Is it Worth Taking Hormone Therapy?
Hot flashes, night sweats, vaginal dryness, increased anxiety, bladder irritation, joint pain, fatigue, insomnia, breast tenderness, foggy headedness, memory lapses…all of these and more are symptoms suggestive of midlife hormone levels shifting. It is normal for hormone levels to decline with age, so one could say these symptoms are normal. “Normal” doesn’t necessarily mean “tolerable” or “acceptable.” For women who find the symptoms too much to bear, hormone therapy may be helpful.
The Continuum of Hormone Balance
When I talk with perimenopausal and menopausal women about hormone balance, I generally talk about a continuum of options which includes hormone therapy at one end of the continuum. We talk about lifestyle, stress management, exercise, nutrition, herbs, and supplements, too. When the vasomotor symptoms of midlife are unmanageable, meaning hot flashes and night sweats, hormone therapy may be indicated. Hormone therapy has risks and benefits that are best evaluated one woman at a time. Ideally, a woman and her practitioner engage in shared decision-making about whether or not hormone therapy is a good choice for her.
The conventional medical community’s response to hormone therapy has run the gamut from “every woman should take oral, synthetic hormone therapy” during the 90s to “all women should stop hormone therapy” on the heels of the findings from the Women’s Health Initiative (WHI) findings in the early aughts. The WHI findings have since been reevaluated, and the pendulum swings yet again. Hormone therapy is having a heyday as the benefits are being touted around social media and by celebrities. How does a woman know if it’s a good choice for her?
It’s imperative that the decision of whether or not to use hormone therapy is individualized. Cookie-cutter solutions to managing the symptoms of perimenopause and menopause, like birth control pills and PremPro, are a mechanized version of healthcare. As a midwife, I’m uniquely positioned and skilled at helping women tease out what’s right for them.
Risks and Benefits of Hormone Therapy
When I refer to hormone therapy, I am referring to bioidentical estrogen with or without bioidentical progesterone therapy. Like any medication, there are risks and benefits to hormone therapy. Risks of hormone therapy include estrogen-dependent cancers including breast, ovarian, and uterine; blood clots; and stroke. Advantages of hormone therapy include Alzheimer’s prevention, heart disease prevention, and osteoporosis prevention, as well as improved quality of hair, skin, and nails, improved sexual function, and improved bladder function. Plenty of women go through menopause without hormone therapy. The body is designed for this transition. Some women have particular symptoms or concerns that ask for intervention. The only ‘right’ answer is the one a woman determines is right for herself. The answer is a risk/benefit analysis for each woman to do herself with the guidance of a trained health care practitioner.
Are Bioidentical Hormones “All Natural” Or “Natural”?
Bioidentical hormones are hormones that are biochemically the same as what our bodies make. Bioidentical hormones are not necessarily the same as natural hormones because they are made in a lab. Using bioidentical hormones means the body can recognize and knows what to do with the entire molecule. I generally prescribe transdermal estrogen in the form of a patch because it is available through conventional pharmacies and bioidentical. Since it is given through the skin, it bypasses the stomach and the liver. Giving hormones through the skin, as opposed to orally in the form of a pill, is advantageous because orally administered hormones are first detoxified in the stomach, and then they go to the liver. If a woman has underlying gut issues, this may negatively impact the way her body breaks down hormones. Hormones are further broken down in the liver through a variety of processes that require we have the genes for those processes, and many women do not.
If a woman has a uterus, she positively needs to be taking progesterone along with the estrogen. The progesterone protects the lining of her uterus from the stimulatory effects of estrogen. I generally prescribe oral progesterone because it is available through conventional pharmacies, is FDA approved, is bioidentical, and works well on GABA receptors in the gut thereby reducing anxiety and supporting sleep.
For women whose symptoms are isolated to the vagina, i.e., vaginal dryness or painful sex, vaginal estrogen alone, i.e., without progesterone, is the treatment of choice. Vaginal estrogen is thought to stay local to the vagina, thereby not having systemic effects, good or bad. Every now and again, a woman who uses vaginal estrogen says to me, “And by the way, those hot flashes I was having, those are better, too.” So even though vaginal estrogen is thought to stay local to the vagina, I do see it have systemic effects in some women.
Guidelines For Prescribing
Once a woman and I complete a risk/benefit analysis of hormone therapy unique to her symptoms, family history, personal history, and preferences, I adhere to a few guidelines when prescribing:
I aim to initiate therapy within 10 years of menopause and before the age of 60.
I prescribe the lowest dose necessary for the therapeutic gain.
I use bio-identical hormones only.
I administer hormones through the skin unless otherwise indicated.
I prescribe hormones for the shortest duration of time.
Testing and Controversies
I recommend women test their hormones annually as well as have routine breast and pelvic exams, along with periodic breast health surveillance. There is controversy about the ‘best’ way to test hormones. Is it through serum, saliva, or urine? This is a huge topic worthy of its own attention. There is also controversy about the best time to initiate hormone therapy and how long should a woman stay on hormone therapy. These controversial issues will be addressed in separate blogs.
It is normal that our hormones decline with age. This is the natural order of things. There is nothing “wrong” with us that we feel this change in our bodies. This change may feel life-altering, undesired, and intolerable for some women. If you are one of those women, hormone therapy may provide relief! Work with a practitioner who is versed in the risks and benefits of hormone therapy, takes the time to look at your personal health history, and prescribes bioidentical hormones to minimize the potential risk of their use. It is your body, and you get to navigate this change in the way that works best for you.
As with all of the advice in my social posts, blog, etc., please consult with your healthcare provider before starting a new diet, fitness, supplement, or treatment regimen. This information is for educational purposes only and does not replace the advice of your healthcare provider.
You might think of these posts (or my book) as a way for you to start the conversation with your healthcare provider about the changes you're interested in implementing.