What Women Need To Know About HRT

While HRT doesn’t solve everything, it can certainly help you get into a place where you are not suffering and your effects with diet and exercise can have a greater impact.

You can sleep better, think more clearly, have a more fulfilling sex life, be less cranky, as well as support the health of your brain, heart and bones. Our fresh take and new research on HRT is a real win for women here in the 2020s and this is a good thing.

It is not without its risks, but for most women, when guided with the help of a knowledgeable provider and a greater understanding of how HRT fits into their larger health and fitness plan, it can be a real win.

This article will clear up some confusion about vaginal estrogen vs. an estrogen patch, what you can expect HRT to do for you and what it is less helpful for and insight into common side effects.

 

But first 3 things Iwant women to understand about HRT:

HRT is a piece of the puzzle but it is not the puzzle. There is simply so much more to this phase of life than HRT, though it dominates the conversation. Midlife is 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.

 

Blood sugar, gut health, stress and cortisol, nervous system dysregulation, exercise, nutrition, and inflammation are vital to address as part of your midlife plan with or without HRT. If you are doing HRT, these other aspects can help reduce risks associated with HRT, to optimize the benefit of HRT and help you thrive and feel your best. Exercise, sleep, nutrition and stress management are all still very important, we sadly can’t just slap on an estrogen patch and forget worrying about eating our protein and veggies. I know, I wish it was all easier but turns out we never get out of having to take care of these bodies!

 

HRT is not mandatory and is not appropriate for every woman. HRT isn’t going to be the answer for every woman for a variety of reasons including unique risks, family history, goals and preferences. There is still a host of support from nutrients and botanicals to nutrition, exercise and lifestyle that can be very helpful and women deserve all the options and all manner of support available.

HRT fixes a whole lot of things HOWEVER it doesn’t fix everything.  HRT is a good thing, but it’s not everything.I have these conversations on the podcast so be sure to check out weekly episodes of the Dr Brooke Show,

 

Terminology + Options For Using HRT In Perimenopause & Menopause

Systemic vs. Low Dose Topicals

Systemic hormone therapy is a dose of hormone (estrogen, progesterone or testosterone) that is give via oral pills, topical creams, gels and sprays or a transdermal patch as well as inserted pellets. Systemic treatment will get hormones to your entire system from brain to bone to heart to vagina at levels that will both relieve symptoms and optimize health of tissues such as bone and heart.

Most over the counter hormone products available for both estrogen and progesterone are not high enough dose to get systemic levels where they need to be in order to protect bones, heart and brain health. They may be high enough for our younger years (i.e. OTC progesterone cream) and to initially alleviate some perimenopause symptoms like hot flashes (i.e. estradiol and progesterone cream). However it is always wise to use hormones only under the guidance of an expert.

Low-dose topical products that are not over the counter but available with a prescription include estriol (a weaker estrogen than estradiol) face creams and vaginal estradiol. Both of these options work locally and are not thought to increase systemic estrogen levels in any meaningful way. Estriol face creams contain a weaker estrogen and likely will not help with symptoms such as hot flashes and certainly will not provide doses high enough to offer systemic protein to bone, heart, brain, etc. Estriol face creams also will not usually cause any high estrogen side effects like breast tenderness, mood swings, etc.

Vaginal estrogen given via creams, tablets or an inserted ring, is absorbed locally the vaginal and vulvar areas and is very helpful in treating menopausal symptoms of painful sex due to vaginal dryness, incontinence and recurrent UTIs. This application is unlikely to help with symptoms such as brain fog or night sweats or provide protection to heart, brain and bones because systemic levels typically do not rise with low dose vaginal estrogen. However, some women do report breast tenderness or other side effects when they use vaginal estrogen and this may be because their dose is too high or they are struggling to metabolize even low dose estrogen. So despite what you hear on Instagram, if you feel your systemic symptoms have changed using a topical hormone it’s wise not to ignore that and speak with your provider about it.

There are also some over the counter products available for various hormones including estrogen, progesterone, and pregnenolone, DHEA. These tend to be lower dose but still can carry some risks. I cover these types of products and common hormone supporitve supplements in this FREE guide.

 

MHT vs. HRT

You will hear the abbreviations MHT (menopausal hormone therapy) and HRT (hormone replacement therapy) used interchangeably and many online experts treat them as the same thing.

On the flip side you will hear certain menopause experts loudly espouse that we should only be using the term MHT because menopause is a normal progression of ovarian decline and not something that needs to be replaced so to speak.

Hormone replacement is technically only referring to replacing hormones when your body can no longer make them but should be able to. For example, if your thyroid can no longer make adequate thyroid hormone and you are given medication like desiccated thyroid or Synthroid. Or if your pancreas is not able to make the hormone insulin as in type I diabetes, you would be prescribed the hormone insulin.

These are cases of true hormone replacement. As well if you are in your 20s or 30s and are not getting a period and diagnosed with hypothalamic amenorrhea and given estrogen and progesterone this is considered replacement therapy as your body in these reproductive years should be making these hormones, but isn’t.

HRT though is a term that has long been used to describe using estrogen, progesterone and testosterone for women in perimenopause and into menopause as well.

Menopause hormone therapy on the other hand is used to describe using estrogen, progesterone and testosterone to treat lower levels of hormones that are typical during perimenopause and menopause when your ovaries should be slowing production as we age into the menopause time. Experts argue that the term HRT should only be used when the loss of hormone is a pathology vs. a normal transition of hormone decline such as midlife.

A key difference though is that MHT is aimed at treating symptoms of perimenopause and menopause, like hot flashes and is typicall intended to be used only temporarily with the lowest dose of hormone possible; whereas experts preferring the term HRT in this same phase of life generally have a slightly different goal.

Many proponents of HRT over MHT consider the hormone decline or deficiency during midlife to be normal or expected as our ovaries age but still something to be corrected in order to optimize function and longevity. This can mean higher, more physiological dosages being used to achieve higher levels of hormone vs. a dose just high enough to manage a symptom like a hot flash. These higher doses can mean that a woman continues to bleed or cycle as this approach to HRT might more closely try and mimic the traditional cycle.

More on cycling HRT regimens in this article.

But please know that not all experts agree on these terms and what is most appropriate, so for the most part you will hear them used interchangeably to mean using estrogen, progesterone and testosterone during the midlife hormone decline to both manage symptoms.

As well, your goal matters: are you merely aiming to use hormones for a shorter period of time during perimenopause and alleviate symptoms? That is reasonable and of course, your choice. Other women might want to treat the insufficiency of hormones during perimenopause and the deficiency of hormones in menopause with the goal of reasonably trying to bring their hormones up to levels and rhythms of their younger years and remain on hormones longer than 5-10 years. Also reasonable and is a viable choice.

Your unique risks and goals should be taken into account as you create a customized plan with your provider that meets your needs and preferences while honoring your health as a whole.

 

Should Every Woman Take Hormones During Midlife & Menopause?

Using hormones is an assessment of risk vs. benefit. While I am grateful for the conversation happening around women and using hormones in midlife and that we have a better understanding of the actual risks and not the overblown cancer concerns from the WHI (Women’s Health Initiative), the accessibility of hormones online without proper guidance is worrisome. The impact of influencers and experts online making every woman feel they must get on some estrogen and the earlier the better can lead to bad practices and sadly a targeting of women in a vulnerable stage of life. This isn’t a good thing.

Women need a knowledgeable provider that knows how to treat your individual goals, risks and unique hormone situation with appropriate, safe and effective hormone prescriptions as well as lifestyle support. You need an appropriate dose (not too high and not too low) that alleviates symptoms and is offering protection against things like osteoporosis, that’s step one.  Step two is understanding how HRT fits into the rest of your plan for midlife: supplements, nutrition, sleep, exercise, etc. Women deserve this type of holistic support.

While there is some risk to HRT as with any medication or medical intervention, there is risk in not taking HRT when appropriate as well. I cover both cancer and cardiovascular risk in greater detail in this article

Women need to know that taking hormones during perimenopause and menopause can be life changing in terms of symptoms and risk reduction but despite how social media and popular books spin it, HRT or MHT is not the only part of your mid life puzzle.

I have a bigger conversation about midlife on The Dr Brooke Show, particullary in part I and part II of Midlife Is More Than HRT. I also put it all together for you in this FREE guide.

Part of what I do in my practice is not only helping women get on the right combination and dosages of hormones but to ensure maximal benefit with minimal side effects and risk. This means supporting clearance of hormones via the liver and gut, optimizing nutrients to support hormone utilization and metabolism, making targeted recommendations for diet and exercise to support women through this time and providing the tools to strategize and be resilient in the face of the unique stressors of midlife.

Women need comprehensive, expert guidance with this phase of life, there’s simply too much at stake.

 

Side Effects Do Happen on HRT

Among the most important things I help women with in my practice is dialing in their diet, lifestyle and supplements to minimize side effects from their HRT providing them with the benefit without the troublesome symptoms.

Most often when side effects occur a woman notifies her provider and her dosage is changed, however that’s not always the next best step! Sometimes that’s the right call but often it’s the metabolism or breakdown of these hormones, the ratio and balance between estrogen and progesterone, the need to get estrogen balanced before adding testosterone that needs to be dealt with first. Sometimes it’s simply a matter of dialing in supplemental support as well as fine tuning diet, exercise, stress management, etc.

Before you change doses it’s wise to know more about the bigger picture because it doesn’t always mean you need a lower or higher dose. In fact, women in my practice have told me they actually didn’t tell their prescribing doc about their symptoms because they were afraid their provider would lower their dose. Don’t take away my estrogen! I get it, but again we don’t always need to take it away, we just need to support it better.

 

What HRT Option Is Right For You?

With so many options from pre-made, FDA regulated hormones you pick up at your local Walgreens or CVS to compounded formulas made by a compounding pharmacy and all of those coming in a variety or delivery forms ranging from patches to creams to pellets to pills, it can make a woman’s head spin. Not to mention the question of synthetic hormones vs. bioidentical hormones when it comes to efficacy and safety.

With so many experts online it can be hard to sift through the overwhelming amount of information, opinions, fear and dogma –  it would be weird if you weren’t confused!

I cover some common questions and other importnat HRT topics in these posts:

The Trust About Compounded Hormones

Understanding Bioidentical vs. Synthetic  Hormone Therapy

The Pros & Cons of Pellet Therapy For HRT

 

Fine tuning HRT regimens, exploring options, maximing benefit while minimzing side effects is what I do in my practice so reach out!