considered on a case by case basis.

There are two main ways that estrogen (estradiol) and testosterone HRT can be administered, and how they are taken is just as important as the form of the hormone:

1) Oral (in a pill or capsule), which means the hormones are processed through the gut and then the liver, causing increased side effects, increased risk of clot formation, and cardiovascular risk.

2) Through the skin (transdermal) or under the skin (pellets), so that the hormones can go right into the bloodstream and bypass the liver. This is the category I recommend to everyone. Transdermal methods include patches, creams and gels applied regularly by the patient. In addition, our Center uses pellets for patients who do not want the hassle of the transdermal methods or who require a more precise consistent delivery system. We implant the pellets under the skin in a quick office procedure and they last up to 6 months.

For progesterone, oral is best because it doesn’t absorb well from the skin and it doesn’t cause the problems the others do when taken orally. Progesterone is given with estrogen to protect the uterine wall and minimize the risks of endometrial cancer. Testosterone also can have a role in female HRT, which I will discuss in greater detail in an upcoming article on male HRT.

So, the most important take home message for HRT is: Bio-identical and not in a pill form (except progesterone)

4) If I am considering HRT, are there any tests I should take?

Before beginning HRT, your doctor should review your medical history, conduct a full physical exam, and discuss with you the pros and cons of HRT and the different options available. Make sure you consult with someone who has the appropriate expertise to help you with this decision. I also recommend a hormone panel for all HRT candidates, which is a blood test that checks levels of key hormones in the body.

Due to rapid and acute bone loss that occurs during menopause, it’s important to have a DEXA bone density test. If the DEXA scan indicates that you are at risk for osteoporosis, bio-identical hormones may play a role in the overall preventive therapy plan.

5) Are there natural alternatives to HRT?

Stress is a significant problem in our culture, particular during the middle decades when a woman is trying to manage multiple roles- career, family, social, etc. Research has shown that stress reduction sometimes can have a positive impact on menopausal symptoms, probably because the adrenal glands can do a better job regulating the sex hormones when there is less of a demand on them to make stress hormones. There also are some natural remedies that have shown to have some effect on symptoms, such as the herb, black cohosh. In our practice, we often recommend a product called “Peak for Her” by Lucentia, which has multiple ingredients designed to ease the effects of menopause and aging.

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Dr. Monti is the director of the Myrna Brind Center of Integrative Medicine at Thomas Jefferson University Hospital and the author of The Great Life Makeover. Read more about him here.