Hormone replacement therapy (HRT) is a treatment that uses synthetic or bio-identical hormones to replace your body’s natural hormones when it’s not making enough. We most often associate HRT with declining hormone levels in menopause, but it’s also used for hypothyroidism and other conditions.
Why Was Hormone Replacement Therapy Labeled Unsafe?
HRT has a long history beginning in the mid 1900s. It became quite popular during the 90s. The first clinical trials on HRT and chronic postmenopausal conditions were started in the late 1990s.
Then the influential Women’s Health Initiative (WHI) HRT study came out in 2002 claiming that HRT had more detrimental than beneficial effects. The study found that the combination of estrogen and progestin they used increased the risk of breast cancer, heart disease, stroke, and blood clots. The study was stopped early because the results suggested that the risks of HRT outweighed its benefits. The media widely reported the results, and people panicked. Doctors had new and different guidance on prescribing HRT (mainly they stopped writing prescriptions). The clear message from the media was that HRT had more risks than benefits for all women. (source)
In the following years, a reanalysis of the WHI trial was performed showing the study was flawed. A new review published in JAMA says the benefits outweigh the risks. (source) The WHI study is considered flawed for the following reasons:
- The study focused on women over 60, some of whom already had heart disease, and not newly menopausal women. The WHI study began hormone therapy for the first time in women who potentially already had heart disease, and we now know that’s not a good idea. “Among women below the age of 60, we found hormone therapy has low risk of adverse events and [is] safe for treating bothersome hot flashes, night sweats and other menopausal symptoms, ” says the JAMA study author.
- The study may have been skewed by the inclusion of older women who would not normally need HRT
- The study also used a daily combined estrogen-progestin pill (Prempro) that eliminated menstrual periods. That may have affected the results. “The results might have been different if they had used a different form of estrogen that resembled a normal cycle,” said one researcher. (source)
- The type of progestin used, known as medroxyprogesterone acetate, is considered highly problematic
- Oral estrogen: Women in the study were taking estrogen (and progestin) orally, by pill, and this may have increased their risk. A better option for people at risk of clots is to take estrogen through the skin, via a patch, a cream or gel. (source)
Data regarding the HRT on breast cancer have also been controversial. Most of the meta-analyses and observational studies performed in the 1990s reported no increase in the risk of breast cancer with estrogen use. However, some increased risks related to dose and duration of use were found with the administration of combined estrogen–progesterone therapies. (source)
New studies show that the use of HRT in perimenopausal women or in early postmenopausal women had a beneficial effect on the cardiovascular system, reducing coronary disease and all-cause mortality. We also now know that estrogen could have a promotional and noncarcinogenic effect on breast tumor cells and that this effect is probably greater with an estrogen–progesterone therapy.
We also know the WHI was designed to study the prevention of chronic diseases, not to look at the prevention of hot flashes and other hormonally-driven symptoms of menopause. (source)
But the damage was huge, leaving many women with no available therapies to address life-altering symptoms. Add to that we now know estrogen has a very protective effect during perimenopause and menopause, and for 20+ years women missed out on these benefits.
Hormone Replacement Therapy Benefits
Menopause experts agree that it’s time to reconsider hormone therapy, because there’s a lot known now that wasn’t known two decades ago. Most significantly, there are now different types of hormones — delivered at lower doses — that are shown to be safer.
Sadly, menopause has not gotten the attention it deserves via studies or even your doctor or OBGYN who often isn’t well educated about this phase of a woman’s life. But the conversations around women’s health are changing, and women are demanding better care and solutions for menopausal symptoms. Today, because we are taking menopause more seriously and reevaluating outdated info, we know that the type and timing of hormones for menopause makes all the difference to risk analysis.
A little physiology: During perimenopause (the years leading up to menopause) and menopause, estrogen, progesterone, and testosterone production begin to fluctuate and then decline, sometimes quite suddenly. This is what causes the unpleasant symptoms. The first thing most women notice is shorter cycles and sometimes heavier bleeding. Hot flashes may start during perimenopause also, as early as your 30s. I often recommend low doses of bio-identical progesterone during this time.
Perimenopause symptoms can last 10 years or more, and menopause is marked as no period for one year. Average age is 51.
You can start HRT as soon as symptoms surface during perimenopause or within 10 years of your last period in menopause. Most experts agree if you wait longer than 10 years you don’t get the same benefit. Research in the last 20 years has shown that menopause hormone therapy can not only improve vasomotor symptoms, such as hot flashes, but also can have important long-term health benefits when used properly. (source)
The biggest HRT benefits are peri- and menopausal symptom reduction, especially hot flashes, night sweats, vaginal dryness, recurrent UTI. It can also relieve brain fog and insomnia. In addition to menopausal symptoms, there are long-term implications of the loss of hormones. Women experience a significant increase in heart disease, osteoporosis, and stroke. Estrogen is hugely protective and can dramatically slash disease risk.
Here are HRT’s other notable benefits: (source)
- Postmenopausal estrogen replacement therapy can alleviate vasomotor symptoms like hot flashes
- Decreases dementia risk by 45-70%
- Very notably, HRT reduces heart disease risk as much as 50%. Heart disease is the #1 cause of death for women and 7x deadlier than breast cancer.
- Decreases diabetes risk. Blood sugar naturally rises in menopause, and estrogen therapy can help.
- Decreased osteoporosis risk.
- Reduce weight gain
- Prevent hair loss
- Reduce brain fog
- Prevent UTIs
- Prevent vaginal atrophy
- Prevent muscle loss
- Prevent high cholesterol that rises during peri- and menopause
The key is the timing and type of hormones used. The North American Menopause Society says HRT initiated soon after menopause has very few risks. Additional research has indicated that hormone replacement therapy started in women under 60 years of age (typically age 51-60) was related to less cardiovascular disease and lower mortality. (source)
Bio-Identical HRT vs Synthetic HRT
Both bio-identical (BHRT) and synthetic HRT are used for any hormone replacement. Both work by releasing estrogen into the bloodstream or vaginal tissue and is available in many forms including pills, patches, vaginal rings, and topical creams, and gels. Most often, progesterone (progestin) is used to balance estrogen which reduces any risk of uterine cancer. HRT is typically pill or patch only; you have more delivery options with BHRT.
BHRT uses plant-based hormones that are chemically identical to the hormones produced by the body, and HRT uses synthetic hormones that are structurally different but are designed to have similar effects.
Bio-identical hormones are made from plants and are thought to be more effective and have lower risks than synthetic hormones (though there is varying info on this). They can also be compounded into customized doses to better fit your needs. HRT just comes in standardized doses.
The most common HRT for menopausal symptoms includes conjugated estrogens or a combination of estrogen and progestin. BHRT can come from soy or wild yam but is produced in a lab and can be compounded into doses made specifically for you by a compounding pharmacy. They can be made into a variety of forms (vaginal suppositories, oral capsules, and topical creams most often). And their strengths and ingredients can be customized to meet your individual needs. That’s a great benefit.
Examples of compounded BHRT includes estrogens (estriol, estradiol, and estrone), progesterone, testosterone, DHEA.
In terms of safety and efficacy, the FDA claims BHRT is not safer, but I like the advantages of the compounded dose. You want the take the lowest dose possible to alleviate your symptoms, and sometimes synthetic HRT can be harder to dose.
HRT Safety
These days HRT is considered quite safe. As mentioned here, recent research shows that if women start hormone replacement therapy within 10 years of their last period, not only do they enjoy significant relief from menopausal symptoms but they also have a lower risk of heart disease and bone loss. However, it may slightly increase the risk of blood clots.
Recommendations (breastcancer.org) say any woman with a history of breast cancer should not take HRT. And it used to be that women with a family history of breast cancer should not take HRT. However, women with a family history of breast cancer, including those with a BRCA gene, can usually take hormone replacement therapy (HRT) safely. In fact, some evidence suggests that women with a family history of breast cancer who take HRT may have a lower risk of developing breast cancer in the future. Research suggests that BHRT, such as low-dose vaginal estrogen creams, tablets, and rings, may not increase breast cancer risk because most of the hormones stay in the vaginal tissue. (source thethemenopausecharity.org)
There may be some slight side effects like sore boobs, bloating, mood swings, and spotting, but this usually means you need to adjust your dosage.
Always discuss any HRT with your doctor, BUT the big caveat is you need to find a menopause-savvy practitioner. Don’t be afraid to fire your doctor or OBGYN if he/she isn’t well versed in HRT or menopause. You can find treatment easily online, either HRT or non-hormonal treatments if you’re not a good candidate for HRT. Try Midi or Alloy.
Both HRT and BHRT are FDA approved.
Conclusion
Demonized for years due to poorly designed studies, HRT has gotten a bad rap, and many women are still concerned about its safety. But new research points to the fact that HRT can not only help you overcome potentially debilitating menopausal symptoms, it can also slash your disease risk.
Menopausal women have historically suffered because doctors don’t understand how to address this phase in a woman’s life and are not trained in the latest research on menopause or HRT. But fortunately the conversations around women’s health are changing, and menopause is getting the attention it deserves. We don’t have to suffer.
Approximately 55 million people in the US and approximately 1.1 billion people worldwide are postmenopausal women. Women deserve the proper care to reduce disease risk and alleviate menopausal symptoms, and most women are excellent candidates for HRT.
As always, discuss whether HRT would be appropriate for you with your (menopause-savvy!) doctor. Be sure to check out the online options like Midi and Alloy if you don’t have a doctor who is up to date on HRT.
Mary Vance is a Certified Nutrition Consultant and author specializing in digestive health. She combines a science-based approach with natural therapies to rebalance the body. In addition to her 1:1 coaching, she offers courses to help you heal your gut and improve your health. Mary lives in San Francisco and Lake Tahoe in Northern California. Read more about her coaching practice here and her background here.
