Dr. Rebecca Brightman and Katie explore the world of hormone replacement therapy.
In an effort to answer all of your burning questions about hormones and menopause, Katie picked Dr. B’s brain in a recent live event. During their discussion, Dr. B ventured into menopausal hormone therapy, who qualifies for hormones, and which hormones might be best for you (spoiler alert: a long discussion with your clinician is key). If you’re dumbfounded by the differences between synthetic, compounded, and bioidentical options, it’s OK — Dr. B also untangles that difficult, intricate mess.
Katie Couric: What qualifies someone to go on hormone replacement therapy?
Dr. B: Not everybody wants to be on hormones. Many women are very happy to be rid of their periods. These are women with heavy periods, painful periods, and extreme headaches. Plenty of women that I see say, “Oh my gosh, it’s done. I’m so happy. I’ve achieved hormonal neutrality.” But I do feel that there are many benefits to being on hormones. There is emerging data in ongoing studies that will look at the benefits of estrogen beyond treating the symptoms we always attribute to menopause.
It’s important to take a thorough history of a woman. If a woman has a history of certain clotting predispositions or a family history of clotting, they need to be evaluated because there can be a clotting risk — particularly with certain estrogens. If a woman has any undiagnosed uterine bleeding, that also has to be evaluated before starting estrogen.
Can you explain why you have to take progesterone alongside estrogen?
Progesterone is used to protect the uterus. In women who don’t have a uterus — like women who have had a hysterectomy — estrogen does not require progesterone because they don’t have to protect their uterus. When you talk about the risks of estrogen, studies show that estrogen use alone is not associated with an increased risk of breast cancer. In existing trials looking at estrogen and progesterone, there may be a slightly increased risk.
I feel that the benefits clearly outweigh those risks. Anyone with a uterus must use progesterone. There are different types of progestins available to clinicians. Some are oral, some are used vaginally. Some women use a progesterone- or progestin-containing IUD. It really helps women during perimenopause and the transition through menopause.
For many years, I was on the estrogen patch. You can use a patch that has estrogen and progesterone, or you can get an estrogen patch and take oral progesterone, which is what I did. I took bioidentical progesterone that was compounded by a pharmacy. What is the difference between synthetic and bioidentical hormones?
All hormones that you can take are synthesized. Synthetic hormones are not molecularly identical to what our body makes. Bioidentical hormones are molecularly identical to what our body makes. My bias — which is supported by the North American Menopause Society and the American Endocrine Society — is that there are FDA-approved hormones available in the United States. These are estrogens and progestogens that have been clinically evaluated. They’re effective and safe. I don’t regularly prescribe compounded hormones in my practice unless somebody has a specific need that can’t be met using currently available FDA options.
The issue with compounded hormones is that we don’t have the same quality control. Compounded hormones are not under federal regulation; there are state-by-state rules. A lot of physicians who are prescribing compounded hormones may have an underlying financial incentive. To me, that’s very concerning.
I’ve encountered problems with women using compounded hormones. If a patient comes to me and they’re doing well on something that’s compounded, I will continue with them. But we have so many FDA-approved options in our country, and there are more to come.
Are compounded hormones different from bioidenticals?
Bioidentical hormones are molecularly identical to what our body makes. There are FDA-approved bioidentical hormones: Patches, tablets, and vaginal rings. There’s oral or vaginal progesterone, there’s a progesterone patch. Your doctor can write a prescription. You can go to your pharmacy, and your insurance should cover it. But insurance rarely covers compounded hormones. Compounded hormones are made by a compounding pharmacy. Frequently, they’re mixed with other hormones and quality control is not necessarily guaranteed.
Women have a sense that bioidentical hormones are safer, but non-bioidentical hormones are also safe. Compounded hormones that are bioidentical aren’t strictly regulated. It’s important to realize that “bioidentical” is an umbrella term. There are two categories: Those that are FDA-approved and may be prescribed by a clinician, and those that are made by compounding pharmacies and not under FDA guidance.
Women can use rings, vaginal suppositories, patches, creams, or oral estrogen and progesterone. Is there any form that’s more effective than others?
It’s a combination of everything. This is absolutely not “one size fits all” medicine. The nice thing is that we have so many options to offer our patients. It’s not a 5-minute discussion. I review options.
The transdermal estrogens show less of an impact on the liver, which means they won’t impact clotting, cholesterol, lipid levels, or triglycerides. If somebody has high cholesterol, that may come into play.
A lot of data suggests that estrogen plays anti-inflammatory roles — particularly transdermal estrogen. Transdermal estrogen may also affect glucose metabolism.
Does estrogen protect your heart from heart attacks?
Yes. Women increase their cardiovascular risks once they go through menopause. Young women who have primary ovarian insufficiency — they’ve gone through an early menopause, they’ve needed surgery, or they’ve had chemotherapy — have accelerated risks of cardiovascular disease. If these young women are candidates, it’s important to get them on hormones early to keep that risk low.
Can you be on estrogen indefinitely?
I’m in favor of estrogen. There’s no set end point for my patients. Clearly, if somebody has developed cancer or there’s a contraindication that occurs, then we will take them off hormones.
The good news is there are ongoing clinical trials looking at the safety of hormones. Hormones received a bad rap because of the WHI study. The study was stopped because there was a small increase in breast cancer: About seven more cases out of 10,000 women. Many doctors stopped prescribing it. That was in 2002. Twenty years later, the women who had taken hormones were not at any increased risk of morbidity or mortality when compared to peers who had never used hormones. Even if the women who had used hormones developed breast cancer, they were not more likely to succumb to their disease when compared to the general population.
How effective are over-the-counter supplements?
There aren’t great studies that look at over-the-counter supplements. There are very few that have really proven clinical efficacy. But there are soy derivatives that are safe. Women are often scared of soy: They’re worried because it’s a plant-based estrogen. However, most women don’t metabolize soy into its active and effective form — it’s important to realize that. But active soy molecules — isoflavones — are available. They are OK if a woman has had breast cancer. These soy molecules do have some proven clinical efficacy.
There are other, lesser studies looking at plant-based options. Some of these products have other issues. It’s important for women to discuss the use of supplements with their clinicians. When I see my patients, I always ask, “What medications are you taking and what supplements are you taking?” Supplements can impact blood clotting and potentially increase other risks.
A lot of women don’t want to tell their other physicians — who are not gynecologists — that they’re on hormones. I think that they feel that their other clinicians may look down on them for being on hormones. But it’s OK to be on hormones.
