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Menopause can sound terrifying. Hot flashes, facial hair growth, and mood swings are certainly nothing any woman looks forward to—and those aren’t even the truly dangerous effects. For starters, heart disease risk and osteoporosis risk skyrocket. It’s no wonder women were so eager to embrace hormone replacement therapy (HRT) when it became available, and it seemed to help. But in a devastating development, physicians and women soon learned that the relief from menopause symptoms came at a high cost: a heightened risk of cancer and heart disease.
Many women stopped HRT altogether and just suffered through the symptoms. But another option has emerged, and many women are giving it serious consideration. That option, bioidentical hormone replacement therapy (BHRT), is dramatically safer than and just as effective as the old HRT.
While HRT uses equine (horse) hormones and synthetic drugs the human body has never seen, bioidentical hormones are produced to exactly match the molecular structure of the body’s own natural hormones. And clinical studies are confirming that makes all the difference. Read on for a detailed discussion of why this difference matters so much and why a whole new generation of women are once again embracing hormone replacement.
Perimenopause, or the menopausal transition, starts in a woman’s 40s. During early perimenopause, ovarian estrogen production is erratic and associated with irregular menstrual cycles. As the final menstrual period approaches, estrogen secretion diminishes and finally ceases. Menopause is defined as twelve months after a woman’s final menstrual period. This natural event, marking the end of ovulation and thus reproductive capabilities, occurs at the average age of 51.
Many women experience symptoms that are both directly and indirectly related to fluctuating and falling hormone levels throughout the menopausal transition. Each woman experiences this time in her own unique way. Symptoms may be minor or they may become major disruptions of health and quality of life.
What are the most common menopause symptoms? Here are 20 that are frequently reported:
- Abnormal uterine bleeding
- Vasomotor symptoms (hot flashes and night sweats)
- Vaginal dryness, irritation, atrophy
- Urinary incontinence
- Trouble sleeping
- Low libido
- Pain with intercourse
- Mood swings
- Muscle pain
- Joint pain
- Weight gain
- Poor memory
- Dry skin
- Dry eyes
- Thinning scalp hair
- Facial hair growth
Hot flashes and night sweats affect 50 percent or more of women as they transition through menopause and persist for an average of 7.4 years. Next to hot flashes, fatigue is one of the most frequent complaints associated with menopause. Fatigue in menopausal-aged women is related to night sweats and sleep disturbances, as well as to increases in perceived stress, depressed mood, and weight gain.
Up to half of perimenopausal and postmenopausal women experience sleep disturbances and they are two to three and a half times more likely to report severe sleep disturbances compared to premenopausal women.
The estrogen deficiency associated with menopause can contribute to a decrease in bone density and the development of osteoporosis, as well as a worsening of lipids characterized by decreased high-density lipoprotein (HDL) levels, increased low-density lipoprotein (LDL) levels, and increased triglyceride levels. It also accelerates blood vessel aging, characterized by the stiffening of large arteries and dysfunctional blood vessel walls. These changes are associated with the increased incidence of cardiovascular disease in postmenopausal women.
If you’re a woman nearing or in the midst of menopause and frequently feel fatigued or have hot flashes or other menopausal symptoms, do not despair. You have many natural treatment options, including bioidentical hormone replacement therapy.
Conventional Hormone Replacement
Conventional hormone replacement therapy in the United States has generally consisted of conjugated equine estrogens prepared from pregnant mares’ urine and containing multiple estrogens not normal to the human body. To prevent the estrogens from causing a buildup of endometrial tissue on the wall of the uterus, which increases the risk for endometrial cancer, synthetic progesterone-like drugs (progestins such as medroxyprogesterone acetate) are used in combination with the conjugated equine estrogens.
These agents were investigated in the large trials known as the Women’s Health Initiative and found to increase the risk of heart attack, stroke, deep vein thrombosis, dementia, and breast cancer. Because of these risks, many women stopped taking hormones altogether, while many others switched to bioidentical hormones.
Understanding Bioidentical Hormones
Bioidentical hormones are synthesized to exactly match the body’s own natural hormones. They are available as FDA-approved prescription patches, gels, suppositories, and oral tablets. Various formulations contain estradiol, estriol, and/or natural or micronized progesterone. Physicians can also order bioidentical hormone prescriptions as compounded medications from compounding pharmacies.
While published information about bioidentical hormones is not as extensive as the research on conventional hormones, the research that does already exist, mostly out of Europe where the use of bioidentical hormones is more common, shows that bioidentical hormones are safer.
Cardiovascular Disease and Hormones
While conjugated equine estrogens increase the risk of cardiovascular disease (coronary heart disease, heart attacks, strokes, venous thrombosis), bioidentical estrogen does not.[7,8] In fact, bioidentical estradiol is protective. In a study just published in Menopause, researchers from Sweden and Finland evaluated the risk of death caused by coronary heart disease, stroke, or any disease among 489,105 users of bioidentical estradiol-based hormone therapy regimens. Here’s what they found:
- The risk of coronary heart disease death was significantly reduced by 18 percent to 54 percent in women using bioidentical estrogen. The longer the women were on estrogen, the greater the risk reduction. Risk of stroke death was also reduced by 18 percent to 39 percent.
- The risk of death from any cause was reduced in bioidentical estrogen users by 12 percent to 38 percent, almost in linear relationship with duration of estrogen use.
- All of these risk reductions were virtually the same in women who started on bioidentical estradiol-based hormone therapy before age 60 and those who started after age 60. The risk of venous thrombosis is also reduced with bioidentical estradiol compared to conjugated equine estrogens. Venous thrombosis is a blood clot that forms within a vein. If it breaks off, it can become a life-threatening blood clot in the lungs.
Taking estrogen by mouth, whether bioidentical or not, increases venous thrombosis risk, but equine estrogens increase the risk more.10 Even safer is using a bioidentical estradiol topical preparation; estrogen administered through the skin does not increase venous thrombosis risk at all.
Similar to estrogens, natural, bioidentical progesterone has beneficial effects on the cardiovascular system and decreases cardiovascular disease risk, while synthetic progestogens increase it. Medroxyprogesterone acetate (brand name Provera, a synthetic form of progesterone) has clearly been shown to negate the protective effects of natural estrogen on the cardiovascular system; it actually promotes cardiovascular disease and increases the risk of heart attack and stroke.
By contrast, bioidentical progesterone is protective and beneficial to the cardiovascular system.12 When combined with topical estradiol and estriol, natural topical progesterone lowers triglycerides and inflammation (as measured by C-reactive protein and interleukin-6), and favorably impacts other cardiovascular biomarkers.
Menopause and Cancer Risk
It has been commonly assumed that estrogen increases the risk of hormone-related cancers like breast cancer, but this is now thought not to be true. While the use of conjugated equine estrogens plus a synthetic progestogen is associated with an increased risk of breast cancer in some, but not all, studies, recent research indicates that estrogen alone neither decreases nor increases risk in younger women initiating hormone therapy close to the time of menopause. It actually decreases risk in older women.
The real risk of increased breast cancer appears to be due to the synthetic progestogens and not the estrogen. Synthetic progestogens, and particularly medroxyprogesterone acetate, increase the proliferation of breast cells, in synergism with conjugated equine estrogens.
On the other hand, bioidentical estradiol, especially when combined with the weaker and protective estrogen known as estriol and/or with natural progesterone, does not increase breast cell proliferation or breast cancer risk and may even decrease it.[17,18] This makes sense when you realize that pregnancy, characterized by high estriol and progesterone, is known to reduce a woman’s chance of developing breast cancer later in life. Many physicians who prescribe bioidentical hormones believe estriol and progesterone should be combined with estradiol for breast cancer prevention.
Benefits of Bioidentical Hormone Therapy
The many benefits of BHRT cannot be ignored.
- It effectively treats the classic menopause symptoms like hot flashes and sleep disturbances.
- It significantly decreases depression and anxiety while general improving mood and cognitive function.
- It improves markers of cardiovascular function such as cholesterol, triglycerides, waist circumference, and inflammation.[21,13,26]
- It prevents decreases in bone mineral density.27
- It significantly reduces the incidence of heart attacks and diabetes, and improves health outcomes related to many other chronic conditions.[22-24,13]
- In one recent study, women taking a sublingual form of bioidentical estradiol, estriol, and progesterone experienced significant improvements in hot flashes, night sweats, irritability, anxiety, emotional lability, sleep disturbances, memory loss, fatigue, and libido.
Deciding for Yourself—and Getting Started on Bioidentical Hormones
Some women might question the wisdom and logic of supplementing hormones at a time of life when those hormones have ceased being naturally produced by the body. In fact, some conventional physicians not trained in BHRT will use this very rationale as the basis for not recommending the therapy to their patients.
But if the same patient’s aging eyesight dims or their aging thyroid gland produces suboptimal levels of thyroid hormone, that doctor doesn’t hesitate to recommend corrective lenses or prescription thyroid hormone. The quality-of-life benefit that results from these “unnatural” corrective actions makes it well worth the effort and the risk. So it is with BHRT.
For many women in the menopausal transition and beyond, the potential risks seem small and not worth worrying about compared to the relief and health benefits they get from BHRT. Many women and their physicians are choosing to use BHRT for these reasons. In fact, even the more conventional and conservative women’s health organizations are beginning to acknowledge the advantages of bioidentical estrogens and progesterone (specifically transdermal estradiol and micronized progesterone).
If you want to explore whether BHRT could help you age more optimally or reduce your menopausal symptoms, work with a qualified health care provider, preferably someone with extensive experience in prescribing bioidentical hormones. This is certainly not a do-it-yourself type therapy. Choosing and working with an experienced physician will help you make informed treatment decisions and receive individualized therapy.
Hormone Replacement Therapy: When to Start?
Hormone replacement therapy should be initiated carefully after a thorough review of your medical and family history to minimize risk. Most physicians will want to order some baseline laboratory work to determine your current hormone levels. This can be done using blood, urine, or saliva. Different practitioners have different preferred testing methods.
The important thing for you as a potential patient is to find a practitioner that has a lot of experience in ordering and interpreting labwork and prescribing bioidentical hormones based on your hormone levels, your medical history, and your current concerns and goals.
Bioidentical hormones can be custom-mixed at a compounding pharmacy but are also commercially available as FDA-approved manufactured pharmaceuticals. Compounding pharmacies can create customized BHRT that provides the needed hormones in the most appropriate strength and dosage form to meet your speciﬁc needs. Every individual will respond to therapy differently and much of your experience depends on the dose, dosage form, and route of administration.
Close monitoring and medication adjustments from your physician are essential. Diet, nutrition, stress level, exercise, and family health history are also important factors in determining your overall hormone health and meeting your personal hormone balancing goals.
Your first step is to find a physician who is well versed in bioidentical hormone replacement therapy. Use the NHA Physician Directory to begin your search. I wish you well in your journey to hormonal balance and optimal health.
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Originally published in 2015 and updated.