A topic that often comes up in my discussions with women in their 40s and 50s is hormone replacement therapy. This is the time of life when menopausal symptoms are at their peak, and they can be pretty severe.
There is no question that hormone replacement therapy helps alleviate hot flashes, night sweats, brain fog, mood swings, vaginal dryness, and other symptoms. Yet, since studies from the early 2000s suggested that hormone therapy had more risks than benefits, many women have been reluctant to consider it.
Based on reanalysis of those studies and other research, the majority of experts today agree that for most women, hormone replacement is a safe and effective therapy during the perimenopausal and menopausal transition. (Women with a history of breast cancer, heart disease, stroke, or blood clots should explore other options.)
My stance when it comes to hormone replacement therapy—and most other health concerns—is that it is an individualized decision that every woman has the right to make for herself. This requires having an in-depth conversation with a trusted healthcare team and learning as much as possible about the various treatments, both hormonal and nonhormonal, for relieving menopausal symptoms.
Testing Is Important
For starters, I recommend having your hormone levels tested.
Many women have come to my office for testing after their medical doctors denied it. The assumption is that if a woman is having clinical symptoms of perimenopause or menopause, her hormone levels are low. Fair enough, but I believe testing is important before deciding on a course of action—and a useful tool for monitoring hormonal therapy.
Blood and saliva tests are great, but I also recommend the DUTCH test (Dried Urine Test for Comprehensive Hormones). It measures levels of estrogen, progesterone, androgens (DHEA and testosterone), and their metabolites (breakdown products) and looks at organic acids and metabolites of vitamins B6 and B12 and glutathione, among others. I like the in-depth analysis it provides and find the individualized data on estrogen metabolism very informative.
The DUTCH test also provides information on adrenal health. Remember, our adrenal glands are what continue to produce sex hormones as our ovaries decrease production, so keeping them as happy and healthy as possible is key!
Types of Hormone Replacement Therapy
Once you have made the decision to try hormone replacement therapy, you’ll have many options. Hormones may be synthetic or bioidentical, single-hormone or combination products. They may be taken orally, rubbed into the skin, or delivered via patches, injections, lozenges, pellets implanted under the skin, or vaginal suppositories.
It is important to discuss all these options with your doctor to determine what is appropriate for you. Despite popular belief, bioidentical hormones—my preferred form—can be prescribed by any doctor and are often covered by insurance. You just need to ask for them.
Consider Progesterone First
If you are first considering hormone replacement and want to take a gradual approach, an option is to start with progesterone alone. Progesterone is often the first hormone to decline. This may result in imbalances in estrogen relative to progesterone (estrogen dominance), which can cause all sorts of problems.
Boosting levels with supplemental progesterone helps balance the estrogen/progesterone ratio. In addition to reducing symptoms, it also helps sensitize your estrogen receptors to the diminishing estrogen that is still in your system—providing both estrogen-like as well as progesterone benefits.
Progesterone is available in two forms:
- Progestins: These synthetic versions of progesterone are produced in a lab and differ structurally from natural progesterone. Progestins are available in pill form (oral birth control pills), intrauterine devices (Mirena, Kyleena, Liletta, and Skyla) and as an injection or gel. If a woman requires birth control during menopause, these could be helpful options.
- Bioidentical progesterone: Originally derived from plant sources, bioidentical progesterone has a chemical structure identical to the progesterone made by the human body. For balancing hormones and relieving symptoms, I prefer to prescribe bioidentical progesterone over synthetic progestins.
Bioidentical Progesterone
Oral micronized progesterone (Prometrium) is a popular form of bioidentical progesterone that is sold in most pharmacies in 100 mg and 200 mg capsules. Lower doses, sustained-release formulations, individualized creams, and vaginal suppositories are available from compounding pharmacists. All require a prescription.
A typical daily dose of oral micronized progesterone is 100 mg. It is often taken at bedtime because it is metabolized by the liver into allopregnanolone, which provides a relaxing, slightly sedating GABA-like effect. This improves both insomnia and anxiety, which many women struggle with during the menopausal transition.
If waking up in the middle of the night is a problem, compounded sustained-release oral micronized progesterone, which is slowly released over the course of the night, is particularly helpful.
In the United States, bioidentical USP progesterone is also available without a prescription in over-the-counter topical creams and oils. The usual dose is 20 g per day but can be lower or higher, depending on individual needs.
Estrogen Therapy Relieves Menopausal Symptoms
Estrogen is quite effective for reducing hot flashes and other symptoms. If you have an intact uterus and choose to use estrogen therapy, it is important to also use progesterone to balance out the estrogen and protect the growth rate and health of the endometrium (inner lining of the uterus).
Estrogen replacement drugs contain either synthetic or natural forms of estrogen:
- Conjugated/synthetic estrogen: Premarin and Prempro contain conjugated estrogens derived from the urine of pregnant mares. (Prempro also includes progestin.) Other synthetic estrogens are also available. I do not recommend conjugated/synthetic estrogen to my patients.
- Bioidentical estrogen: Most bioidentical estrogen replacement drugs contain estradiol, the most potent natural estrogen. Other products prepared by compounding pharmacies may include estriol, a weaker estrogen with additional protective effects.
Bioidentical Estrogen
The only type of estrogen replacement hormones I prescribe are bioidentical, which are identical to the estrogens produced in a woman’s body. Because of safety concerns—most notably an increased risk of blood clots and stroke—I do not recommend oral estrogen therapy. (This includes Premarin and Prempro, which are in oral tablets.)
Bioidentical estradiol can be applied topically through transdermal extended-release patches (e.g., Vivelle-Dot, Climara, and others) or creams rubbed into the skin. It may also be administered in a vaginal cream (Estrace) or ring (Femring, Estring). Different strengths are available depending on individual needs. These products or their generic versions are often covered by insurance.
Many women prefer the ease of the patch since it is applied less frequently (usually twice a week), is discreet, and unlike topical creams doesn’t have the risk of inadvertently transferring the hormone to a loved one.
Compounding pharmacies can also create topical bioidentical estrogen creams and vaginal suppositories as well as Bi-Est creams, which contain estradiol plus estriol. An advantage of compounding is that hormone concentrations and combinations can be adjusted to suit each individual’s needs. For example, estriol-only vaginal creams or suppositories are a good solution for vaginal dryness, which is a common menopausal symptom.
Support Your Adrenal Hormones
I believe it is always a good idea to support your adrenal hormones as well as your sex hormones. Cortisol and adrenaline may be the best-known adrenal hormones, but the adrenal glands also produce pregnenolone and DHEA, which your body can use to make sex hormones.
In the U.S., pregnenolone and DHEA can be purchased over the counter without a prescription. These hormones can also be compounded into creams and applied topically. I recommend testing your adrenal hormone levels first to see if you are low before supplementing, and following up with additional testing to see how your body is absorbing and metabolizing these hormones.
As with the addition of any new hormone, it’s best to start low and go slow. DHEA, for example, may increase levels of estrogen and/or testosterone, depending on how it is metabolized. When taken in higher doses, it can have unwanted side effects, including acne and male pattern hair growth such as facial hair.
Women Produce Testosterone Too
Testosterone may be the “male hormone,” but females also produce it, albeit in much smaller amounts. Functions in the female body include supporting bone strength, reproductive health, and sex drive.
If levels are low on hormone testing, talk to your doctor about prescribing small doses of topical testosterone, available commercially and through compounding pharmacies.
Natural Options to Hormone Replacement Therapy
For my patients who are experiencing early symptoms of the menopausal transition, I recommend first trying natural herbal remedies to help balance hormones, support adrenal health, and relieve symptoms.
Herbal preparations have been used by traditional healers in cultures around the world for thousands of years, and the benefits of several of those herbs are now backed by substantial scientific research. They include:
- Ashwagandha is one of my favorite herbs. KSM-66, a standardized ashwagandha root extract, has been shown in clinical trials to increase estrogen levels and reduce hot flashes, night sweats, insomnia, and other menopausal symptoms. Because it is an adaptogen, it also supports adrenal health and helps your body counter the adverse effects of stress.
- Black cohosh, which is native to North America, is one of the best-studied herbal remedies for estrogen-related problems, including menstrual cramps, premenstrual syndrome (PMS), and the full range of menopausal symptoms.
- Fenugreek has long been used as a culinary spice, but research reveals that it also has medicinal benefits. In a recent study, fenugreek extract was shown to effectively reduce vaginal dryness, irritability, hot flashes, and other symptoms.
Additional natural compounds with a proven history of supporting hormonal levels include Maca (Peruvian ginseng), Vitex (chasteberry), Shatavari (an adaptogenic herb), and Hesperidin (a flavonoid with anti-inflammatory effects). A good vitamin and mineral supplement with plenty of vitamins B, D, and E provides further nutrient and adrenal support. Seed and oil cycling is another wonderful way to help balance your hormonal cycle at any age, but especially as it is starting to change.
In Summary
Menopause is a natural transition that all women go through at one time or another, but it is not without its challenges. Fortunately, there are proven therapies for easing the symptoms that crop up during this time, and one of them is hormone replacement therapy.
As you contemplate what path to take, I suggest asking yourself these questions:
- How distressing are your menopausal symptoms, and do they negatively impact your quality of life?
- Have you tried herbal therapies and other natural products without relief?
- Do any of the potential risks of hormone replacement therapy pertain to you?
- Have you explored your options and discussed them with a trusted healthcare practitioner?
Whatever you decide is right for you, I hope you feel confident and supported in your decision. I also hope you feel empowered knowing that you have control over many aspects of your health and wellbeing—and that this empowerment can make a huge difference during this time and in the years ahead.
