The pros and cons of hormone replacement therapy (HRT) for menopausal women have been hotly debated for many years. As a naturopathic physician, I’ve helped women navigate the choppy waters of menopause for over two decades. I believe that hormone management should be very individualized, and generally practice a philosophy of lifestyle first, natural medicines second and pharmaceuticals third, if possible. I recently completed a course that analyzed the research on HRT over the last 20 years. When you look carefully at the research, there is a role for hormone replacement therapy not only to help to safely and effectively manage symptoms of menopause but also as a preventative medicine.
First a bit of history. HRT was used for 70 years before the Women’s Health Initiative (WHI) did the first large placebo controlled study on it in 2002. This groundbreaking study sounded some alarms regarding increased breast cancer risk in the women who took Premarin (estrogen) and Provera (synthetic progesterone). In addition they found a higher rate of blood clots, which can cause strokes and more. As a result, many women were taken off HRT at that time.
Then subsequent analysis determined that the study had some major flaws. The average age of the women starting estrogen therapy was 65. We now understand that there is a critical window for starting hormone therapy to maximize the benefits and reduce the risks, which is within 10 years of one’s menopause, or under 60 years of age.
Secondly, the type of estrogen they used was extracted from pregnant mares’ urine and contained non-human estrogens. Now almost all prescriptions written use a bioidentical estrogen called estradiol or E2. It is processed much differently in the body and has less risks. The progesterone used was a synthetic cousin of our progesterone called progestin, which has many more side effects. Thirdly, the route of administration of estrogen matters. Yes, taking oral pills of estrogen does increase blood clotting especially in women over 60. But using a patch or cream on the skin does not do so in any significant way. We’ve come a long way from 2002 to understand how to use estrogen safely.
According to the North American Menopause Society, estrogen has strong evidence showing that it helps with hot flashes, and night sweats. They say it can be used for women of any age in very low doses locally for genital and urinary symptoms and to improve sexual function. Systemic estrogen also helps to prevent bone loss and fracture associated with osteoporosis. The research shows that this benefit is most relevant if estrogen is started within five years of menopause and the benefit is lost after ceasing the estrogen. Estrogen therapy can slightly reduce cardiovascular disease risk but only if started early.
To me, the most interesting evidence regarding estrogen replacement therapy is around reducing cognitive decline. One in three people develop significant cognitive decline in their lifetime, and ⅔ of the people with Alzheimer’s are women. Estrogen has many protective effects on the brain, including increasing neuronal growth and repair, increasing neuroplasticity, decreasing build up of tau proteins and amyloid plaques (associated with Alzheimer’s) and much more. Estrogen seems to help slow cognitive decline, not reverse it. One study showed that women who started estrogen at 75 years old had a worse rate of decline. So yes, there is a critical window for starting estrogen. Women who have their ovaries removed may especially benefit from starting estrogen therapy right away.
There is some evidence showing that estrogen may help with joint pain, muscle weakness, sleep issues, depression, skin laxity, dry eyes, hearing loss and diabetes. But what about breast cancer? Well, after years of analysis of the WHI study, it has been shown that when they gave horse estrogen and synthetic progestin to women far beyond the critical age window in oral vs transdermal doses, after three years, there was an increase of less than one case of breast cancer over the placebo rate per 1,000 women per year that could be attributed to the hormones. That risk is less than the increased risk of breat cancer associated with drinking two glasses of wine a day, and the same as the risk of being obese or inactive. In women who took only estrogen (women who’d had a hysterectomy), there was a slight decrease in breast cancer rate vs. placebo. Three French studies showed that when estrogen is used with women in a better age window, and coupled with bioidentical progesterone there was no increase in breast cancer rates.
So the bottom line is that bioidentical estrogen with bioidentical progesterone can have a role to play in the management of symptoms of menopause and possibly to enhance the aging process along with a healthy lifestyle. It’s not for everyone, so discuss it with a doctor who is up to date on the latest research analysis to see if you would be a candidate. For people without extended health insurance, compounding pharmacies can make up HRT prescriptions for about ⅓ to ½ the cost of 1pharmaceutical suppliers, so be sure to let your naturopathic doctor or medical doctor know your preference. Another advantage of compounded bioidentical hormones is that there are a variety of delivery methods that can be used depending on the desired effects and preference of the patient. Transdermal absoption of hormones has been well established in scientific research.