Hormone Replacement Therapy

I have been consulting concerning Hormone Replacement Therapy in pre-menopausal, peri-menopausal and menopausal women since 1992. I have a great deal of experience in this area. Much too much to put it all down here. When you see me you will have the advantage of all that experience.

What Are The Symptoms Of Menopause?

menopausal women Symptoms of early peri-menopause:

Changes in the pattern of your periods; sleep disruption
Less interest in sexual intimacy and more difficulty reaching orgasm
Anxiety
Emotionally very sensitive with unexplained heightened emotions

Symptoms of late peri-menopause and menopause:

All of the above plus:
Hot flashes
Night sweats
Inability to stay asleep through the night
Pain in joints, especially in our feet
Mental confusion or “foggy brain”
Fatigue, especially in late afternoon
Decreased interest in sexual intimacy
Difficulty responding to sexual intimacy or to climax
Dry or uncomfortable vulva and/or vagina
Lack of lubrication with sexual intimacy
Unexpected loss of urine (incontinence)
Increasing belly fat and inability to lose weight.

Menopause is a normal process, not a medical problem unless the symptoms disturb you and disrupt your life.

Why Do I Need Hormone Replacement Therapy (HRT)?

Many women experience no challenge during their experience of the change. They accept the hot flashes and interruption in their sleep without much difficulty and make the transition. You need HRT if you are having symptoms that disturb the quality of your life. You might need HRT if you have tried herbal approaches without success No one but you can tell if you find the symptoms associated with menopause intolerable.

What Kinds of HRT Are Available?

There are three natural estrogens that we create in our bodies and one kinds of synthetic estrogen. They are:

17 Beta Estradiol: Is what our ovaries produce and what we refer to as human identical hormone.
Estrone: Is made as the body breaks estradiol down in our intestines and our fat. I believe estrone is a very important hormone in menopausal women. However Western Medicine has focused almostcompletely on estradiol. Estrone may be the pantry for Estridiol, the ovary converts Estrone to Estridiol. Estrone is about equal in amount to estradiol during our menstrual cycle. Once we become menopausal, estrone becomes about three times higher than estradiol.
Estriol: Is a weak estrogen that is produced as estrone is broken down in the liver. Estriol does not affect breast or uterine tissue in most women. We can use estriol in menopause to potentiate the effect of estrogen replacement therapy in order to decrease the risk of cancer from estradiol use. Studies have shown that if the estriol/ estradiol and estrone ratio is balanced, there is less risk for developing gynecologic cancers. Estriol can be used as a vaginal cream to reverse the effect of low estrogen in the vagina and urethra.
Conjugated equine estrogen(CEE): Is an intense synthetic estrogen that is very effective in controlling menopausal symptoms. It is known as Premarin or Cenesta. The problem with CEE is that it has forms of estrogen that our body is not designed to deal with and has side effects that human identical estrogen does not.
Estrace is also a synthetic estridiol. It is closer to our natural form and it is sythetic

The following is a list of other hormones that are involved in menopause:

Progesterone: Is a hormone produced by the ovaries after ovulation to prepare the uterine lining for pregnancy. I believe progesterone does much more. Women who take progesterone often sleep better, have less PMS and feel more at home in their bodies. Correct levels of progesterone affect the estrogen receptor, making it more receptive to estrogen. Too much progesterone can block estrogen receptors making our estrogen less effective.

Testosterone: Is referred to as a male hormone; however we women don’t do well without it. Our levels of testosterone are about 1/100th of a man’s. Testosterone is frequently the first hormone that is deficient in early peri-menopause. It can also become deficient in women taking oral contraception. Low levels of testosterone cause worsening changes in lipid profile, fatigue( especially in mid-afternoon), loss of muscle mass with resultant decrease of our metabolism, loss of thinking about and desire for sexual contact, difficulty in having orgasms, discomfort in your vulva and problems with thinking clearly.

DHEA: Is an adrenal hormone that naturally declines as we age. Highest normal levels occur in our 20’s. Literature from anti-aging research suggests supplementing with DHEA helps with physical stamina. In my experience, the majority of women users have no improvement on DHEA. However it helps a small percentage of women have better stamina and less hot flashes. DHEA has been used for menopausal symptoms in women who cannot use estrogen. I believe it works by conversion in our bodies to Estrone.

I do not use DHEA in women who are at risk because of cancer, heart disease or clotting without a baseline test for estradiol and estrone. I ask for a follow up in six weeks with another set of blood work to verify that estrogen levels remain unchanged.

Pregnanolone: Is the precursor hormone from which all other hormones are made. Claims are made that Pregnanolone helps memory, mood and feelings of well-being. It helps reduce stress induced fatigue. In the past, I inherited an influx of patients from a retiring MD who were taking pregnanolone and noticed no improvement in their symptoms. I rarely prescribe it.

Thyroid: Is a very important group of hormones for peri and menopausal women. When our thyroid is not working, our sex hormones are affected as well. Symptoms usually considered to be menopausal can also be caused by thyroid dysfunction. Low thyroid causes fatigue, weight gain, mental confusion, dry skin and hair loss. Overactive thyroid causes anxiety, hot flashes and heart palpitations. About 50% of women over 50 years old have some form of thyroid dysfunction. If you are menopausal you should know if your thyroid is working normally by having blood work. [thyroid testing]

What is the best way to take HRT?

There are many ways to take hormones. Each hormone has individual ways that make it better or problematic.

The following is a discussion of each hormone and why there is a preference for a way of taking it. Keep in mind that what works for the majority may not be what works for you. HRT is a personalized, customized process. All hormones need to be evaluated after you use them to ascertain effectiveness and dosage.

Estrogen: In women estradiol is made in our ovaries and is converted to estrone in our intestines and fat. In menstruating women estrone is usually about equal to estradiol. In menopause estrone is usually three to seven times the amount of estradiol. It may be that estrone is the form of estrogen that causes many of the unwanted side effects of HRT.

Pills: I avoid giving Estradiol as pills, or placing transdermal creams or patches over fatty areas of the body such as belly, thighs and hips. Intestinal bacteria and our fat is how we convert estradiol to estrone.
Troches: I also avoid troches. These are waxy squares of hormone that dissolves in the cheek and are supposed to be absorbed through the mucous membrane of the mouth into the blood stream. In my experience however, women using troches have a higher estrone/estradiol ratio. I believe this is because most of the hormone is swallowed in our saliva and ends up in our intestines.
Trans-Dermal Creams: THE PROS: For someone starting, HRT creams are a good approach. when applied to areas such as forearms and ankles that have a lot of blood vessels and little fat. Estradiol is easily absorbed through skin into the bloodstream. THE CONS: Some women do not absorb hormones well through their skin. The circulating amount of hormone initially goes up and then gradually comes down over 12 hours, with another spike after the second application at night. Some women object to the creams because they consider them messy. If you have pets, children or a sexual partner who have extended contact with the part of your body where you apply the cream, they may get a dose of the hormone as well. (Pets can pick up the cream on their fur and ingest it when they lick to groom. Hormone transfer to another is uncommon although it is a theoretical possibility.)
Patches: THE PROS: Patches are convenient with bi-weekly or weekly applications. Dose is exact and steady through 24 hours with a mild increase as we are more physically active. THE CONS: Some women react to the adhesive and develop a rash under the patch. For this reason I tend to prescribe a patch that is smaller and is changed twice a week. Patches may leave a small amount of adhesive on the skin. Some women find the patches do not stay on. Some women do not absorb estrogen from the patch.
Vulvar Creams: The lips of the vagina are called the vulva. The vulva has a lot of blood supply, very little fat, no hair and is a good place to apply HRT. The vulva is close to all your sex organs and so offers a higher dose of estradiol to the uterus and ovaries. If you still have your uterus and ovaries, this may be a concern because of risk for ovarian or endometrial cancer.
Vaginal Cream: Is placed in the vagina with an applicator. There are two kinds of vaginal creams. One is used for local effect in the vagina and is a low dose. The other is used for systemic effect and is a higher dose. THE PROS. It absorbs well through the vagina while decreasing dryness, painful intercourse and urinary incontinence. THE CONS. For systemic HRT, using creams twice a day can be messy, and if you are having intercourse may expose your partner to estrogen. Vaginal creams used for the vagina only are of a much lower dose and do not carry the same risks.
Injections: I have never used estrogen injections with clients so I have no experience with this method, pro or con.
Pellets: Are small tubes of compressed hormones and contain nothing else. They are inserted between the skin and muscle of your hip or belly. THE PROS. They last 3-5 months. Pellets most closely mimic the natural production of hormones in your body. Most HRT will handle symptoms of menopause such as hot flashes and interrupted sleep. Pellets seem to help women feel good in a way that other modes of replacement do not. THE CONS. They tend to be more expensive than other forms of replacement. Once they are inserted they cannot be removed. To get the correct dose we do two sets of blood work, before and six weeks after insertion. In the first six weeks of pellets, the amount of hormone can cause effects that will resolve once your body adjusts.

Progesterone:

Cream: THE PROS: Progesterone cream is very effective, easy to use and relatively inexpensive. THE CONS: Progesterone can accumulate in your fat decreasing its effectiveness. This will not necessarily show in your blood test. Saliva testing can be inaccurate because of contamination from the cream on your hands and a possible interaction with the plastic containers in which the saliva is collected.
Oral Capsules: THE PROS: It is well absorbed by most women and works well. There are timed release capsules that allow for more gradual absorption and more even blood levels. I prescribe these for women who are sensitive to progesterone. Oral progesterone can help you sleep. THE CONS: If you are taking estrogen as well as progesterone, I prescribe them separately as they cannot be combined because oral estrogen becomes Estrone.
Troches And Sublingual Tablets. . If you are using estradiol patches to get a steady dose of estrogen (women with migraines) or for convenience, progesterone troches or sublingual tablets work well. THE CONS. Estradiol cannot be taken orally so we cannot combine estrogen and progesterone in a troche.

Testosterone:

Oral: Absorbed from the intestines directly to the liver. This is called a first pass effect and results in alteration in our clotting mechanism making us more likely to form clots. It also triggers the binding globulin called Sex Hormone Binding Globulin which binds both testosterone and estrogen. An elevated SHBG makes testosterone replacement difficult. If small doses are needed oral testosterone can be used. However women who need supplementation to functional levels of testosterone need larger doses than 1 mg per day so oral is not a good choice.
Topical Cream: This is a good way to apply testosterone. If applied to the skin it may increase hair growth in the area to which it is being applied. Application to wrist and back of knees decreases this possibility.
Vulvar Cream: Is a good way to apply testosterone. The vulva is sensitive to testosterone and using it there thickens the tissue, improves the net of blood vessels in the vulva and makes us more comfortable, much in the way estrogen helps the vagina. If you have loss of sexual desire, using vulvar testosterone can affect your clitoris with a lower systemic exposure. Since the inner lips of the vulva have no hair, testosterone placed there will not affect hair growth. In some women the level of replacement needed, if placed in the vulva, will increase the size of the clitoris and may increase sexual desire to individually unacceptable levels. It is important to pat dry after urinating, rather than wiping.
Pellets: The dosage the body gets is directly affected by the level of blood flow around the pellet. For this reason, the more active you are the more testosterone you absorb. This means that you are getting testosterone when you need it and not when you don’t need it. In the first six weeks of pellets, the amount of hormone can cause effects that will resolve once your body adjusts.

Combining Hormones Versus Keeping Them Separate.
Combining hormones offers convenience and financial savings. Taking four different hormones separately can increase the cost. However, keeping hormones separate allows for changes in dosing. Estradiol and testosterone are better not taken orally, while progesterone and DHEA do well as an oral dose.

In my experience most of us have a strong preference for how we take hormones. Given what is PRO and CON for each hormone, you can see why this is a complex decision. I weigh the pros and cons with you to discover the optimal mode of administration. Informed choices are fluid. Keep in mind that whatever choice we make can be changed.

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