In today’s world of corporatized healthcare, where a premium is paid on seeing as many patients in the shortest amount of time possible and most medical care—especially peri-menopausal and menopausal care—is based on a “cookbook” approach (whether it be by traditional primary or gynecologic practitioners or so-called, usually franchised “BHRT Practitioners,”), there is much confusion when it comes to hormonal therapy, menopause and sexuality. Good, honest information and true personalization when it comes to therapy is rarely presented by either one’s PCP or general Ob/Gyn.
What is the honest information on hormonal therapy (“HT”) for menopause? What are the pros and cons of hormones, the difference between hormones, the place of hormonal testing and the safety of HT?
What exactly is “BHRT”? Is it more or less safe than “conventional” HT, and how is it prescribed? What, really, is in all those over-the-counter or “alternative practitioner”-recommended herbal and progesterone therapies?
And what about your sex life as you pass through the menopause transition? Are you supposed to just “forget about it” as many PCPs and Ob/Gyns thoughtlessly proclaim as they try to get you in and out of their exam rooms in under 15 minutes?
Read on for the straightforward, knowledgeable and honest answers to these questions. These are the “encapsulated” overviews of this information; you will find more in-depth information on all of these topics in other blogs and elsewhere on this site if you’d like to dive in deeper.
Pros and Cons of HT During Peri-Menopause and Menopause
Hormonal therapy in the form of oral contraceptives (such as birth control pills) can help significantly with the irregular, frequently heavy and generally “weird” bleeding of peri-menopause. When peri-menopause is over and true menopause begins, switching to lower-dose “BHRT” can also help (see below). A well-trained menopause practitioner will know how to tell when this transition occurs.
Therapy with low-dose transdermal (through the skin via patches, creams/gels or implanted pellets) estrogen (estradiol) with or without progesterone may begin during peri-menopause, or may await the advent of menopause, when menses cease. Progesterone may be given to help with anxiety or sleep, as well as to protect the uterus (if present) from potential adverse effects of “unopposed” estrogen on the uterine lining.
Pros: HT/BHRT can control the frequently weird bleeding patterns of peri-menopause (birth control pills work well here) and will eliminate the bothersome, often crazed symptoms of the transition (which can last an average of 7½ years), including hot flashes/night sweats, memory problems, headaches, sleep disturbances, fatigue, disruption of sexual function, mood disruption, etc.
If started close to menopause, HT/BHRT will significantly diminish the risk of cardiovascular death, protect your bones, significantly lower you risk of dementia and colon cancer and improve post-menopausal sexual health. Estrogen helps maintain a healthy collagen layer under the skin and helps with the metabolic problems associated with menopause (weight issues, memory, overall strength and quality of life”). The sooner HT/BHRT is started the better; within 3 years of the last period is best, but certainly within 7-8 years at maximum.
Cons: You have both to pay for this treatment and take it on a regular basis. Women on postmenopausal hormones are more likely to have occasional periods after menopause. Often, you need to work with a knowledgeable practitioner to “get it right.”
If started late (more than 7-8 years after the final manses), there are more adverse and fewer beneficial effects for HT. If taken for more than 10-15 years, there is a small (less than 1%) increase in the risk of dying from breast cancer (along with an approximately 30% diminished risk of cardiovascular death and very significant diminishment in the risk of hip fracture, vertebral fracture, Alzheimer’s and colon cancer).
The Place for Hormonal Testing
There is in reality a very limited need to “test your hormone levels,” especially during the menopausal transition but also afterwards. Hormonal testing is a marketing ploy used by unscrupulous and undereducated cookbook practitioners who recommend “testing your hormone levels to get you balanced.” It simply does not work that way.
First, hormone levels shift day-by-day. Second, there are no “norms” to hormonal balance—different women thrive on significantly varying hormone levels. And third, when you have your blood drawn (an hour, 4 hours, 24 hours or more after your last hormone dose) will result in vastly different results. The confusion is only compounded by saliva testing, which unfortunately has a built-in inaccuracy factor approaching 25%. You will find that the chief individuals utilizing saliva testing are people—chiropractors, so-called alternative practitioners” naturopaths, etc. —who legally cannot order and interpret blood testing. So they say saliva is “better” because they are limited in their scope.
It’s all one big con. Yes, properly done testosterone testing can help. And yes, occasionally estradiol levels can help with a therapeutic decision (although it’s rare). But progesterone testing is always a waste of time and money. Oh, and did I tell you that most of the time, the person ordering the saliva test makes $10-20 off of each test? (Getting the idea…?)
Hormonal “balancing” is best done by an educated, experienced menopausal practitioner. You will never go wrong if you choose an NAMS-Certified Menopausal Practitioner (found on www.menopause.org), as these individuals must study and pass a rigorous full-day exam to become certified.
So What Exactly Is BHRT? Is It True That It’s Safer Than “Conventional” HT?
This is an honest answer here, and not necessarily what you’ll hear from the cookbook franchise “hormone mills” staffed by non-menopause general docs who basically spout company rhetoric.
BHRT stands for “bioidentical hormone replacement therapy.” “Bioidenticals” are synthesized hormones, which are synthesized from plant sterols such as soy and wild Mexican yam in a laboratory to molecularly mimic hormones produced in the human body (estradiol, progesterone, testosterone). All of the estradiol for the world is produced by two factories in Germany (Mallenckrodt Chemicals and Organon Pharmaceuticals) and sold either to pharmaceutical companies who prepare it in various patches, gels/creams or tablets, or to wholesalers who sell it to compounding pharmacies, who then blend it into various creams, gels and pellets.
What you get from a compounder is exactly the same product you get from your regular pharmacy or from a “drug company.” The difference it that one (conventional HT) is FDA-regulated, so you know the exact amount you’re getting and its safety profile, and the other (BHRT) is “approximated,” and there is no research or regulation on the compounded product in regards to how much to give or safety profile.
Personally, I feel that compounding is quite reasonable and safe, but the reality is that the classic BHRT compounded product as prescribed by many undereducated practitioners is definitely less safe than the FDA-approved product, as many “BHRT practitioners” routinely give higher than safe dosages that have never been tested, making the risk of breast cancer theoretically higher than with the tested FDA-regulated product.
What’s In All Those “Alternative Herbal Products” with Names That Sound Like Hormone Therapy?
If you buy a product over the counter, from your chiropractor or alternative practitioner, or from an online site or magazine, even if the name sounds “hormonal,” the product contains no hormones. It’s just clever marketing, relying heavily on the placebo efficacy (which actually can be quite effective if no harm is done). Clever marketers have devised names for these products to make you think that what you’re getting is a hormonal product or a substitute for a hormone.
Only one thing is guaranteed: if it was not prescribed by an MD, DO or qualified NP or PA, there are no hormones in it. It is illegal to sell any estrogen or testosterone product, or any product with more than a very small amount of progesterone in it, without a prescription. That’s why practitioners who legally cannot write prescriptions often tout these frequently useless products. You’re better off sticking with an integrative licensed MD or DO, or a “midlevel” practitioner who has the choice of different technologies and products, rather than someone (frequently a self-named alternative practitioner) who has a good spiel but is prohibited from providing any true medical or hormonal care.
What About My Sex Life During Peri-menopause, Menopause and Beyond?
This is an area of shame for so many medical practitioners! I can’t tell you the huge number of patients who come to me after seeing their family practitioner or general gynecologist with concerns over dwindling sex drive and overall sexual function and are dismissed with the thoughtless comments like “Well, it goes along with age…” or “That’s what happens when you get older…”
Well! Maybe that’s the sad fact of the practitioner’s or general gynecologist’s own life, or more likely they’re in a hurry and it’s easier to just put you off, but the fact is that sex can [continue] to be great into later decades.
Good sex into the 4th, 5th, 6th and 7th decades of life flows from a combination of good general health (stress reduction, proper diet, an ongoing no-nonsense exercise program); good hormonal health (vaginal micro-dose estrogen or substitute, ongoing low-dose transdermal systemic estrogen and possibly testosterone administration); good communication with your partner; the willingness of both of you to re-evaluate and “update” your sexual relationship; and of course your partner’s erectile ability. If the quantity and quality of your sexually intimate relationship with your significant other needs strengthening, do not hesitate to seek counsel from a sexual medicine practitioner—an MD or therapist knowledgeable abpit and interested in women’s sexual needs and issues.
Image source: Susan Dixon