One of the most hotly debated topics in women’s health over the last two decades has been whether or not it’s safe to undergo hormone replacement therapy (HRT) when menopause (the end of menstruating years, prompted by a drop in estrogen) is reached.
HRT is prescription medication that helps balance levels of estrogen and progesterone in order to relieve menopausal symptoms, such as hot flashes, night sweats, anxiety, skin issues and loss of libido — to name just a few of the unappealing side effects.
The problem? HRT has a checkered past: Early clinical trials showed that the treatment caused more harmful effects than benefits. But are those health concerns still legit?
Before we get into that, one important note: Though HRT and BHRT (Bioidentical Hormone Replacement Therapy) are sometimes used interchangeably, they are different — the major difference being the substances used to create them: BHRT is derived from plant sources that are chemically similar to the hormones your body naturally produces; Traditional HRT products are made from the urine of pregnant horses and other synthetic hormones.
Below, experts weigh in on where things stand now, in general. Replacement therapy is a complex medical issue —and a personal choice — and the following information is a cursory look at the research on safety and what other factors should be explored before deciding what's right for you.
Is Replacement Therapy Safe?
Although the initial HRT studies conducted by the Women’s Health Initiative in 2002 showed HRT caused harmful effects (such as an increase in coronary disease and breast cancer), "there were many issues with the study's conclusions, which unfortunately caused a great deal of fear in women," explains Jordan Crofton, FNP, Director of Patient Care at THE WELL. "Some women transition smoothly into menopause without the need for hormonal intervention, but for those who are suffering, we know that starting hormones earlier on — closer to the onset of menopause and before age 60 — can be safe and potentially heart and brain protective; the women included in the WHI study were, on average, older. "
In addition, the study looked at Progestin, a synthetic form of progesterone. "Subsequent studies have shown that oral micronized progesterone did not increase breast cancer risk in women treated with transdermal estradiol," says Crofton, adding: "Synthetic hormones do not have the same chemical structure as the hormones we make on our own and waste energy by giving incomplete messages to cells, which then fail to produce a balanced hormonal response. Furthermore, an oral route versus transdermal application impacts risk level."
Julia Walker, RN, concurs, noting that newer guidelines have been created by experts in women’s health and endocrinology. “HRT is considered the most effective solution for serious menopausal symptoms, such as hot flashes, night sweats and vaginal dryness,” she says. “And many of the safety concerns around HRT have been clarified or debunked, in particular for women under 59.”
Elaborating a bit more, Tara Cullen, NP, the chief nursing officer at Sollis Health, says: “The risks and benefits of HRT are varied based on the patient’s medical history, the type of hormone prescribed and also the form that it is given in.” HRT can be delivered in various forms, including pills, vaginal rings, implants, patches and creams — and there are differences in how each works and affects the body.
At THE WELL, practitioners assess each patient individually to see if they're a good candidate for hormone replacement therapy, and, says Crofton, "I personally prefer bioidentical hormones (BHRT). Hormone replacement is an art and a science — I certainly don't believe in giving everyone who walks in the door hormone replacement therapy. I use a precision medicine approach — when a woman is the right candidate for BHRT, her prescription is tailored and individualized to her specifically, based on symptoms, history and comprehensive testing."
Cullen adds that the safety and efficacy of replacement therapy will likely continue to be studied and references one study conducted at the University of Southern California that showed some promising benefits of HRT in the heart health of menopausal women.
Is Replacing Hormones the Only Remedy?
Beyond whether replacement therapy is safe lies another question: Is it necessary? “Thinking the solution is simply to add more hormones is not nuanced enough,” says Alisa Vitti, a hormones expert and founder of FLO Living. “Instead of looking at perimenopause and menopause as disorders of hormone deficiency that require adding replacement hormones, we should look at them as a much more complex network of changes that need dietary and lifestyle management.”
From a functional nutrition perspective, “dietary and lifestyle improvements also move the needle dramatically as insulin and cortisol, metabolic hormones, affect reproductive hormone levels.” For example, Vitti cites this study , which showed cortisol levels from lack of sleep, worry and overwork can decrease growth hormones, increase the risk of cardiac issues, increase weight gain and worsen menopausal symptoms.
Traditional Chinese Medicine practices (such as acupuncture) can also be tremendously helpful in balancing hormones. “By utilizing various therapies, we can boost and regulate vital energy, called Qi, to support the body throughout perimenopause and menopause,” says Jessica Sowards, MS, LAc, THE WELL Director of Chinese Medicine and Acupuncture.
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“In Traditional Chinese Medicine, we believe that most things in the body can be divided into either Yin or Yang — Yin representing female, moon, nighttime and water and Yang representing male, sun, daytime and fire,” explains Sowards. “Menopause is when a woman's Yin factors dramatically reduce in quantity. Through specific acupuncture needles, bespoke herbal prescriptions, dietary and lifestyle changes, we can help boost and nourish Yin factors to balance a woman through the transition of menopause.”
A few natural Yin boosters, according to Sowards:
- Eight (or more) hours of sleep
- Sesame oil massage
- Clean, wild-sourced fish and fish oils
- Flax seeds
- Organic soy
- Diet of healthy meats, fats, veggies and warm cooked foods
Sowards recommends avoiding Yang boosters such as too much coffee, late nights, alcohol (especially wine!), sugar, fast food, gluten, dairy and commercial soy.
How to Know What's Right For You
Like many medical choices, one of the biggest factors in deciding if replacement therapy is a road you want to go down is family history; HRT is typically not recommended for women with a history of breast, ovarian or womb cancer, blood clots or liver disease. “The patient, along with their health provider, need to review and discuss the risks and benefits prior to making a decision,” says Cullen.
"For patients with a past history of breast or uterine cancer, there are non-hormonal tools. Research shows that many women respond well to Siberian rhubarb for vasomotor symptoms (aka hot flashes and night sweats) and applying hyaluronic acid with aloe can help with vaginal dryness," says Crofton.
Still, regardless of whether you opt for replacement therapy or not, Vitti emphasizes the importance of adjusting your diet, exercise and lifestyle habits to match what your body needs in this new chapter. Moreover, she encourages making changes in your twenties and thirties as part of the long game of hormonal management during the aging process.
“Key supplements started around 35 years old, when perimenopause begins, can dramatically lessen the experience of symptoms as a woman goes through this natural process,” says Vitti, adding: “A major study a few years back showed how increasing consumption of beans and omega-3-rich fish two to three times per week delayed the onset of menopause by up to three years.”
When it comes to a Functional Medicine approach, hormones alone aren't the complete story. "We now have the ability to look at a woman's genetic pathways to better understand how her body detoxifies, which is hugely important when it comes to hormonal metabolism and balance. There are herbals and nutraceuticals we can utilize in combination with hormone therapy to mitigate potential side effects and optimize response," says Crofton.
To learn more about how THE WELL can help with hormone health, go here.