To HRT or Not To HRT?Details to help you decide

Because medical research in this field is rapidly evolving, the SHINE doctors recently attended an intensive, three-day professional webinar on HRT, to ensure our clinical protocols are informed by the latest data. Hormones are prescription-only medications, so an individualized assessment by a qualified healthcare provider is required to determine if you are a good candidate for them. Here are some factors to consider in your decision-making.

Human-identical estrogen has been found to provide relief from many menopausal symptoms, including:

• hot flashes and night sweats 

• poor sleep and brain fog 

• dry vagina, skin and eyes 

• anxiety and mood swings

• low libido 

• increased aches and pains

While estrogen has long been known to help maintain bone density, it has more recently been shown to reduce the propensity to cardio-vascular problems such as heart attacks and strokes, and to help slow cognitive decline.

The Role of Progesterone-Only Therapy

While there is substantially less published research on the isolated use of progesterone, clinical experience shows that it can be highly effective for many perimenopausal women. It has been shown to reduce hot flashes, alleviate anxiety, and improve mood. When administered orally rather than transdermally it may significantly improve sleep quality, which is frequently disrupted during this transition.

Current research indicates that safe usage of HRT should follow these guidelines:

• The Age Window: The optimal window for initiating estrogen replacement therapy closes at age 60, or 10 years after your final menstrual period (whichever occurs first). After this window, the protection from initiating HRT is outweighed by increasing cardiovascular risks that come with aging. However estriol vaginal suppositories or creams can be safely used in older women for vaginal comfort and to reduce recurrent bladder infections.

• Breast Cancer Risk: Human-identical estrogen used alone demonstrates a very low impact on the promotion of breast cancer. After 4 years of continuous use, estrogen was seen to increase breast cancers by 1 in 10,000 women. When combined with bio-identical progesterone, this minor risk is balanced out, rendering the combination "breast-neutral." Conversely, synthetic progestins are known to promote breast cancer.

• Cardiovascular Health: Human-identical estrogens provide protective benefits against heart attacks and strokes. They do this by maintaining good cholesterol and keeping artery walls elastic which promotes vasodilation and improves blood flow. They also reduce inflammation in the cardiovascular system and elsewhere. 

• Uterine Health: Estrogen naturally thickens the endometrium, the lining of the uterus. If you have a uterus, progesterone should be prescribed alongside estrogen. Because the uterine lining is no longer shed monthly during menopause, un-opposed estrogen can cause a dangerous thickening, potentially increasing the risk of uterine cancer. Natural progesterone effectively mitigates this thickening while maintaining a protective or neutral effect against breast cancer. While oral synthetic progestins strongly protect the uterine lining, they simultaneously increase breast cancer risks—which was the primary issue identified in early HRT trials.

  • Monitoring: A vaginal ultrasound is used to monitor endometrial thickness.

• Perimenopause and Contraception: Estrogen levels can become highly erratic during perimenopause, occasionally triggering more than one ovulation within a cycle. This is why reliable contraception remains vital until you are a full year past your last menstrual period. Unexpected pregnancies can occur in women in their 40s, as fertility may not decline as rapidly as anticipated.

• Cancer Considerations: If you have a personal history of breast cancer or a strong family history of the disease, an in-depth consultation with your health care provider is required to carefully assess the pros and cons of HRT in your individual case.

• Delivery Methods: Clinical guidelines recommend anyone still taking oral estrogens at the age of 60, should transition to transdermal estrogen (via a patch or cream) to reduce systemic risks of blood clots and liver problems. While estrogen is still available in oral pill form, at the time of writing this Health Post, there is no human-identical estrogen pill on the market.

Prescribing Access

Naturopathic doctors with prescribing rights can prescribe bio-identical estrogen and progesterone. However, they cannot prescribe testosterone. While medical doctors have the authority to prescribe testosterone, many are hesitant to do so for female patients. There is limited clinical research on testosterone use by women, and most available testosterone products are formulated primarily for men.

The Bottom Line

When considering HRT, timing and formulation are everything. Choosing the correct form of hormone replacement therapy at the right stage of your menopausal transition is essential to improving symptoms, maximizing the health benefits while minimizing potential risks.

If you missed part 1 on the history of HRT, here’s the link: To HRT or Not To HRT?