Hormone Replacement Therapy (HRT) & Menopause | The Contradictions

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I'd been feeling crummy for a few years.

I didn't really know what was wrong, but I felt like my body had been hijacked. It wasn't acting the way it usually did. I wasn't sleeping. (My friends got used to seeing emails sent at 3 a.m.) I started having problems recalling things that I normally wouldn't. It made me feel stupid - and I hated it. My dentist thought I might have sleep apnea, so my doctor prescribed a sleep study. It came back negative.

My eyes got so dry that I needed these very expensive prescription drops to keep them from throbbing.

I felt anxious. I'd get heavy periods and light ones and sometimes none at all (life is like a box of chocolates - you never know what you're gonna get!). My skin got itchy and dry and I started getting the jowls that you see on older women (GASP!!). And I started to put on weight - even when exercising and eating right - and then I felt ugly.

Then came the hot flashes. LOTS and LOTS of them. My husband would laugh and yell, "POWER SURGE!" as I stripped off layers. That's when I realized it was perimenopause. Occasionally, my heart would race for no apparent reason (while standing in the kitchen) and sometimes I felt out of breath (again, while standing in the kitchen).

I'd talked to my primary care doctor at a checkup about my severe lack of sleep / hot flashes. He followed up with questions about how many pregnancies I'd had, and when I got my first period. He ended with, "That's a lot of estrogen over your lifetime." I got the impression that not sleeping and hot flashes were something to be endured.

Then I got shingles. I got to the doctor right away and again told him that I wasn't sleeping (to the point that I don't remember having any dreams for the past couple of years). He prescribed some medications and after about 6 weeks, I started to recover from my shingles (but I still have a scar above my right eye).

A few days later, my doctor asked if I'd thought about hormone replacement therapy (HRT). He sent a link to a Peter Attia podcast with the authors of Estrogen Matters, the book by Avrum Bluming and Carol Tavris.

That podcast was life changing for me. I'd been feeling awful for so long - and here these people were telling me that I didn't have to! That estrogen & HRT could improve my quality of life - with very little, if any increased risk of breast cancer!

See, at that point, I didn't even know HRT was an option. Two of my dearest friends had breast cancer. My best friend died from complications of breast cancer when she was 40. Both friends took Tamoxifen, essentially an estrogen blocker, to help prevent more cancer. And so I - like so many other people - was led to believe that estrogen causes breast cancer.

So I bought the Estrogen Matters book and read it in 2 days. I learned that estrogen could help me to feel better - and that the thinking on hormone replacement therapy has changed. It's not the "EVIL breast cancer causer" after all. At the very least, it's the great alleviator of hot flashes - and at most a way to prevent breast cancer, osteoporosis, and things like Alzheimer's. WOW!

As I did more research, I also learned that very few doctors agree on HRT and what it can and cannot do. I will say that Estrogen Matters is very well researched and written. It's easy to verify the information the authors share because they list all their resources. It's also why I feel it's so incredibly important to share this information with you. (But it took me a while and prodding from others to share my own story. I'm sorry for that!) Following is what I found.

Hormone replacement therapy is a volatile subject in medicine.

You'll find doctors arguing about it. Just read the comments below this post. You'll see what I mean. The arguments arise because some doctors say we need to rethink our stance on hormone replacement therapy & menopause.

The most prevalent thought right now - and what we've all been told - is that essentially, hormone replacement therapy (you'll hear it called HRT or HT) is bad. It increases your risk of breast cancer. And I think we can all agree - nobody needs that!

But before we go any further - there are a few terms you need to know:

Perimenopause: the years before menopause when a woman has changes in her menstrual cycle. Periods change both in timing and heaviness. Estrogen and progesterone hormone levels fluctuate. For most women, perimenopause hits during the 40s and lasts 4 - 8 years. During the late stage of perimenopause, women start missing at least 2 menstrual cycles in a row.

Menopause: Most women reach menopause around the age of 50, when they've had 12 consecutive months without a period. After menopause, estradiol, the main estrogen made by the ovaries drops to about 1/10 of the levels of women still getting periods.

In general, hormone replacement therapy comes in 2 flavors:  estrogen alone or estrogen + progesterone.

Estrogen alone:  Women who have had a hysterectomy (their uterus was surgically removed) are prescribed estrogen.

Estrogen + Progesterone: Women who still have their uterus are prescribed a combination of estrogen and progestin. When estrogen alone has been prescribed for women who haven't had a hysterectomy, it's been tied to uterine cancer (endometrial hyperplasia).

What is menopause like?

For some women menopause is easy.

For others, not so much. They experience difficulty sleeping, vaginal dryness, stress incontinence, mood swings, weight gain around the abdomen, bloating, breast tenderness, muscle loss, thinning hair, a racing heart, shortness of breath, irritability, anxiety, mood swings, headaches, dry eyes and mouth, bone fractures related to osteoporosis, heart disease, colon cancer, depression, dementia, short-term memory problems, and difficulty concentrating.

There are also vasomotor symptoms, like hot flashes and night sweats. Most women experience these vasomotor symptoms for a few months. But for some, the hot flashes and night sweats last for over 10 years!

  • 80 - 90% of women going through menopause will experience symptoms.
  • The median duration of hot flashes, flushing and night sweats (vasomotor symptoms) is 7.4 years.
  • African American women have a median of 10.1 years of symptoms.
  • Women whose vasomotor symptoms begin during perimenopause (That's me!) experience symptoms for a median of more than 11.8 years - which sounds like a really, really long time.
  • 20 - 40% of women going through menopause will seek medical care as a result of their symptoms.

Women look at hormone replacement therapy to get relief from their symptoms - because it works better than anything else we have right now.

Following is some information about hormone replacement therapy from a 2017 article in Medical News Today, What You Need to Know About HRT by Yvette Brazier:

  • HRT is effective at relieving the symptoms of perimenopause & menopause.
  • HRT can reduce the number & severity of hot flashes
  • HRT can reduce the risk of osteoporosis (when bones become more porous and fragile and your risk of fractures is much higher).
  • "Past studies have suggested a link with cancer, but this is still being investigated."
  • HRT may help keep your skin young, but it will not reverse or delay the overall effects of aging.
  • Any woman considering HRT should talk to a doctor who knows her medical history.

BUT if you research hormone replacement therapy, the information you'll find is riddled with contradictions. There are lots of conflicting opinions. It's alluded to in the Medical News Today sentence above, "Past studies have suggested a link with cancer, but this is still being investigated." All the contradictions make it very difficult to determine the best course of action.

Before We Move on, You Need a Quick Lesson on the History of HRT:

Since 1942, when Premarin (an estrogen product) was approved by the FDA for treatment of hot flashes, women have taken hormone replacement therapy. When started at menopause, HRT eased hot flashes and memory loss. It reduced the risk of heart disease and osteoporosis. Like the pill, it had a low risk of blood clots and other adverse effects, but both doctors and their patients felt the benefits outweighed the risks. Many women felt better taking HRT.

But then came a 1991 study by the Women's Health Initiative (WHI). It followed more than 68,000 postmenopausal women between the ages of 50 to 79. The study was stopped in 2002 - earlier than planned. Researchers found that estrogen + progesterone was associated with an increased risk of breast cancer, some increased risk of cardiovascular disease and more harm than benefit. The estrogen alone trial was stopped early (in March of 2004) because it found an increased risk of stroke and showed no benefit for coronary heart disease.

In 2002, the Women's Health Initiative study was published in the prestigious Journal of the American Medical Association (JAMA) and was called a "landmark trial." It was large, randomized, prospective, placebo-controlled, and double-blind - considered the gold standard in clinical trials. The cost was estimated to be around $1 billion.

So women and their doctors abruptly changed course. In 1999 - 2000, about 38% of women were using HRT. Now the percentage of women over 40 using HRT is close to 5%. And the percentage of women 50 - 59 is around 7%. It was a huge drop.

But some women still needed relief from the symptoms of menopause. They tried other things, but Premarin (estrogen) or Prempro (combined estrogen & progesterone) worked best for them. Doctors cautiously started to prescribe HRT. (Now most prescribe bioidentical hormones.) You'll often hear, "the smallest dose for the shortest amount of time." And this recommendation is usually for patients whose symptoms make them miserable.

Fast Forward to Now - There Are Lots of Contradictions About Hormone Replacement Therapy:

  1. If estrogen can cause breast cancer, then rates of breast cancer should decrease after menopause as women's estrogen levels decline - BUT they don't. Breast cancer rates increase with age.
  2. "So far, there is still no conclusive data demonstrating that estrogen is a cancer-causing agent," from the 2009 study, Current Breast Cancer Risks of Hormone Replacement Therapy in Postmenopausal Women by Shah & Wong.
  3. A study published in JAMA in 2017, by the investigators in the Women's Health Initiative found that compared to placebo, hormone therapy for 5 - 7 years was not associated with risk of long-term all-cause mortality.
  4. A 1999 article by Nananda Col et al. published in JAMA Internal Medicine, estimated HRT would prolong life by as long as 3 years.
  5. Animal models and molecular studies have shown estrogen had beneficial effects on the brain, especially if administered early BUT research in humans indicated that women treated with estrogen therapy had an increased risk of dementia.
  6. Some clinical trials have shown a higher risk of stroke and venous thromboembolism (VTE - when a blood clot forms in the deep veins of the leg, groin or arm known as deep vein thrombosis, then travels and lodges in the lungs) but there's other data that shows HRT may work to protect the heart.
  7. The Heart and Estrogen / Progestin Replacement Study (HERS) compared users of CEE (conjugated equine estrogens 0.625 mg / day - made from pregnant mare's urine) plus MPA (medroxyprogesterone acetate 2.5mg / day continuously) to placebo in 2763 postmenopausal women with a uterus. The average age was 67 and each had coronary artery disease. The HERS study showed that women taking HRT had more venous thromboembolic events (vein clots) and gallbladder disease. There was no cardiovascular benefit BUT there was also no significant difference in the rates of cancer, fractures or mortality when compared to placebo.

So here they are - the best references I've found about the benefits and drawbacks of hormone replacement therapy.

First, let's talk about Estrogen Matters, the book by Avrum Bluming, M.D., and Carol Tavris, PhD.

The full name of the book is, Estrogen Matters:  Why Taking Hormones in Menopause Can Improve Women's Well-Being and Lengthen Their Lives - Without Raising the Risk of Breast Cancer and was published in 2018. It was eye opening and thought provoking for me, all at the same time. It's also the reason I started taking HRT myself. AND I FEEL BETTER!

The book focuses on dispelling the myth that estrogen and hormone replacement therapy are "bad."

And while some of my questions were left unanswered, Estrogen Matters helped me to better understand. My hope is that it will help you as well.

Avrum Bluming is an oncologist (doctor who specializes in cancer). 60% of his practice has focused on breast cancer. For over 20 years he has been studying the benefits and risks of hormone replacement therapy when given to women with a history of breast cancer. Dr. Bluming spent 4 years as a senior investigator for the National Cancer Institute. For 2 of those years he was director of the Lymphoma Treatment Center in Kampala, Uganda. He was elected to mastership in the American College of Physicians, an honor given to only 500 of over 100,000 board-certified internists in the United States. (You should know that many oncologists are very familiar with menopause. This is because the chemotherapy drugs used to treat cancer can damage a woman's ovaries. Damaged ovaries can create the symptoms of menopause or actual menopause.)

Carol Tavris has a PhD in social psychology. She's written several books including, Mistakes Were Made (But Not by Me), with Elliot Aronson; Anger: The Misunderstood Emotion, and The Mismeasure of Woman. She's also written for publications like the Los Angeles Times, the New York Times Book Review, and the Wall Street Journal. She has received awards for her promotion of gender equality, science, and skepticism and is a fellow of the Association for Psychological Science.

Since the Women's Health Initiative report, there have been follow up studies on the effects of hormone replacement therapy. Some of the studies have reversed the WHI findings. Others just created more questions. In their book, Bluming and Tavris report the details of these new findings. They also point out flaws in the original WHI study.

One of Bluming and Tavris's main criticisms of the WHI is that the study didn't meet the Bradford Hill Criteria. Not surprisingly, the man who thought of it was Sir Austin Bradford Hill, an English epidemiologist (a scientist who studies the cause and patterns of diseases and injuries) and statistician (someone who prepares and analyzes statistics). Bradford Hill came up with the randomized clinical trial and, working with Richard Doll, he was able to make the connection between cigarette smoking and lung cancer.

Bradford Hill thought that studies should work the way a police detective proves a case. They needed to prove a causal relationship. He came up with 9 criteria to help determine causation in a clinical study - and rule out correlation.

Correlation is not causation.

Just because there is a connection (where one thing affects or depends on another), it DOES NOT NECESSARILY mean that one causes the other. An article written by Statistician, Nathan Green, for The Guardian gives a great example. People tend to spend more money in the winter when it's cold. That's a correlation. But it's unlikely that they spend more because it's cold. Instead, they're probably spending more because of the Thanksgiving and Christmas holidays that take place during chilly November and December. That's causation.

Following are some highlights of the research in Estrogen Matters using the Bradford Hill Criteria:

1. Strength of Association - a clinical trial needs strong evidence that is statistically significant.

Bluming and Tavris found that most of correlations in the WHI were not statistically significant.

The HERS trial found that, "HRT was associated with a non-significant trend toward higher breast cancer risk." (from the 2006 article, Current Breast Cancer Risks of Hormone Replacement Therapy in Postmenopausal Women by Shah & Wong)

Wait - What's statistical significance?

Statistical significance is a way to test a hypothesis. The hypothesis is what the researcher thinks will happen in the study.

The Women's Health Initiative showed that the risk of getting breast cancer while taking HRT was statistically significant. And "statistically significant" sounds scary. Dr. Isaac Schiff, a professor at Harvard Medical School, explains the breast cancer risk with HRT in much simpler terms - so his patients can make better decisions for themselves:

"If you aren't on hormones, your risk of breast cancer is 3 out of 1,200 per year. If you're on hormones, it's 4 out of 1,200. Some women are comfortable staying on hormones with that risk. It's a very individual decision."

2. Consistency - the evidence should be consistent across different studies and different populations.

BUT the results of the studies on HRT and breast cancer have been remarkably inconsistent.

  • A study by Bush, Whiteman, & Flaws in 2001 found that "the evidence did not support the hypotheses that estrogen use increases the risk of breast cancer and that combined hormone therapy increases the risk more than estrogen only. Additional observational studies are unlikely to alter this conclusion. Although a small increase in breast cancer risk with hormone therapy or an increased risk with long duration of use (15 years or more) cannot be ruled out, the likelihood of this must be small, given the large number of studies conducted to date."

3. Specificity - a risk factor or cause produces a specific result that adds support for the hypothesis. This specificity criteria is NOT definitive because diseases are often caused by many factors. But the absence of specificity supports the inference that something is NOT a cause of something else.

In the case of estrogen and breast cancer, the majority of women who have breast cancer have never taken estrogen and the vast majority of women who have taken hormones never developed breast cancer. (This comes from the book, Estrogen Matters.)

4. Temporality - exposure to the risk factor always precedes the outcome.

In this case, taking estrogen does not always (or often) precede breast cancer.

  • "The probability that a woman will have breast cancer increases throughout her life and most breast cancers occur during the postmenopausal years. Thus age might be considered the single most important factor for determining breast cancer." (from the article, Risk Factors for Breast Cancer Development by Craig Henderson, published in 1993) So breast cancer risk increases with age as estrogen levels decline. This is true even among women who have never taken estrogen.

5. Dose response relationship / Biological Gradient - an increased dose / exposure leads to an increase in the disease. So the longer a woman takes estrogen, the higher her risk for breast cancer should be.

Studies have found no consistent risk of breast cancer with cumulative exposure.

  • A study by Li et al. published in JAMA in 2003, found that "Women using unopposed estrogen replacement therapy (ERT) (exclusive ERT use), even for 25 years or longer, had no appreciable increase in risk of breast cancer."
  • And in the NIH-AARP Diet and Health study of 2008, researchers found that, "Among all women, ET-only (estrogen only) use was associated with a RR of 1.15 (95% CI 1.04–1.27), with no further evidence of increase seen for longer durations of use. Current users were at a slightly higher risk (RR=1.24) than former users (0.99). There was no evidence that risk rose with increasing durations of use among current users."

6. Plausibility - the evidence and theory behind a hypothesis must agree with the currently accepted understanding of the disease process.

Estrogen has had beneficial effects for women with HER2 breast cancer and in women with early breast cancer that has been successfully treated.

7. Experiment - a disease is prevented by a particular experimental intervention.

Women in Norway and Sweden stopped taking HRT at a similar rate as women in the US, but they had no additional drop in rates of breast cancer. (from a letter to the editor of JAMA, A Decline in Breast Cancer Incidence, from September 2007)

8. Alternative explanations / Analogy - researchers should consider other causes and rule them out.

For this particular situation, alternative explanations haven't been considered. Bluming and Tavris say, instead there's been data mining.

What's data mining?

Wikipedia defines data mining like this:

"If one looks long enough and in enough different places, eventually data can be found to support any hypothesis. Yet, these positive data do not by themselves constitute evidence that the hypothesis is correct."

Dr. Jon Lorsch, director of the National Institute of General Medical Sciences explains in an article titled, Hypothesis Overdrive:

"It is too easy for us to become enamored with our hypotheses, a phenomenon that has been called confirmation bias. Data that support an exciting, novel hypothesis will likely appear in a “high-impact” journal and lead to recognition in the field. This creates an incentive to show that the hypothesis is correct and a disincentive to proving it wrong. Focusing on a single hypothesis also produces tunnel vision, making it harder to see other possible explanations for the data and sometimes leading us to ignore anomalies that might actually be the key to a genuine breakthrough."

Dr. Robert Hoover, Director of Epidemiology and Biostatistics at the National Cancer Institute, explains it really well in Estrogen Matters:

"The scientific method I was taught involved setting a hypothesis and then trying everything you could to destroy it, and if you couldn't, then you began to accept it. Somehow we've gotten away from that. We develop hypothesis and then we do everything we can to find something that supports it."

If you'd like to learn more from Avrum Bluming and Carol Tavris, I'd recommend listening to the Peter Attia, MD Podcast #42.

In the podcast, Avrum Bluming, and Carol Tavris address the controversy surrounding the use of hormone replacement therapy through menopause and beyond. They make a compelling case for long-term HRT and work to dispell the myth that it causes breast cancer.

Their book, Estrogen Matters, is available on Amazon.

To add some balance to this post, I've included some information from Dr. JoAnn Manson, one of the principal investigators in the WHI.

Dr. Manson's views on HRT & breast cancer are different from those of Avrum Bluming and Carol Tavris.

Dr. JoAnn Manson has collaborated on studies predicting the risk of breast cancer. She served as Principal Investigator of several National Institute of Health funded research studies including the Women's Health Initiative (since the study's inception) and the cardiovascular disease component of the Nurses' Health Study. She has some impressive titles:  Professor of Epidemiology at the Harvard T.H. Chan School Of Public Health; Michael & Lee Bell Professor of Women's Health at Harvard Medical School; Chief of Preventive Medicine at Brigham & Women's Hospital; AND she is Co-Director of Womens Health at Brigham & Women's Hospital.

Are the Women's Health Initiative Results Being Misunderstood?

In an article, "Managing Menopause: Are the WHI Results Being Misunderstood?" on Medscape, Dr. Manson explains that the Women's Health Initiative trial studied the benefits and risks of hormone therapy to prevent chronic disease in postmenopausal women over a broad range of ages - even women in their 60s and 70s. She says that at the time of the study, it was becoming more common for doctors to prescribe HRT for women 10+ years past menopause in an effort to prevent future heart disease, cognitive decline and chronic disease. But since then, the results of the trial have been extrapolated to include 40 - 50 year old women with severe hot flashes, night sweats, insomnia, and other symptoms that affect their quality of life. Because of these misunderstandings, many doctors don't feel comfortable evaluating the symptoms of menopause or prescribing HRT. So women have turned to custom compounded HRT. The formulas are untested and unregulated. And women are not being told the risks of these therapies because there's no package insert that comes with them.

Reasons Why the WHI Results Should NOT Be Generalized According to Dr. Manson:

  1. Only one formulation of estrogen, Premarin (conjugated estrogens), was used, either alone or with one progestin (medroxyprogesterone acetate).
  2. HRT was only given by mouth. Now HRT can be taken orally, via a transdermal patch, or vaginally.
  3. The mean age of women in the trial was 63.
  4. Women in the trial had more risk factors than the younger women who typically use HRT to treat the symptoms of menopause.
  5. Many of the women in the trial did not have severe symptoms of menopause.
What are Dr. Manson's views on the risk of breast cancer for women using HRT? Are the risks clinically significant?

Wait - What's clinically significant (vs. statistically significant)?

Clinical significance tells whether a treatment / medication was noticeable or had an effect on the patient's everyday life. It is NOT THE SAME AS STATISTICAL SIGNIFICANCE. Remember, statistical significance measures the p-value. The lower the p-value, the less likely the trial results were due to chance.

Here's an example of clinical significance. Say you get bad heartburn, so your doctor prescribes Protonix. You try it for a month, but don't feel any better - even though Protonix does a really good job of relieving heartburn in clinical studies. Protonix is NOT clinically significant for you. Then you start taking Nexium, and your heartburn disappears completely. In this case, Nexium is clinically significant because it relieved your heartburn and your quality of life has improved.

Often the researcher and the patient in the trial decide whether or not a result is clinically significant.

Dr. Manson feels the breast cancer risk for women using HRT is clinically significant:

    • There's about 1 extra case of breast cancer per 1,000 women using estrogen / progesterone replacement therapy each year. So the rates start at 3 out of 1,000 and increase to 4 out of 1,000 for each year of estrogen / progesterone replacement therapy use.
    • In absolute terms the risk is quite low. So if a woman has severe hot flashes and night sweats that interfere with her quality of life, the benefits of hormone replacement therapy are likely to outweigh the risks - especially if she only uses HRT for short-term treatment.
    • Short-term use of HRT (2 - 3 years), which is the amount of time that many women require HRT, should not appreciably increase breast cancer risk.
    • Breast cancer risk is a duration issue. When you've used estrogen / progesterone therapy for 4 - 5 years or longer, the risk becomes an important thing to consider.
    • The WHI findings suggest that an increased risk of breast cancer continues for 2 - 3 years after stopping HRT.
    • Estrogen / progesterone therapy can increase breast density, which may obstruct mammogram readings - especially in the early stages of breast cancer.
What does Dr. Manson think about the declining rates of breast cancer? What's causing them?

The lower rates of breast cancer may be caused by a combination of things:

  • Decreased use of HRT - especially in women who are not appropriate candidates for HRT
  • A change in mammogram screening patterns
  • She also says that there's controversy about the declining rates of breast cancer and why they've gone down over recent years.

What about the different kinds of HRT? Do they all work the same way? Are they safe?

Dr. Manson says there isn't much research on HRT formulations and breast cancer. There are many different formulations:  estradiol, conjugated estrogens, transdermal (through the skin), oral, micronized progesterone, and synthetic progestin. But there aren't any rigorous clinical studies to compare the formulations.

  • The strongest evidence shows that adding progesterone therapy increases the risk of breast cancer when compared to estrogen alone.
  • Dr. Manson says there's no conclusive evidence that low dose HRT is safer than higher doses when it comes to breast cancer. But she feels it's a reasonable assumption based on breast density studies, animal research and clinical evidence.
  • There's also no evidence that taking estrogen and progesterone daily causes more harm than taking daily estrogen with cyclic progestin.
  • The North American Menopause Society says that FDA approved estrogen applied to the skin (via patches, gels, and sprays) and low-dose estrogen pills have shown a lower risk of blood clots and strokes than standard doses of estrogen pills. But studies directly comparing oral vs. transdermal hormone therapy still have not been done.
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What about bioidentical hormones? What does Dr. Manson think about them?

Bioidentical hormones are chemically identical to those made by the human body.

  • There's no evidence that bioidentical HRT carries a lower risk for breast cancer than traditional HRT (Traditional HRT includes the brands that have been studied most, probably because they've been around the longest - like Premarin and Prempro by Pfizer.).
  • Women have been led to believe that bioidentical HRT is safer and more effective than traditional HRT, but there's no evidence that's true.
  • Bioidenticals require a prescription and usually contain estradiol, the predominant form of circulating estrogen in women, estrone, or estriol. These estrogens are made from yams and soy.
  • Bioidentical progesterone is progesterone that has been finely ground or micronized to be more easily absorbed by your body.
  • Bioidentical hormones are approved and regulated by the FDA.

How about compounded bioidentical hormones?

Compounded bioidentical hormones are made by a local pharmacy according to the prescription your doctor writes.

In some cases compounded hormones work well. For example, in women with a peanut allergy or if a certain dose or mixture isn't commercially made, custom-made HRT may be the best choice. But compounded bioidentical hormones have their drawbacks:

FDA-approved bioidentical hormones are made in monitored facilities. They are widely available and are safe and effective in clinical trials. So according to a study by Santoro et al. published in the Journal of Clinical Endocrinology & Metabolism,

"there is no rationale for the routine prescribing of unregulated, untested, and potentially harmful custom-compounded bioidentical HTs (hormone therapies)."

Are there any natural solutions? Do botanicals work on the symptoms of menopause?

The American College of Obstetrics & Gynecology's practice guidelines say that complementary botanicals and natural products (soy, Chinese herbs, black cohosh) haven't been shown to be effective. They're not regulated so there's no guarantee that they will be safe.

Traditional HRT:  Premarin, Prempro & Premarin Vaginal Cream (+ Ways to Get Discounts)

Premarin (estrogen) and Prempro (estrogen & progesterone) are considered "traditional" formulations because they've been around so long. As mentioned above, Premarin was the first formulation approved by the FDA. Unfortunately, there are no generic versions - and they tend to be higher priced than bioidenticals. If your doctor prescribes them, give Pfizer a call. You might qualify for a discount from the manufacturer.

Discounts on HRT (Premarin & Prempro) through Pfizer:  https://www.pfizerrxpathways.com/?step=1

Call Pfizer Pathways:  1-844-989-PATH (7284)

Discounts on Premarin Vaginal Cream through Pfizer:  https://www.premarinvaginalcream.com/savings-and-support

You might also try Blink Health for HRT pricing:  https://www.blinkhealth.com/about-us

Call Blink Health:  1-855-979-8290

How long does HRT take to work?

It can take a few weeks to feel better. Most doctors will prescribe a low dose and then slowly increase the dose until you get relief from your symptoms.

Is there anyone who should not use hormone replacement therapy?

Contraindications to Oral Estrogen:  active gallbladder disease, elevated triglycerides, history of a blood clot in a vein, known thrombophilia (abnormal blood clotting like factor V Leiden). Women who get migraine headaches with auras are often prescribed transdermal estrogen.

Contraindications to Estrogen + Progesterone:  breast cancer, coronary artery disease, active liver disease, high risk endometrial cancer, unexplained vaginal bleeding, TIA (mini-stroke), stroke, pregnancy, or blood clot in a vein or lung. If you are allergic to peanuts, you should tell your doctor.

Are there any side effects?

*Regular mammograms and breast exams to screen for breast cancer are recommended.

Mild Side Effects of Estrogen:  bloating, breast tenderness, swelling, nausea, leg cramps, indigestion, headaches, vaginal bleeding

Mild Side Effects of Progesterone:  breast tenderness, headaches, migraine headaches, swelling, depression, mood swings, acne, abdominal pain, vaginal bleeding, back pain

*Most mild effects pass after a couple of weeks. If they don't, your doctor may recommend changing your HRT formulation or dose.

Watch JoAnn E Manson, MD, DrPH, speak about personalized menopause management.

So Are Doctors Changing Their Stance on Hormone Replacement Therapy?

It seems that many med school graduates, internal medicine and obstetrics & gynecology residents get very little training in menopause management. Other doctors don't keep up with latest research and changing treatment options. So it shouldn't come as a surprise that many don't feel comfortable managing the symptoms of menopause. And prescription rates remain low despite studies showing HRT is safe when prescribed for women without any contraindications during perimenopause or early menopause.

The challenge for you will be finding a doctor who keeps up with the latest research on menopause and HRT.

8 Things the North American Menopause Society, the American Society for Reproductive Medicine, and the Endocrine Society Agree on Regarding HRT.

Hormone replacement is the most effective way to get relief from hot flashes. And many experts agree that most healthy, recently menopausal women - without any contraindications - can use hormone therapy for relief of their symptoms of hot flashes and vaginal dryness.

  1. Hormone therapy is an option for healthy women with moderate to severe symptoms of menopause. The best candidates are women up to age 59 or within 10 years of menopause.
  2. For vaginal dryness or discomfort with intercourse, the preferred treatment is low doses of vaginal estrogen.
  3. Hot flashes usually require a higher dose of systemic estrogen therapy.
  4. The risks and benefits should be considered on an individual basis, for example a woman's quality of life vs. her age, time since menopause, and risk of blood clots, heart disease, stroke, and breast cancer.
  5. There is not enough data to support the use of hormone therapy in women who have had breast cancer. Non-hormonal therapies should be the first approach in managing the symptoms of menopause in women who are breast cancer survivors.
  6. Both estrogen AND estrogen + progesterone increase the risk of blood clots in the legs and lungs. However, the risk is rare in women from 50 - 59.
  7. There is an increased risk of breast cancer with 5 or more years of continuous estrogen / progesterone therapy, possibly earlier. This risk decreases after a woman stops HRT. For this reason, the recommended duration for estrogen + progesterone is 5 years or less.
  8. The WHI trial showed that the use of estrogen alone for an average of 7 years did not increase a woman's risk of breast cancer.

The research is leaning towards a timing theory (called the critical window theory). That is, the closer to menopause that HRT is started, the better the benefits - 10 years or more past menopause is too late.

Opinions are all over the place. I wouldn't expect you to come away feeling like you've found all the answers. As far as I can tell, right now, no one knows for sure what the best course of action is. And things will continue that way until new research shows us a clear path.

I think this comment on Dr. Harriet Hall's Estrogen Matters post sums it up pretty well. The comment is posted by "Who?" She says:

"HRT has now given me back my quality of life in my 50s. Are there risks? I understand so. However, life brings with it a 100% risk of death. It's about understanding the risks, mitigating the ones you can, and deciding what's important to you at your stage of life."

It's about empowering women to make the best choices for themselves! Good luck!

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References:

Peter Attia MD Podcast #42 – Avrum Bluming, M.D. and Carol Tavris, Ph.D.: Controversial topic affecting all women—the role of hormone replacement therapy through menopause and beyond—the compelling case for long-term HRT and dispelling the myth that it causes breast cancer

https://sciencebasedmedicine.org/estrogen-matters/

https://estrogenmatters.com/

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https://www.fertstert.org/article/S0015-0282(05)03422-9/fulltext  A critique of the Women’s Health Initiative hormone therapy study

https://www.nurseshealthstudy.org/about-nhs

https://academic.oup.com/humrep/article/18/11/2241/644070  Issues to debate on the Women's Health Initiative (WHI) study. Epidemiology or randomized clinical trials—time out for hormone replacement therapy studies?

https://www.nytimes.com/2003/04/22/science/hormone-studies-what-went-wrong.html

https://www.2minutemedicine.com/nurses-health-study-estrogen-associated-lower-cardiovascular-disease-risk-classics-series/

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2670363/  Current breast cancer risks of hormone replacement therapy in postmenopausal women

https://www.ncbi.nlm.nih.gov/pubmed/15883114/  Appropriate use of hormones should alleviate concerns of cardiovascular and breast cancer risk

https://jech.bmj.com/content/59/9/740 Hormone replacement therapy, cancer, controversies, and women’s health: historical, epidemiological, biological, clinical, and advocacy perspectives

https://www.aarp.org/health/conditions-treatments/info-2018/menopause-symptoms-doctors-relief-treatment.html

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https://www.medscape.com/viewarticle/859512  Managing Menopause: Are the WHI Results Being Misunderstood?

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https://www.medscape.com/viewarticle/885292  Menopausal Hormone Therapy: Why Mortality Outcomes Are ‘Vital’

https://www.medscape.com/viewarticle/890522  Hormone Therapy and Chronic Conditions: Let's Get Rational

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https://jamanetwork.com/journals/jama/fullarticle/2653735  Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific MortalityThe Women’s Health Initiative Randomized Trials

https://www.ncbi.nlm.nih.gov/pubmed/15261840  Hormone Replacement Therapy: Controversies, Pros & Cons

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https://www.medicalnewstoday.com/articles/322040.php Why does perimenopause cause ovary pain?

https://www.medicalnewstoday.com/articles/317765.php 10 Essential Menopause Facts

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https://www.ncbi.nlm.nih.gov/pubmed/15852202 Breast Cancer:  The Role of Hormone Therapy

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https://www.medscape.org/viewarticle/573450  Hormone Therapy and Breast Cancer: An Expert Interview With JoAnn E. Manson, MD, DrPH

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https://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with-hormone-therapy doctors get little training and hrt dosing plus bioidentical hormones and compounding

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https://academic.oup.com/jcem/article/101/4/1318/2804494  Compounded Bioidentical Hormones in Endocrinology Practice: An Endocrine Society Scientific Statement

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https://www.endocrineweb.com/news/other-endocrine-disorders/20696-endocrine-society-warns-against-use-custom-compounded-bioidenti

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