If you’re here on my site you are likely more holistically minded and because of that, you might be leaning towards bioidentical hormones as the most natural option for HRT, and you’d be right.
Right now HRT (hormone replacement therapy) is really back in fashion, which is great. Far too many women have been scared that using hormones during perimenopause and menopause would inevitably give them cancer and/or worsen their cardiovascular health. This fear was generated by the findings of the Women’s Health Initiative or WHI from 2002. The good news is that we know now these findings are misinterpreted and our fear around HRT is largely unfounded.
The findings of the WHI have cast a scary shadow over using hormones during perimenopause and menopause for over 20 years now, creating much fear and confusion, and it warrants a closer look. I cover what the WHI was actually looking at, how we came to flawed conclusions and current thinking on cancer and cardiovascular risk related to HRT for women in menopause and perimenopause in greater detail in this post.
One of the most important distinctions to make is that the hormones used in the WHI studies were not the same as what’s typically used in modern hormone therapy for women today. The hormones used in the WHI that did show some cancer risk were synthetic estrogen and synthetic progestin (not the same as progesterone), and it is bioidentical hormones that are predominantly used today. As well, the hormones given in the WHI were oral and that is not the currently preferred way to give estrogen today, as oral estrogen carries a higher risk of clotting.
Different hormones and different delivery methods make the new landscape of HRT very different these days and is considered to carry a much lower risk and confer many benefits. Of course, it should never be a one size fits all women approach and each patient needs to have their personal and family history, goals and risk factors taken into consideration so that risks and benfits can be individually weighed.
During all this confusion though with the WHI findings, there has been some misinformation and misunderstanding about where a woman can get bioidentical hormones with many women thinking they have to come from a compounding pharmacy.
The truth is you have a lot of both FDA regulated and compounded options for your bioidentical HRT and this article will help you understand all of them and why it matters. If you’d rather listen, I cover it in this episode of The Dr Brooke Show.
You will see me use the terms HRT and MHT interchangeably although they are thought to mean different things to different experts. Currently, most conventionally minded experts prefer the terms MHT (menopause hormone therapy) over HRT (hormone replacement therapy) because HRT implies replacing a hormone that is deficient but should not be. Experts in this camp feel taht MHT is more accurate because hormone decline is a normal progression in midlife. Their position is that during the menopause transition ovaries will naturally stop making sex hormones, thus they truly don’t need to be “replaced” in the same way thyroid hormone for example would need to be replaced if your thyroid gland could not make it.
As well, some experts suggest there is a different goal in mind with MHT vs. HRT. MHT generally aims to use the lowest dose possible for the shortest time possible to alleviate symptoms like hot flashes as a main goal. This approachs uses hormones only temporarily through the midlife transition to manage symptoms. Whereas other goals for a woman might be improving overall quality of life, lowering risk for chronic health issues and boost a woman’s hormone levels higher than just those needed to alleviate a hot flash, but rather restore function and vitality. When higher levels of HRT used, the goal isn’t merely to survive the symptoms of perimenopause and menopause but to provide better wellbeing and improve longevity.
These strategies illustrate different goals of therapy as well as expectations for treatment but I will use them interchangeably here as most women are more familiar with the term HRT and your particular goals for using hormones during perimenopause and menopause should be discussed with your prescribing doctor.
What Are Bioidentical Hormones?
Hormone medications used for MHT and HRT come in both synthetic and bioidentical forms and these both come in a variety of different delivery options from patches to creams to pills. This matters because the risks and side effects can vary between all of these various options.
Synthetic hormones are artificially created compounds designed to mimic the effects of our own hormones. While they share similarities with the hormones our bodies make, their structure is not identical and this influences how these types of hormones will interact with our hormone receptors. These differences create some issues with their efficacy and potential side effects as well.
Bioidentical hormones on the other hand are structurally identical to our own hormones and are derived from natural sources. Having the same molecular structure as our own hormones means they more closely mirror the function of the hormones we produce compared to synthetic hormones.
The most commonly prescribed synthetic hormones as part of HRT are conjugated equine estrogens (such as those found in Premarin) and synthetic progestins (such as Provera and various progestins found in birth control pills as well as hormone secreting IUDs like the Merina or Skyla). Bioidentical hormones prescribed include testosterone, progesterone, estradiol and estriol.
Both bioidentical and synthetic hormone preparations come in a variety of delivery forms including oral pills/capsules, topical gels and creams, transdermal patches, troches and pellets.
Where Can You Get Bioidentical Hormones?
You need to be working with a licensed provider to prescribe estrogen, progesterone and testosterone whether they are going to be compounded or are from your local pharmacy.
It’s a common misconception that bioidentical hormones are only available from compounding pharmacies. While once the case, there are now bioidentical options available via FDA regulated products as well.
There is a lot of misinformation about compounding pharmacies out there. Claims that they are unregulated or unsafe are largely unfounded and they are an important part of the bigger conversation about getting women HRT options that work for them.
I cover how compounding pharmacies are regulated, what fears we can let go of and when we should utilize them in this article.
This is an important topic and one I feel very strongly about, perhaps because I was a pharmacist before becoming a naturopathic and functional medicine doc, but also I feel this issue of compounding pharmacies being unregulated is one more way fear and divisiveness is created in this HRT and midlife conversation. This kind of black and white stance with no nuance only does a disservice to women trying to understand what their options are and what choices are best for them.
While most women using HRT are using forms and dosages that are available only with a prescription, there are some lower dose bioidentical options for progesterone and estrogen available online and over the counter as well but it’s not recommended to use any hormones without expert guidance and there is far less oversight with an over the counter hormone preparation.
For progesterone, over the counter creams can be adequate for low progesterone in our 20s and 30s but higher doses and often oral forms will be needed to alleviate insomnia and anxiety for most women in perimenopause. As well, over the counter topical progesterone products are not adequate to protect a woman’s uterus if she is taking estrogen as part of HRT.
Bioidentical estrogen creams are also available from a variety of online retailers and hormone experts. While we do not need to fear estrogen the way we did 25 years ago, it is still very unwise to use estrogen without the guidance of a professional as there are still risks and monitoring is very important. If you try some topical over the counter progesterone cream the side effects might be uncomfortable but not life threatening: bloating, headache, irritability, grogginess, breast tenderness. However, risks with estrogen, while smaller than we thought, do exist and we need to ensure proper dosing and metabolism. As well, over the counter estrogen products tend to be too low a dose to get systemic levels high enough to protect your bones, brain, heart, etc. even though they may temporarily work to relieve some symptoms such as hot flashes in the short term.
Lastly, bioidentical DHEA and pregnenolone are also available over the counter. Because these hormones convert to both testosterone and estradiol it isn’t recommended to use either of these hormones without some guidance and proper testing.
For more on DHEA and pregnenolone and their uses as part of your bigger HRT plan check out this episode of the Dr Brooke Show.
There are also a host of herbal and supplemental products available without a prescription that while not actual hormones, with a few exceptions, that can help hormone related symptoms during perimenopause via a variety of mechanisms. I cover all of that in this article.
Delivery Forms For Bioidentical & Synthetic HRT Formulations
Both bioidentical and synthetic estrogen are available in a variety of delivery forms including patches, creams, gels and oral pills.
Progesterone is available in oral capsules, troches and creams. There are a lot of options and what is best for you given your goals (i.e. oral progesterone is better for sleep typically than topical progesterone), your sensitivity or preferences (i.e. it’s not common but some women don’t do well on oral progesterone, some women’s skin is sensitive to patch adhesives) and safety (i.e. oral estrogen isn’t ideal due to an increased risk of clotting not found with transdermal).
I cover sensitivity to progesterone on this episode of the Dr Brooke Show. It is a great listen if you don’t feel well taking progesterone and have been wondering why when your girlfriends absolutely love i.
There is also bioidentical hormone therapy available via pellets that are inserted below the skin. These are my least favorite way to give hormones for a woman for a few important reasons. I cover pellet therapy in more detail in this article.
Is HRT The Miracle It Seems To Be?
It certainly can help women feel much better, reduce risk of all cause mortality (which is huge) and increase their quality of life significantly.
It’s not without risks but it is an important consideration for midlife and should be discussed in detail with a knowledgeable provider and monitored appropriately.
It should never be a one size fits all, protocol approach and sadly, it doesn’t fix everything.
There is a lot to unpack about using HRT in perimenopause and menopause and while bioidentical hormones are a very important part of the puzzle there are three things I want all women to know:
HRT is a piece of the puzzle but it is not the puzzle.
It simply isn’t as easy as slapping on an estrogen patch and calling it a day. Metabolism of our HRT medications via the liver and gut varies woman to woman based on genetics and other lifestyle inputs. We can support breakdown of these hormones with the right nutrients and even dietary strategies. As well, blood sugar, gut health, stress, lifestyle, exercise, nutrition and inflammation are vital to address as part of your HRT plan or without it in order to reduce risks associated with HRT, to optimize the benefit of HRT and to overall thrive and feel our best.
HRT is not mandatory and not appropriate for every woman. Yes, I said what I said. Contrary to what you see online, HRT isn’t going to be the answer for every woman and those women needn’t suffer with no support because for whatever reason HRT isn’t right for them. Using herbs and nutrients is not the same as HRT, as well eating broccoli or a carrot is not an adequate substitute for an estradiol patch BUT there is merit in these other resources both with and without HRT and by all means, women deserve to have all the options and all the various types of support available to them.
Lastly, HRT fixes a whole lot of things and I’m so grateful it’s been such a win for me personally and so many of my patients as well, HOWEVER it doesn’t fix everything. Midlife is still a major reckoning where women come face to face with their past choices, their finances, their changing body, their every shifting relationships and most often with the pressure of growing children, aging parents and evolving (and often scary) career demands.
I’ll say it again: midlife is not for the faint of heart! HRT is a very important conversation to have, but we need a bigger conversation. We need to talk about nervous system retraining, healing on a deeper level, finances, relationships, nutrition, exercise and ALL the other stuff that in my experience is so helpful for this phase of life.
I have that conversation often on The Dr Brooke Show (like in this part I and part II) and have put it alltogether for you in a FREE Guide you can grab here.
References
The Use of Compounded Bioidentical Hormone Therapy
Does hormone replacement therapy (HRT) increase the risk of cancer? | Cancer Research
Hormone Replacement Therapy: Would it be Possible to Replicate a Functional Ovary?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214095/