Female Hormone Replacement

Female Hormone Replacement for Menopause and Perimenopause Using Bioidentical Hormones

Michael C. Brown, MD (November 2016)

Hormone therapy (HT) in women has been an ongoing subject of controversy since estrogen was first used in the 1930’s to treat hot flashes. (1) The use of hormones became more popular during the 80’s and 90’s when certain studies suggested HT might help prevent heart disease, osteoporosis and even Alzheimer's disease.

 

This all changed with the Women's Health Initiative study published in 2002.

 

This was a study of some 16,000 women that found a significant increase in heart disease, stroke and breast cancer in women receiving Premarin (conjugated equine estrogen) and Provera (medroxyprogesterone). As a result of this study, many thousands of women suddenly had their prescriptions discontinued or they voluntarily stopped their hormones. Since then, for many women suffering menopausal symptoms and for many physicians, uncertainty remains about the safety of a treatment that otherwise seems very beneficial. So where are we today, and how should hormone treatment be addressed?

First of all, it should be noted that this large women's study used Premarin, a combination of estrogens derived from the urine of pregnant horses, and medroxyprogesterone, a synthetic progestin, for replacement hormones. To the researchers, these choices made sense, since these were the most commonly prescribed hormones at the time. However, critics of the study point out that these substances are NOT normally present in the human body and go on to suggest that estrogen and progesterone that are molecularly identical to natural hormones (so-called Bioidentical Hormones) may NOT have these negative side effects. Indeed, certain small studies suggest this may be the case, but so far no large studies of bioidentical hormones have been conducted to prove this theory as fact. (2)

Unquestionably, administration of estrogen and progesterone, the main sex hormones produced by the ovary, is the most effective way to treat the many symptoms associated with menopause (complete cessation of menses) and perimenopause (decreased hormone production, but menses continues). In fact, this remains the only FDA-approved indication for treatment with estrogen.

However, estrogen and progesterone have been proven to help prevent osteoporosis, and in combination reduce the incidence of endometrial hyperplasia (which sometimes leads to uterine cancer). The jury is still out regarding the correlation of bioidentical hormone replacement and breast cancer and heart disease. Also, there is no question that estrogen of any form increases the risk of blood clots and stroke, especially when estrogen is taken orally by a person who smokes.

Given what we think we know to date, I feel that hormone replacement should be made available to most women suffering symptoms of menopause. Estrogen and progesterone should be bioidentical and may include either compounded or pharmaceutical agents. Estrogen should probably never be taken orally, but rather transdermally as a cream or patch, or in a sustained release form as a pellet (more about this later). Estrogen is contraindicated in persons with a history of blood clots, and is probably NOT a good idea for the older woman who has already gone through menopause and is having no symptoms. Breast cancer, or a history of breast cancer, is also a relative contraindication.


I urge women considering hormone replacement to research the data and make an appointment with me to discuss this important topic further. A couple of good review articles are listed below. (3,4)

(1)  “A Brief History of Hormone Treatment”
(2)  Micronized progesterone vs medroxyprogesterone, breast cancer.
(3)  “COUNSELING Postmenopausal Wm BIHR, Richa Sood, Lynne Shuster et al, Women's Health Clinic Mayo
(4)  Bioidentical Hormones, Evidence based review, Eileen Conaway

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