The Pros and Cons of Hormone Replacement Therapy: An Integrative Medicine Approach

When menopause is approaching and uncomfortable hormonal symptoms start to pop up, many women turn to Hormone Replacement Therapy (HRT) to ease the transition. An average of 44% of postmenopausal women have used HRT. But, certain women are more likely than others to try it.

Surgical menopause is when the ovaries are surgically removed before the onset of natural menopause. 74% of women who have had surgical menopause have used HRT, whereas only 29% of women who went through natural menopause have tried HRT. Non-Hispanic white women were also more likely to use HRT than non-Hispanic black or Mexican American women. Also, the more educated the woman, the more likely she is to use HRT.

HRT has many benefits and helps many women significantly overcome their hormonal symptoms. However, there also are some risks, and HRT is not for everyone. Functional medicine can help thoroughly monitor levels and evaluate other aspects of health that may be affected by menopause, HRT, or both.

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What is Hormone Replacement Therapy?

Menopause is a phase of life for women where estrogen levels fall significantly. This decrease in hormone levels creates uncomfortable symptoms. Hormone Replacement Therapy (HRT) is also known as hormone therapy, menopausal hormone therapy, and estrogen replacement therapy. Whatever you choose to call it, it is considered the most effective treatment for menopause symptoms.

Hormone Replacement Therapy (HRT) is the medical replacement of female hormones that the body stops producing post-menopause. This therapy is typically prescribed to reduce the common symptoms during menopause, such as vaginal dryness and hot flashes. HRT is also prescribed to prevent certain conditions that are at a higher risk in menopause, such as osteoporosis (or bone loss and reduced fractures).

There are two types of HRT, systemic hormone therapy and low-dose vaginal products. Systemic hormone therapy uses estrogen throughout the body and is prescribed to treat any common symptoms of menopause. It can come in different forms, such as a pill, skin patch, ring, gel, cream, or spray. Low-dose vaginal products offer HRT at a minimum dose and are provided locally to the vagina as a cream, tablet, or ring. This local use is typically only prescribed for vaginal and urinary symptoms of menopause.

While estrogen is the prime hormone in HRT, progesterone (or progestin, a progesterone-like medication) will be prescribed alongside it in women who still have a uterus because estrogen by itself leads to excess growth of the uterine lining, increasing the endometrial cancer risk.

What Is Bioidentical Hormone Replacement Therapy?

Bioidentical hormone replacement therapy (BHRT) uses processed hormones that are designed to mimic your body's natural hormones. Just like in HRT, BHRT is recommended mainly for those going through peri and post menopause to combat the symptoms that result from the hormone decreases.

The processed hormones used in BHRT come from plants, and the most commonly prescribed bioidentical hormones are estrogen, progesterone, and testosterone.

In the USA, the FDA has approved some bioidentical hormones made and produced by drug companies. However, other forms are custom-made by a pharmacist and are called compounded bioidentical hormones. The FDA has not approved the compounded forms.

Bioidentical hormones from drug companies and compounded can both come in various forms, such as pills, creams, gels, sprays, and local vaginal inserts.

What are the Signs You Need Hormone Replacement Therapy?

Some women may benefit significantly from HRT, especially if they have one or some of the following signs:

• Significant vasomotor symptoms (such as severe hot flashes and night sweats) because HRT is the most effective treatment to relieve these symptoms
• Vaginal symptoms such as dryness, itching, or painful sex because local applications of HRT can be helpful
• Signs that you are trending towards osteoporosis (HRT isn't the primary prescription for preventing this, but it may still be beneficial, especially if you can't tolerate the other treatments)
• Estrogen deficiency, which is a decrease in estrogen before perimenopause, such as in primary ovarian insufficiency (loss of ovarian function before age 40)
• Early menopause, such as women who had their ovaries surgically removed before age 45 or women who stopped having periods before age 45

What Are The Pros to Hormone Replacement Therapy?

Hormone Replacement Therapy (HRT) does have many benefits since it can affect the following symptoms, giving much-desired relief:

• Help improve sleep
• Reduce vaginal dryness and itching
• Relieve vasomotor symptoms, such as night sweats and hot flashes
• Help sex feel less painful and more enjoyable
• Help prevent osteoporosis and fractures due to thinning bones
• Reduce the risk of developing heart disease
• Reduce the risk of developing dementia

BHRT can provide the same relief of symptoms as HRT. One unique benefit to BHRT is that custom formulations can allow practitioners another option for women who can't tolerate conventional HRT or its non-hormonal ingredients.

What are the Cons to Hormone Replacement Therapy?

There are some risks associated with both HRT and BHRT, and patients should be aware of these risks before deciding to choose these treatment options.

HRT is associated with endometrial cancer when taking estrogen without progestin while still having a uterus. It is also associated with blood clots, stroke, and breast cancer.

However, there are steps to take to lessen these risks. For example, if you start HRT within ten years of menopause or before age 60, if you start with the lowest effective dose, if you take progesterone/progestin (for those with a uterus), and if you get regular pelvic exams and mammograms you are less likely to have risks.

Because the FDA does not approve BHRT coming from a compounded pharmacy, the side effects do not have to be reported. When consumers don't see side effects reported, it contributes to the belief that BHRT is safer, although that is not necessarily true.

Some side effects of BHRT include:

• Fatigue
• Skin issues, such as acne
• Blurred vision
• Weight gain
• Headaches
• Spotting
• Cramping
• Bloating
• Breast tenderness
• Mood swings
• Increased facial hair

Side effects are more typical at the start of treatment while your body adjusts to new levels of hormones. Often these symptoms subside over time.

Functional Medicine Labs to Consider for Your Patients on Hormone Replacement Therapy

The best functional lab for monitoring HRT is the DUTCH Complete Test. This test examines sex and adrenal hormones. It assesses hormone metabolites, cortisol and melatonin, organic acids, and oxidative stress. This test was designed to accurately detect levels and monitor HRT by examining the sex hormone metabolites in the urine instead of serum or saliva measurements.

Thyroid function is intertwined with reproductive hormone function (both natural and HRT). For example, low estrogen often leads to a hypothyroid picture. However, HRT has been shown to affect the thyroid by stimulating it. Therefore, running a thorough Thyroid Panel on all patients on HRT is essential.

The liver's health is vital to hormonal health because the liver processes all hormones within the body, including hormones we make and take. When taking HRT, it is essential to understand the health and function of the liver. A Hepatic Function Panel can give a good overview of the health status of the liver.

There is a clear association between the gut microbiome and HRT. Research shows that HRT can alter the gut microbiome makeup of a postmenopausal woman and encourage it to resemble the gut microbiome of a premenopausal woman. A GI-MAP test analyzes the gut microbiota DNA, classifying the various present strains. This test would be helpful for women on HRT because if the gut microbiome is diverse and robust, it could indicate a positive response to HRT.

Does Every Woman Need Hormone Replacement Therapy?

No, not all women need hormone replacement therapy. In fact, some women don't tolerate HRT well or have certain risk factors prohibiting them from trying it. For example, if you have a history of one of the following, you should avoid HRT: blood clots, reproductive cancers, heart disease, liver disease, gallbladder disease, known or suspected pregnancy, stroke, or unexpected vaginal bleeding.

If HRT is something you either can't do or are uninterested in, just know that other treatment options are also quite beneficial for reducing menopause symptoms.

For example, a perimenopause diet can help boost overall nutrition while reducing symptoms, even in postmenopause. There are also herbal options such as Black Cohosh and Panax Ginseng, which have been shown to significantly reduce menopausal discomforts, such as hot flashes and night sweats.

Summary

Hormone Replacement Therapy (HRT) is a medical treatment that replaces the hormones that have diminished due to menopause. HRT is FDA-approved. However, Bioidentical Hormone Replacement Therapy (BHRT) is typically not FDA-approved. It may only be available when compounded specifically for you (with your physician's prescription) by a compounding pharmacy.

The ultimate benefit of HRT or BHRT is that it can significantly relieve symptoms of menopause. HRT can be used systemically for any menopause symptom or locally and topically in the vagina for specific vaginal and urinary consequences of menopause.

There are many benefits and risks. However, deciding whether to use HRT is a personal choice. Functional medicine can help thoroughly monitor HRT levels and assess the whole body's health, specifically areas where HRT can have a significant impact.