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The Benefits and Risks of Hormone Replacement Therapy

September 16, 2019

"Ultimately the decision about whether to pursue hormone replacement therapy is individual and unique."

In part 1 of his series on menopause, Dr. Keller Wortham, MD, took us through some menopause basics: signs, symptoms, and natural tips for managing some of those uncomfortable symptoms. He also explained how a sharp decrease in two important hormones plays a role in menopause.

In today's part 2, Dr. Keller will take a look at the complex question of hormone replacement therapy, and discuss the benefits and risks of this possible treatment option.

Video Highlights

  • 01:02: Quick Review of Menopause
  • 02:26: Hormone Replacement Therapy Considerations
  • 03:33: Replacing Estrogen
  • 05:12: Replacing Progesterone
  • 06:55: Replacing Testosterone
  • 07:55: Risks of Hormone Replacement Therapy
  • 09:38: The Possible Silver Lining
  • 11:13: Hormone Replacement Best Practices
  • 14:47: Women Who Should Avoid Hormone Replacement
  • 16:13: Wrap-Up

In part 1, we talked about menopause — what it is, what women experience when they go through it, and some of the things that they can do to help counteract some of the symptoms.  If you watched the video, you know those symptoms include things like insomnia, irritability, hot flashes, and a whole host of things that can be really unpleasant as well as some that can be even more serious, like osteoporosis and heart disease.

A lot of women out there who are dealing with these symptoms, have probably thought about Hormone Replacement Therapy, and have researched it and have talked about it with their doctors. If you haven’t, we’re going to lay out some of the aspects of hormone replacement therapy — the benefits, the risks, and some other considerations so that you can make the choice that's right for you.

Quick Review of Menopause

Menopause is a natural occurrence in women in their late 40s or early 50s, which naturally resolves itself (meaning you don’t have to do anything about it).  It is the body's natural aging process. That being said, if you are getting some of those side effects that are really disruptive to your life like the hot flashes or depression, or if you are at risk for some things like heart disease and osteoporosis, then you might want to have a conversation with your doctor about whether or not hormone replacement therapy is right for you.

As we discussed, menopause is not only the time you stop having monthly periods, but also involves a precipitous decline in two very important hormones in the body: estrogen being the fundamental one, and progesterone. So, since these hormones are dropping and all the sudden a woman is experiencing all these terrible and sometimes potentially dangerous things, replacing these hormones could be the solution that makes sense. While this is a possible solution, unfortunately there are also some risks and some drawbacks.

Hormone Replacement Therapy Considerations

When you're talking about hormone replacement therapy for menopause, there are a lot of things to think about:

  • Number one, what kinds of hormones am I going to replace?  Is it estrogen or progesterone or both? Testosterone also decreases, so that is another one that could be replaced.
  • Number two, which route am I going to use? There are oral hormone replacement therapies, transdermal, and intravaginal.
  • Number three, what kind of hormone? Hormones may be compounded, bioidentical, or animal-based. So, there are a lot of options there. There are certain levels of hormones, and you have to figure out what the optimal levels are for each. 

So, there are a lot of considerations, even within hormone replacement therapy, that give you options.

In Dr. Keller’s last video, he went over some natural things that you can do for a lot of menopause symptoms, but since hormone replacement is another option, let’s break it down according to the hormones in question.

Replacing Estrogen

When you replace estrogen, you take care of a lot of the symptoms that we mentioned that occur due to low estrogen. It can help reduce the symptoms of hot flashes, improve your mood, and help prevent depression, because low estrogen means low serotonin levels. Putting the estrogen back can increase those serotonin levels and restore some stability to your mood. It can also help improve collagen in the skin, and reduce wrinkles, as well as improving bone density. So, replacing estrogen can reduce your risk of osteoporosis, because low estrogen reduces calcium absorption into the bones. It also can improve your cardiovascular system because estrogen helps protect the endothelium, which is the lining of the blood vessels, and has a positive effect on cholesterol ratios. Estrogen tends to make higher levels of good cholesterol and lower levels of bad cholesterol. We talked about some of the vaginal implications of low estrogen like vaginal dryness, or incontinence, which can also be improved with estrogen therapy. You might notice an increase not only in your libido but also in the lubrication of the vaginal canal and the strength of the tissue there, which can make sex a lot more comfortable. 

Replacing Progesterone

When we replace progesterone, we get a benefit for some of the symptoms related to the low progesterone. Insomnia is a big one, as progesterone helps induce sleep. Taking a progesterone supplement can help regulate your circadian rhythm (your sleep cycle) and get you back to restful sleep. Progesterone is also a diuretic, which means it helps you get rid of excess water in the body. A lot of women complain about postmenopausal bloating, or feel like they're retaining more fluid. Taking progesterone can help reduce that excess fluid in the body. 

It also helps improve insulin sensitivity. Many women going through or having gone through menopause complain of a sharp decrease in their metabolism function. There are multiple reasons why that actually happens, but insulin is one of them. Higher insulin levels can translate to a tendency to hang on to more weight and to store more fat. And when your progesterone levels go down, your insulin doesn't work as well, so your body starts making more of it. As your insulin sensitivity decreases and your insulin levels go up, you tend to store more fat and that can make it feel like your metabolism has slowed down. So again, replacing progesterone can make the insulin work better and therefore make you less prone to storing fat.

Replacing Testosterone

The third hormone that decreases with menopause is testosterone. Some women choose to replace their testosterone with hormone replacement therapy, although obviously not in the same levels that a man might do when he is experiencing andropause. The levels that you replace for women with testosterone are lower, but you can actually give a woman testosterone replacement, and this can help improve libido. Testosterone also helps with muscle strength and repair, promoting healthy muscles and joints. It also can promote lean body mass. So, there you go, a whole host of things that you can improve just by restoring the levels of those hormones — estrogen, progesterone, and testosterone — that all the sudden collapsed when your body went into menopause.

Risks of Hormone Replacement Therapy

This may all sound fantastic, but unfortunately there's never a free lunch in medicine. There are some definite risks and considerations that come with replacing these hormones. Initial studies that examined the question of hormone replacement therapy revealed some really concerning things.

  • The studies showed that when menopausal women took estrogen supplements, they experienced an increased risk for clots, which put them at risk for things like stroke, pulmonary embolus (a clot in the lungs), and heart attack. These are very devastating consequences that you definitely want to avoid. 
  • Also according to these studies, women who took estrogen replacements had an increased risk of breast cancer. A lot of cancers in the breast are estrogen-sensitive, so if you start putting estrogen in that can actually feed or promote certain breast cancers. 
  • Finally, studies saw an increase in the risk of endometrial cancer. The endometrium is the lining of the uterus. After menopause, the uterus is no longer making tissue there, and you've stopped having periods, but if you put estrogen into the system after it's naturally stopped, that could actually increase the risk of growing a cancer of the uterus. 

So, those are three huge and serious things. When you start looking at whether or not to replace hormones, it's really important to weigh these risks against the benefits. It would be great to get rid of those hot flashes, and depression, and low libido. But of course you don’t want to increase your risk of breast cancer, endometrial cancer, and clots — that doesn’t sound like a good trade. 

The Possible Silver Lining

However, people started looking further into this question, and there may be some uncertainty about the results of the earlier studies.

First of all, those studies that were done were several decades ago, and often employed oral estrogens, which are thought to increase clotting. These studies also often used estrogens alone, without  progesterone. Some of the studies actually used horse-based estrogens, so there weren't bioidentical — they weren't the kind of estrogen that a woman has in her body naturally. Many of those studies were also pairing horse estrogens with another kind of progesterone, which is called progestin, which is not a real hormone that exists in the body.  

In other words, there are a lot of factors that may have influenced the risks these studies found. They may not be pairing the hormones the right way, or using the right hormones to begin with and they were using these animal-based or lab-based hormones, that aren't like what we have in our body. These factors have brought up a lot of questions about whether or not hormone replacement therapy was safe. It may be that we just need to develop the proper way to do it, so that we could get the benefits like reduced hot flashes, better sleep, and reduced risk of osteoporosis and heart disease, without increasing some of these other risks.

Hormone Replacement Best Practices

After multiple years of looking at various studies, there are some things that are widely considered safe and good practice:

  • First of all, we know that if you're going to replace estrogen that you should combine it with progesterone for women who have a uterus. When you replace both estrogen and progesterone, you reduce the risk of uterine cancer.
  • Second, if you pair estrogen and progesterone together you'll also see a decreased risk in other cancers like colon cancer and potentially even breast cancer.
  • Number three, it's thought that lower levels of estrogen replacement, when paired with progesterone, might actually only increase the risk of breast cancer by about one in a thousand (so one additional case per thousand women). That’s not a huge increase, considering the potential benefits.
  • Additionally, they found that if you only replace the hormones for about five years, there might not be any increased risk of breast cancer at all.  
  • Finally, it’s thought that maybe the transdermal (skin-based estrogen creams or patches), might be better for the body when it comes to estrogen than the oral product.  This could be because when you take an oral estrogen it actually gets absorbed into the bloodstream and passes through the liver, and that passing through the liver is thought to increase some of the clotting factors in the liver, increasing the risk of clots.  When you put a patch of estrogen on, it's going right into the bloodstream, not passing from the gut, through the liver. One of the risks of estrogen replacement therapy is an increased risk of clots.

Again, there are still a lot of questions but some of the agreements include, as we listed above: First, if you have a uterus you should be taking estrogen and progesterone together.  Second, it's thought that hormone replacement therapy is safe for the first five years after menopause, after which, it might lead to increased risk of cancer. Third, if you have primarily vaginal symptoms (vaginal dryness, incontinence, pain during sex), then you should replace the estrogen vaginally. There are vaginal creams that are formulated for the vagina, or there are rings that you can insert, which will keep the estrogen concentrated in that area of the body to help you avoid some of the increased risks associated with replacing estrogen.

Women Who Should Avoid Hormone Replacement

There are some populations of women who should probably not have estrogen replacement therapy. These include women who have a history of clots, women who have a history of breast cancer, and those who have a history of uterine cancer. If you are in any of these groups, you should probably avoid estrogen replacement therapy.

For Dr. Keller’s patients, he makes sure the estrogen is always bioidentical (not horse-based, or any other hormones that are unlike what your body naturally makes). He recommends using the transdermal method, so that the hormone goes right into the bloodstream and doesn’t through the liver like a pill would do, increasing the list of clots. He also always pairs estrogen with progesterone, but gives the progesterone orally, as it doesn't have the same effect on the liver. It can, however, have a bigger effect on the brain, so if you're having insomnia, progesterone can help that more than estrogen does. Pairing progesterone with estrogen can reduce the risks of you endometrial cancer and breast cancer because progesterone again can help offset some of the effects of estrogen. Finally, he recommends using the natural kind of progesterone the body makes, not the synthetic progestin.

Wrap-Up

So, those are some things just to think about.  Ultimately the decision about whether to pursue hormone replacement therapy is individual and unique. It's always about the woman herself, her goals, her individual symptoms and how disruptive they are, as well as her other risk factors for things like osteoporosis or heart disease. Have this conversation with your doctor if you're going through menopause — the pros and cons of hormone replacement therapy, how they fit into your life, and what you're experiencing — and hopefully you and your doctor can develop a treatment plan that meets your individual needs.

We hope that gave you a little bit more of an understanding of hormone replacement therapy.  Remember, in part one of this video series, you'll get some natural remedies that you can try if you feel like you're on the fence about hormone replacement therapy. If you have any more questions, feel free to write to us and we will always try to answer them.

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