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  • Writer's pictureGavin Guard, Medical Director

A Guide on Hormone Replacement Therapy for Menopause

Updated: Jan 22, 2022

Key Takeaways

  • Menopause is associated with many undesirable health outcomes

  • Hormone replacement therapy (HRT) is an effective strategy to improve a woman’s health as she ages

  • There are more benefits of HRT than risks

Why should you care about menopause and your hormones?

Technically, menopause is characterized by the cessation of regular periods. But it’s much more than that.

It’s also accompanied by awful hot flashes, depression, lethargy, bloating, joint pain, insomnia, and brain fog. Some women even report a “midlife crisis” as they enter into their menopausal years.

More sinister health consequences can also result from menopause. This includes osteoporosis, Alzheimer’s, and cardiovascular disease.

The average age is 51 years old- some women earlier, and others later. However, 95% of women become menopausal between the ages of 45 to 55 years old.

On average, this menopausal transition and associated symptoms last for 7 years. But again, this can vary- some women less and unfortunately, some women more.

In this article, I will walk you through what you can do about your menopausal transition in order to make it a seamless transition that is relatively free of symptoms.

I will also present evidence of the pros and cons of hormone replacement therapy so you can make an educated decision about what to do.

A woman’s guide to understanding her hormones

It shocks me how few women understand their hormones. And to be honest, I didn’t really care too much about understanding it either. That was all until I got married and had two girls. I also had a few women in my life enter menopause and start experiencing insomnia and hot flashes. All of a sudden, my interest peaked and I started my deep dive into this topic.

There are 4 major hormones a woman needs to know about:

  1. Estrogen

  2. Progesterone

  3. Follicular stimulating hormone (FSH)

  4. Luteinizing hormone (LH)

The first two are produced mainly by the ovaries during the reproductive years. That all changes during menopause when the adrenal glands (the “hat-shaped” organs that sit on top of the kidneys) become mainly responsible for producing them. The last two are produced by the brain and coordinate the rhythm and flow of estrogen and progesterone production.

Without going into too much detail, estrogen levels peak right around ovulation (day 14 of a 28 day cycle). Progesterone then peaks around day 21. Both estrogen and progesterone then fall in the last week of a menstrual cycle- This is what causes monthly bleeding. This rapid fall in progesterone is also what may be causing PMS symptoms many women experience.

normal monthly rhythm of female sex hormones
normal monthly rhythm of female sex hormones

This all becomes less rhythmic as a woman enters menopause. Instead of a rise and fall of estrogen and progesterone, levels of these hormones become more stagnant. Not only that, but overall levels reduce dramatically.

This rapid plummet of estrogen (and progesterone) is what can lead to hot flashes, bone loss (osteoporosis), cardiovascular disease, and potentially dementia as well.

What is hormone replacement therapy (HRT)?

Hormone replacement therapy (HRT) is just that- replacing the hormones that fall as a result of menopause. Specifically, it is where a woman takes estrogen and progesterone in a pill, patch, or gel form.

We will talk more about the best forms of HRT a little later.

Who should take HRT?

So who should take HRT? Admittedly, this is a contentious topic for reasons explained later.

In my perspective, HRT is a good option for a woman who is experiencing symptoms of menopause (e.g. hot flashes, insomnia, brain fog) or detrimental health effects of menopause (e.g. osteoporosis).

HRT is best started within 10 years of menopause. However, this should be a personalized decision made with your doctor as some women may have a net benefit even if started outside this time frame.

There are some reasons for pause in regard to starting HRT. Such reasons are:

  • Active liver disease

  • Unexplained vaginal bleeding

  • Endometrial cancer

  • History of clot

  • History of heart attack

Again, these are not absolute contraindications to start HRT and a decision is best made in conjunction with a knowledgeable doctor.

Evaluating the risks of HRT

Before I talk about the multitude of benefits of HRT, I want to give a nod to the potential risks of HRT. With any medication, you will inevitably go on Google only to find that this medication has 1,000 side effects, one of which is death. I’d like to prepare you for what you may find online and discuss how accurate these claims truly are.

you don't know what you'll find if searching for answers on Google

The reported risks of HRT include:

  • Possible increased risk of stroke

  • Gallstones

  • Increased risk of clots

  • Increased breast cancer

To me, the largest risk that holds up to the research is that of clots. This is mostly a concern in women with other risk factors such as prior cardiovascular disease, smoking, and inflammation. So if a woman comes to me who is very overweight, has had a past blood clot, smokes, and drinks a lot, I think it would be best to address these risk factors before putting her on HRT. In this case, there is a net negative of taking HRT.

Regarding the stroke risk, there is a relatively low absolute risk increase in those >60 years old. To be exact, 0.15 out of 100 women will experience a stroke who are on HRT as compared to 0.13 out of 100 women not on HRT. This is a very small increase.

The biggest controversy out there is that of HRT and breast cancer. Let’s discuss that next.

Does estrogen cause breast cancer?

Back in the early 2000’s, major news headlines wrote “Estrogen Kills” and “Estrogen Causes Breast Cancer”. Why did news organizations write this and is it even true?

This warning came out of a result of a major study. The Women’s Health Initiative (WHI) was the largest and most expensive study ever performed in the United States. However, there were many problems with this study:

  • The study participants were not an ideal group to give HRT.

The average age was 63 years old (10 years after menopause), 70% were overweight, many had high blood pressure, over 50% were smokers, and many did NOT even have menopausal symptoms. In the words of respected OB/GYN physician Dr. Avrum Bluming,

“This was not an ideal, healthy sample, by any means.”

  • The very small increased risk of breast cancer in the study was just barely statistically significant.

In other words, there is more than a 1 in 20 chance that this finding could be merely due to chance alone. This is worth taking pause to this reported finding.

  • The placebo group in the study has LOWER than expected breast cancer rates.

Furthermore, many in the placebo group were women who were previously on HRT. If HRT is protective for breast cancer, then this group could have a reduction in breast cancer. This made the HRT group look as if it had higher breast cancer. In the placebo group of those who were NOT on prior HRT, there was NO difference in breast cancer risk.

I know I might get some hate mail from other physicians but, from my research, I’m not convinced that estrogen and HRT causes or contributes to breast cancer. Here’s why:

  • The evidence behind the notion that HRT contributes to breast cancer was from the WHI which has many flaws already discussed.

  • A follow-up study of the WHI in 2006 reported that the increased risk of breast cancer was NOT found after more years of followup of the study participants. Another study found similar results.

  • The Nurses’ Health Study of over 120,000 nurses followed for 30 years found that women taking HRT for 5, 10, 0r 15 years had NO increased risk of breast cancer.

  • Another study giving HRT to patients who had had breast cancer over the course of 14 years showed NO increased risk of cancer recurrence compared to those not on HRT.

  • Progesterone (as part of HRT) may actually be protective for breast cancer. In a trial comparing a conventional breast cancer medication (Tamoxifen) showed that progesterone did a little better than Tamoxifen in treating existing breast cancer. Another study found that progesterone taken during time of surgery to remove breast cancer improved risk of cancer recurrence.

What are the benefits of HRT?

What are the possible benefits of HRT? In other words, why would you start taking HRT if you are a menopausal woman?

Important point: The sooner you start HRT during menopause, the greater the potential benefit.

Symptom improvement

Perhaps the most obvious but most important of all given that it can increase your quality of life. HRT has the potential to reduce hot flashes, brain fog, joint pain, bloating, lethargy, and even symptoms that look like depression.

Colon cancer

The Nurses’ Health Study showed a 20-25% decreased risk of colon cancer among women taking estrogen

Bone loss (osteoporosis)

Osteoporosis is the gradual loss of bone as you age. This is more of a problem for women than men given the dramatic abrupt loss of estrogen during menopause (estrogen is protective for bones). Approximately 21% of women who fracture their hip will die within a year of the hip fracture and about just as many women die from bone fractures than breast cancer.

HRT can decrease risk of fracture by 50%
HRT can decrease risk of fracture by 50%

Studies show that HRT can decrease risk of fracture by up to 50%. In other words, the benefit of HRT to osteoporosis and bone fractures is greater than the possible small increased risk of breast cancer.

Cardiovascular disease

Let’s put heart disease in context. Dr Peter Attia warns that,

“heart disease kills more women than the next 16 causes of death, including all forms of cancer, AIDS and accidents”.

Another way of putting this is that women are 5 times more likely to get heart disease and 10 times more likely to die from heart disease compared to breast cancer. This is frightening given the fact that almost two thirds of women who die suddenly of heart attacks have NO PREVIOUS SYMPTOMS.

Check out this chart where I pull data from the National Cancer Institute to explain your risk of dying from cardiovascular disease compared to breast cancer. Out of 1,000 women by 70 years old, 183 will die from cardiovascular disease compared to just 15 in breast cancer. Overall, we have pretty good treatment for breast cancer whereas cardiovascular disease management is based more on proactive prevention than treatment.

risk of death for cardiovascular disease vs breast cancer
risk of death for cardiovascular disease vs breast cancer

Dementia (Alzheimer’s Disease)

On average, HRT decreased the incidence of Alzheimer’s disease by between 20 to 50% depending on the study. This is a very important finding given the suffering that takes place over the course of decades in those who have dementia. For me, I’d rather pass away from a heart attack at age 80 than live to 100 years old but have dementia in my last 10 years of life.

dementia is one of the most frightening diagnosis

All-cause mortality (death from any cause)

My favorite benefit of HRT is that it reduces the overall death rate of women. This is perhaps the most important benefit. There are 5 fewer deaths per 1,000 women per 5 years in those who take HRT. Over 15 years, this is 15 fewer deaths.

This study suggested that if every woman in America took HRT, it would increase the survival rate of women by 3.3 years. This study suggests thousands of women die prematurely due to being taken off HRT.

How to take HRT?

With recent knowledge in mind, here’s my current practice of how I counsel women on taking HRT.

1. We first get baseline hormone levels. I want to know what their initial hormone levels are so that I may start them off on an appropriate dose of HRT. This is in conjunction with assessing other health metrics such as blood sugar, inflammation, cholesterol, liver health, kidney health, oxygen carrying capacity, and nutrient status. I do both in order to get a better understanding of the broader landscape of my patient’s health.

2. If the patient is a good candidate, has symptoms, and looks like she’s in menopause, I will counsel her on the pros and cons of HRT including possible side effects and what to expect.

3. I start on a lower dose of an estradiol patch that she puts on her skin and changes twice a week. The progesterone is in the form of “micronized progesterone” and it’s a pill that she usually takes at night given it’s benefits on sleep quality.

4. I will then follow up on her symptom improvement and make adjustments to her dose appropriately.

5. She usually takes HRT for 10 years. But this can be individualized and a woman may need to take it longer depending on how severe her symptoms are.

This all needs to be done alongside improving her overall health patterns. This may mean also addressing her sleep physiology, movement patterns, and nutrition habits. We do this in order to get the most amount of benefit out of the HRT.

What about bioidentical hormones?

I’m not a big fan of bioidentical hormones. At surface level, this sounds a whole lot better. Who doesn’t want a natural version, right?

However, it’s important to know that there are a few unknowns and potential risks associated with taking bioidentical HRT:

  • Bioidentical HRT has not been rigorously studied in trials. Whereas conventional hormones have been studied in large trials for the last 60 years.

  • You don’t really know what you are getting with bioidentical hormones. Since these are compounded prescriptions, there is no assurance that you are getting the prescribed dose. This can lead to undesirable side effects or lack of symptom improvement.

  • There’s a lack of FDA quality assurance with bioidentical HRT. On the other hand, conventional medications are watched closely for their safety and efficacy.

In summary, stick with what’s been proven to be safe and effective. Don’t fall for the trap of bioidentical being better just because it has the word “bioidentical” in it.

My favorite resources on HRT?

If you want to learn more about this topic, I would suggest looking into the following resources.

The Bottom Line

Menopause can be a hard decade for many women. Don’t let it hold you back from experiencing some of the best years of your life.

HRT can truly make this a much easier transition and allow you to experience a graceful transition into late womanhood. My opinion is that HRT has many more positives than downsides.

I hope you found this information useful and helpful in your journey back to a healthier and happier life.

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