The topic of hormone replacement therapy (HRT) during menopause, especially with bioidentical hormones, seems to raise more questions than answers. Given the amount of misinformation and confusion that exists, I have prepared the following primer. It covers the ABCs of HRT and addresses some of the most commonly asked questions.
How Do You Know If You Are In Menopause?
The term “menopause” refers to the final menstrual period. When doctors use the term “menopausal,” we really mean that someone is going through perimenopause, the process leading up to menopause, and which ends a year or so after the final menstrual period. Now, the final menstrual period is a retrospective diagnosis. You don’t know you’re done until one year has passed. And, even though your hormones are in flux during that year, you could still get pregnant, so use birth control! Plus, you may require hormonal support both during and after perimenopause.
Who Needs Hormone Support?
Hormones are a Godsend for some women and just aren’t appropriate for others. Healthy women going through perimenopause may not require any additional hormone support. Menopause is, after all, a natural process, not a medical event requiring medication. In fact, some women make all the hormones they need from their own adrenals and ovaries, and they sail through the process.
However, many women enter perimenopause exhausted from chronic sleep deprivation, nutritional deficiencies, difficult marriages, or a lifestyle of over-giving to parents or children. These women are running on empty and often their bodies lack the raw materials to produce adequate hormones.
In addition, women who’ve had hysterectomies (with or without ovary removal) frequently require additional hormone support because surgery interferes with the blood flow to the ovaries. The end result is low hormone levels. And, in the case of ovary removal, instant menopause.
What Hormones Do You Need?
Most people believe that midlife women need estrogen. However, there are actually three sex hormones that can drop to low levels or become out of balance relative to one another:
- Androgens (such as Testosterone)
Because all three hormones are produced by the ovaries, when a woman approaches menopause and stops ovulating, these hormone levels typically change.
Some women might be perfectly comfortable with no supplemental hormones, some might need progesterone only, and some might need all three. Another thing to keep in mind is, as you transition from perimenopause to post menopause, you might need to adjust which hormones you are taking. This can mean adding or subtracting a specific hormone, increasing or decreasing an amount, and even eliminating them altogether.
What Symptoms Can Supplemental Hormones Help With?
Supplementation with any combination of estrogen, progesterone and testosterone, or all three, can help ease many of the symptoms women experience during perimenopause and menopause. These symptoms include:
- Irritability, sleeplessness, anxiety, premenstrual migraines. Natural progesterone can calm these symptoms very effectively. Sometimes the only thing that is necessary is 1/4 tsp. –1/2 tsp. of 2% progesterone cream (about 30-60 mg), which is available over the counter. Research has shown that small amounts of transdermal progesterone are, indeed, absorbed into the blood stream. Burry ¹
- Hot flashes and night sweats. Hot flashes and night sweats are caused by fluctuating levels of estrogen, which is why estrogen therapy is the gold standard for relieving hot flashes. I always recommend using the lowest dose you need to feel better. Interestingly, natural progesterone cream can also relieve hot flashes in many women.
- Chest Pain. Some women also experience midlife chest pain from coronary artery spasm. Natural progesterone has been shown to be very helpful in this regard—and at very low doses of only 30 mg (1/4 tsp. of 2% progesterone cream) applied as a cream to the skin. Hermsmeyer²
- Low sex drive. Many women experience a waning sex drive during perimenopause. Low sex drive is associated with low testosterone levels, so a little bit of testosterone (or its precursor, DHEA) supplementation may help. Also, most of the time low sex drive at midlife is the result of unfinished business in a relationship, the need for more sleep, low vitamin D levels, or simply the need to reinvent oneself. That’s why the number one predictor of good midlife libido is a new partner! I always tell people that they need to become that new partner, not necessarily ditch their husbands.
- Vaginal dryness. Vaginal dryness can play a part in loss of sex drive, too. For most women, a little estrogen applied vaginally is all that’s needed to restore sex drive and make intercourse more pleasurable. Some don’t even need that. A little KY Jelly or one of the other numerous lubricants on the market is fine.
Are Hormones Safe?
Bioidentical hormones are, theoretically, safer than estrogens made from horse urine or synthetic progestin. As a matter of fact, some studies show that natural progesterone is far safer than synthetic progestin. The bottom line is that, because of the confusion about which hormone preparations are bioidentical and which are not, most experts lump everything together and warn women of the well-defined risks that have been associated mostly with the synthetic compounds. That said, even bioidentical estrogen is a growth hormone in the body and may have adverse effects on uterine and breast tissue, especially if not balanced with progesterone.
In my opinion, there’s no harm in trying a small amount of bioidentical hormone replacement to see if it’s right for you. You will know the answer very quickly because your body will either say “yes” or “no.”
What Are Bioidentical Hormones?
Bioidentical hormones are hormones that match the hormones found in your body. Their chemical structure and shape were designed by Mother Nature. Pharmaceutical companies make some bioidentical hormones (synthesized from yams and soy) that are FDA-approved and sold in standard doses. These include a wide variety of patches and vaginal gels. They are available by prescription, and can be purchased in a typical pharmacy, including those that accept insurance.
You can also get bioidentical hormones made specifically for you through a compounding pharmacy. You need a prescription for custom-made hormone preparations.
One thing you need to remember is that “natural” or “plant-based” does not necessarily mean bioidentical. When it comes to a hormone, bioidentical means that it matches exactly what’s normally occurring in your body!
Are Progestins and Progesterone the Same?
Progestins are a class of hormones that include bioidentical progesterone. The confusion stems from the fact that there are many synthetic progestins available that have some progesterone-like actions in the body. Medroxyprogesterone acetate (MPA), also known as Provera (and used in drug Prempro), is a good example. Other synthetic progestins that have progesterone-like activity include norethindrone acetate and norgestryl are frequently used in synthetic HRT formulations. These three progestins are commonly found in birth control pills, too.
Because synthetic progestins are not found anywhere in nature, they have many more side effects than bioidentical progesterone, causing PMS, headaches, bloating, and even constriction of coronary arteries. Numerous studies show that bioidentical progesterone typically relieves these cycle-related concerns and provides relief for women with angina. But because synthetic progestins are lumped in the category “progesterone” in the medical literature, many doctors think synthetic progestins and bioidentical progesterone are the same. The only “real” progesterone occurs naturally in the female body (or is made in the lab to match it exactly.)
Are Pills or Creams Better
The most physiologic way to take hormones is through the skin—either with a cream or a vaginal gel. That way the hormone goes right into the blood stream without having to be metabolized by the liver. All the patches work this way (transdermally). There are a number of estrogen gels available and a progesterone gel that is used vaginally. Because taking hormones in pill form forces the liver to first process the hormone, you have to use bigger doses to get the same effect. This is undesirable because it can cause the liver to produce increased clotting factors.
How Do Stress Hormones Affect Perimenopause?
The stress hormones cortisol and epinephrine, which are produced by the adrenal glands, can wreak havoc on normal hormone metabolism. For example, if you are skipping ovulations, have progesterone levels that are very low, but estrogen levels that are high (called estrogen dominance,) your body will convert your estrogen into substances that act like additional stress hormones. That’s why so many women notice that their symptoms go away when they learn to meditate, get more sleep, or go on vacation. Their bodies, when relaxed, can metabolize excess stress hormones beautifully.
Many experts believe that the key to quelling menopausal symptoms lies in getting stress hormone levels under control. Given that stress hormones are associated with everything from midlife weight gain to poor sleep, I certainly agree!
What About Thyroid Hormones?
When women start skipping ovulations, they may develop a condition known as estrogen dominance. In the face of stress, estrogen can be metabolized into substances that act like stress hormones. To compensate, your body may lower levels of thyroid hormone so as not to overstimulate your heart. The result is subclinical hypothyroidism.
It’s always a good idea to get your thyroid checked. Your TSH level should be no higher than 3, even though in many labs the range for normal is up to 4.5! You should also get your Free T4, Free T3 and Reverse T3 checked to be sure you have enough circulating thyroid hormone and that you are not converting T4 to Reverse T3.
Finally, up to 15 percent of women are iodine deficient, which can also cause subclinical hypothyroidism as well as sore breasts! (Believe it or not, breasts require 3 mg of iodine per day to be healthy!) The safest way to increase your iodine level is through eating kelp tablets, seafood, and a couple eggs per week. Iodine supplements are available, of course, but it’s important to work with a healthcare practitioner who has experience with this.
What Is a Compounding Pharmacy?
Compounding pharmacies, also called formulary pharmacies, specialize in creating hormone (and other) prescriptions tailored to individual needs. The bioidentical hormones used by compounding pharmacies are all FDA approved—and are the same hormones that drug companies also use in their pills, patches and vaginal gels.
How Do You Individualize Your Hormone Treatment?
Your doctor can prescribe customized hormones based on test results or any symptoms you have so that you take only what you need to maintain the optimal levels of hormones in your body. For example, you may have a prescription created using a combination of one or more of the bioidentical estrogens (estradiol, estrone, estriol) combined with bioidentical progesterone and an androgen in the form of DHEA or testosterone, if needed. These hormones are mixed into a lotion, cream, or other base and applied to the skin. (Because the estrogen known as estradiol can be converted by the body into the other types of estrogen, I generally recommend just that one.)
You may need to purchase your hormones from a compounding pharmacy, but it’s also possible to create a bioidentical hormone replacement regimen using hormone preparations available from conventional pharmacies.
Is Hormone Testing Helpful?
Hormone testing is controversial because a hormone level measures only a point in time (like looking at the speedometer in your car only once during a road trip) and hormones fluctuate widely throughout the day. This is true whether you use blood, saliva or urine tests. Results also depend upon what you eat, your activity level, the time of day, and your nutritional status. Still, a baseline blood test is a good starting point for monitoring therapy. Today, most experts prefer blood, or serum, hormone values over saliva. These should be done by a lab that has a lot of experience in this area. I, personally, like the Dutch test, which stands for Dried Urine Test for Comprehensive Hormones. You collect samples throughout a 24-hour period and it’s far more accurate than a serum test, which measures just one point in time. The test is done by Precision Analytical, Inc., and it is proving to be a real game-changer in providing patients with their full hormonal health picture.
How Can You Find a Healthcare Practitioner?
Fortunately, more and more healthcare providers, including OB/GYNs and nurse practitioners who specialize in women’s health, are knowledgeable about HRT and bioidentical hormones so all you need to do is ask around or search online for one near you. You can also contact a local compounding pharmacy. They are usually happy to provide the names of local practitioners who work with them.
Where Can You Go For More Information?
My book The Wisdom of Menopause is a complete resource for health concerns at midlife. Chapter 5 provides in-depth information on hormone therapy. It even lists the names of some of the bioidentical formulations available with a prescription at conventional pharmacies, such as Estragel (bioidentical 17 beta estradiol as a skin cream).
I’ve also been interviewed on television and radio programs a number of times to talk about hormone replacement and bioidentical hormones. I encourage you to explore the Press & Media section of this site and catch up on any that you’ve missed.
Remember that a one-size-fits-all approach to hormone replacement therapy (HRT) is not good medicine. Every woman is different. If you’re approaching or in perimenopause, I encourage you to learn all you can about the different options so you can partner with your doctor effectively. Midlife and beyond can be the best years of your life! They don’t have to be laden with medical challenges.
Do you use HRT? Please share your experiences with me.
Learn More — Additional Resources
The Wisdom of Menopause, by Christiane Northrup, MD
Burry, K., Patton, P., Hermsmeyer, K., 1999. Percutaneous absorption of progesterone in postmenopausal women treated with transdermal estrogen. American Journal of Obstetrics and Gynecology, June 180(6 Pt1):1504-11.
Hermsmeyer, K., et. al, 2008. Cardiovascular effects of medroxyprogesterone acetate and progesterone: a case of mistaken identity? Nature Clinical Practice: Cardiovascular Medicine, Jul 5(7):387-95.