WTF to think about hormone therapy

Photo by Lucie Hošová on Unsplash

I recently interviewed a well-known academic, doctor, and expert on hormone therapy. Off-camera, she shared her candid thoughts with me.

“When hormone therapy first came out, everyone wanted to put it in the water. Then people got scared off by the Women’s Health Initiative in 2002. Now, someone has spotted a gap, and they want to put it in the water again.”

This expert has practiced for decades through these pendulum swings. Her point is that the truth is far more nuanced. You may have heard that hormone therapy is essential, that it can bring women back to life, or even help people live longer.

On the other hand, you may have heard that hormone therapy causes cancer, and that things need to be really bad before you should consider it. Add to that our personal views — whatever they may be, like “I’m way too young to need this!” —and what the women in your family might have told you about it, and it all gets very confusing.

No matter how you think about it, or even if you’ve never thought about it before, it’s worth taking the emotions out of it and learning a few basic truths so you are prepared to make informed decisions.

Hormone therapy 101

» Hormone therapy is prescribed to help women with their perimenopause and menopause symptoms, often in the form of estrogen, progesterone, and testosterone. While early hormone therapy formulations were made from the urine of pregnant horses (conjugated equine estrogens), most current formulations are derived from yams and are “bioidentical,” meaning they are chemically identical to the hormones our bodies produce.

» Bioidentical estrogen is available in patches, pills, and creams; bioidentical progesterone comes in creams and pills; and testosterone is typically available in creams applied to the skin.

» Hormone therapy (estrogen and progesterone) is recommended by many leading health organizations worldwide as a safe and effective option for treating a range of symptoms, from sleep and mood disruptions to hot flashes and night sweats.

» Many women swear that it helps in other ways, such as boosting energy or helping with weight management. It’s also recommended for treating some symptoms during perimenopause, although many doctors are still unaware of this.

» The birth control pill is sometimes prescribed for perimenopause symptoms, but it’s not hormone therapy; it contains far higher doses of synthetic hormones, and shuts off ovulation. The progestin-containing IUD can also be prescribed for heavy bleeding in perimenopause. It’s not hormone therapy either.

» Testosterone is becoming increasingly popular among women for various reasons, including combating fatigue and brain fog. However, current scientific evidence only supports its use for addressing low libido, and there is a large placebo effect.

» There are also less-researched forms of hormone therapy, such as DHEA, which some women find helpful, or just to feel better; there is not enough hard data yet to support this and it’s much more likely to be an option recommended by a naturopath, naturopathic doctor, functional medicine specialist or integrative physician. Someone who treats the whole person, and is often on the cutting edge. DHEA is not available in some countries; in others it’s treated as a supplement.

» Hormone therapy is produced commercially in FDA-approved (or the equivalent regulatory body) large batches – estradiol and oral micronized progesterone – by pharmaceutical companies. In most countries testosterone is not produced for use in women, so is used off-label and not covered by insurance.

» Compounded hormones are produced in pharmacies that are regulated, by qualified pharmacists. But since the batches themselves are bespoke in the form of specially prepared creams, the individual doses are not and can’t be.

» People turn to compounded hormones when the commercially available versions have ingredients they can’t tolerate or don’t want – peanut oil in the progesterone, for example – or to include things they don’t have, like estriol, for example. This is something Dr Leigh Erin Conneally talked about on the Hotflash inc podcast.

Hormone therapy should be respected

» As a good friend of mine is fond of saying, “estrogen makes things grow”.

» One crucial point: If you have a uterus and are prescribed estrogen, you need to take oral micronized progesterone or a progestogen to protect your uterus.

» Even if you don’t have your uterus, you should probably also take progesterone. (Not medical advice, just common sense.) Why just take estrogen? You walked in to the surgery with both hormones, didn’t you? Believe it or not, there are still women getting hysterectomies who are not being given hormone therapy. Many more not being given progesterone. And no one is talking about the possible associated increase risk in ovarian cancer with taking only estrogen when you don’t have a uterus.

» There are risks and side effects associated with hormone therapy (see below), so it’s essential to do your own research and consult your doctor before making a decision.

» It’s also important to keep track of how you feel when you go on hormone therapy, perhaps in a journal. When women in my community talk about side effects, they often sound similar to menopause symptoms, making it difficult to discern what’s going on. And as Dr Vikram Talaulikar told us on the Hotflash inc Podcast, it can take about four months on average to iron these things out.

» When prescribed by a knowledgeable healthcare professional and within a 10-year “window of opportunity” from the onset of menopause, hormone therapy can be a safe and effective option, according to recent guidelines from the International Menopause Society.

» There is a risk of bleeding with high doses of estrogen, as well as mid and long-term risks of endometrial hyperplasia and uterine cancer in women with a uterus if it’s not properly opposed with progestin/progesterone – and as we know from the recent BBC Panorama documentary. In April the British Menopause Society issued an alert on this topic.

» As for the unnecessary amount of testing that goes on, the British Menopause Society was clear: “There is no recommended systemic level of estrogen in association with use of HRT and response to treatment with HRT should be based on symptom control. Checking serum estradiol levels is influenced by many factors including the timing of the dose and type of assay and cannot be assumed to be indicative of levels over a 24-hour period.”

Hormone therapy can’t fix everything

Now, about the “putting it in the water” thing.

A new wave of social media-savvy influencers is raising awareness about menopause while enthusiastically promoting hormone therapy. I like to call them “estrogen maximalists”. Many of the Doctor Menopause Gurus people are listening to now are – in my opinion – strangely obsessed with estrogen. Their lack of attention to, care for, and lack of knowledge about the role of bioidentical progesterone pr-, peri- and post-menopause is unsettling.

If you listen to this group, not only can menopause hormone therapy help with symptoms, but it can also prevent dementia, heart disease, and even help us live longer. I’ve seen these doctors flat-out say ‘no’ when followers on social media ask if there is a risk of breast cancer.

The message, at times, is that it’s dangerous not to take hormone therapy.

The message is that we are ‘deficient’ without it.

This, however, could not be farther from the truth.

This is where it makes sense to pay attention to what the world’s guiding bodies say – and not just one of them. Luckily we have a lot of fresh guidance about hormone therapy.

The International Menopause Society has issued a white paper on hormone therapy for Menopause Awareness Month, with the express goal of preventing a further polarizing of views. I urge you to read it for yourself, here. It’s very well done, and addresses many of the things I’m always complaining about, including how progestin and progesterone aren’t the same and aren’t separated out in research, and they should be; how the findings in the Women’s Health initiative were “overblown” using a common tactic in presenting research (relative versus absolute risk, a topic of an upcoming post), and that menopause has been around since the beginning of time.

As for those risks and benefits of hormone therapy – ie does it cause breast cancer? Will it prevent heart disease? Or does it cause it? What about dementia? – this is what they have to say:

“Given the ongoing controversy, there is clearly a need for a definitive long-term randomized clinical trial where conven-tionally regulated bioidentical/biosimilar MHt is started in women at the usual age of menopause and followed for long enough and in sufficient numbers to assess major outcome measures such as cardiovascular and breast cancer events. Unfortunately, the costs of such a trial would be prohibitive, making unbiased recommendations based on the current literature all the more critical. Continued collection of high-quality, prospective observational registry data may be the best compromise solution.”

The Menopause Society of North America put out an alert this week correcting hormone therapy “misinformation”.

“Based on existing science and clinical evidence, estrogen-containing hormone therapy is not recommended for

• Primary prevention of cardiovascular disease or dementia in women who experience menopause at the average age

• Management of musculoskeletal conditions outside of osteoporosis risk reduction (eg, arthritis, joint pain, frozen shoulder, etc)

• Prevention of aging

• Management of other primarily age-related changes (eg, hair loss, skin changes, weight gain, etc)

This prompted one DMG to make a head-scratching Instagram post that said simply “Weaponization of Guidelines” with a caption that seemed to suggest that a body charged with providing guidelines to practitioners reminding them of what the guidelines are was somehow an ominous thing to do, so close to an election year. It has now been taken down, which is a good thing. When a doctor with massive influence suggests that the guiding body, based on the research, is to be ignored, we have problems.

I’m not a fan of how Dr Jen “Debunker” Gunter, an American obstetrician-gynecologist and author of The Menopause Manifesto, bullies and takes people down, but she’s the most vocal counterweight to the current outsized claims that doctors who should know better are making.

Many smart researchers back her up, as do all the guiding bodies in the world. We need our hormones when we are supposed to have them. Whether we want to top them up after menopause is up to us. One day, we might have that prevention and longevity data — and hormone therapy might be seen as the ultimate biohack — but that day is not today. If you want to try it out for those reasons, just know that. And don’t let anyone try to FUD you into it.

In the meantime, there are many other proven ways to prevent disease: reversing insulin resistance and pre-diabetes, getting good sleep, regular movement, eating nourishing, whole foods, spending time in nature, and cultivating solid, connected relationships.

The best way to get through this is one step at a time, slowly taking responsibility for it. Because that, my friends, is exactly what you are being called to do.

AMx

Additional sources:

• The 2022 hormone therapy position statement of The North American Menopause Society

• The British Menopause Society Toolkit

• Australasian Menopause Society Practitioner’s Toolkit for the Management of Menopause

• European Menopause and Andropause Society Guidelines and Education

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