By Dr. Mercola
Hormone replacement is a complex topic, and medical recommendations have fluctuated back and forth when it comes to replacing hormones like estrogen in women suffering from symptoms of menopause and surgically induced medical menopause following a hysterectomy.
In the past, hormone replacement therapy (HRT) was also widely prescribed for preventive purposes, based in part on early observational studies that had suggested it could help protect women against heart disease, weak bones, and dementia.
In fact, many may not know this, but I was a paid speaker for the drug companies in the mid-80s, promoting the benefits of hormone replacement therapy. This was about 10 years before I converted to natural medicine and 15 years before the landmark studies showed the serious dangers of standard hormone replacement therapy.
The tide quickly turned a decade ago...
In July 2002, the 15-year long Women's Health Initiative (WHI) abruptly ended its combination of estrogen and progestin therapy study, three years ahead of schedule, when their data revealed higher rates of breast cancer, heart attacks, strokes, and blood clots in the population taking the hormones, compared to those receiving a placebo.
The WHI findings triggered enormous changes in the use of hormone therapy, and by 2003, prescriptions had dropped by 38 percent.
Between 2001 and 2011, estrogen replacement therapy in women aged 50-59 subsequently dropped by a whopping 79 percent. Now, a new study1 suggests that denouncing the use of HRT across the board may have been a mistake, especially for women having undergone a hysterectomy.
This certainly makes sense, since your body needs estrogen and other sex hormones for optimal functioning. As reported by both Forbes2 and Time Magazine3, anywhere from 18,600 to as many as 91,600 women in medical menopause may have died prematurely over the last decade as a result of avoiding estrogen replacement.
According to the study4, a conservative estimate of the true number of deaths caused by estrogen avoidance is likely to be around 50,000:
“Estrogen therapy in younger postmenopausal women is associated with a decisive reduction in all-cause mortality, but estrogen use in this population is low and continuing to fall.
Our data indicate an associated annual mortality toll in the thousands of women aged 50 to 59 years. Informed discussion between these women and their health care providers about the effects of ET is a matter of considerable urgency.”
Avoiding HRT May Have Killed 50,000 Women Over the Last Decade
As reported by Time Magazine5, and discussed in the featured video:
“Before the WHI study, about 90 percent of women who had a hysterectomy would have relied on estrogen therapy to replace what their reproductive system no longer produced. Following WHI, however, 10 percent of these women used the hormone, and based on a formula the researchers created to estimate their survival rates, they determined that 50,000 women died during the study period, between 2002 and 2011, prematurely.
[N]one of these women, who were aged 50 to 59 at the start of the study, lived to reach their 70s. Most died of heart disease, bolstering the connection that earlier studies had found between estrogen-only therapy and a lower risk of heart problems among women who had a hysterectomy.”
The study found that estrogen therapy for women in premature surgical menopause was associated with “a decisive reduction in all-cause mortality,” primarily by reducing deadly heart attacks and deaths from breast cancer. The researchers believe the protective effect found in their study may be due to the fact that they only analyzed the effects of estrogen-only therapy, not the combination treatment of estrogen and progesterone used in the Women's Health Initiative (WHI) and other studies finding troublesome effects.
“It may be that the combination HRTs are what fuel the negative health effects seen in previous studies,” Forbes writes.
But the featured media reports fail to mention that in April 2004, the WHI also halted the portion of the study for estrogen-only therapy, upon finding the hormone did not offer any protective heart disease prevention, but rather increased your risk of stroke and blood clots.
Indeed, many large-scale trials, besides the WHI, have indicated that taking estrogen alone, or the combination of estrogen and progestin, increased women's chances of developing not only strokes, but also dementia, deep vein thrombosis, urinary incontinence and gallbladder disease. There are several factors to seriously evaluate when considering if hormone replacement therapy would be wise for you or someone you love.
- Surgically-induced menopause vs. natural menopause vs. using HRT for preventive purposes
- Your age
- The form of hormone you take (bioidentical vs. synthetic). For example, the WHI study used one specific formulation of HRT called Prempro, which contains potent horse estrogens that are manufactured from the urine of pregnant mares, in combination with a synthetic (read FAKE) form of progesterone (medroxyprogesterone acetate). It's likely that bioidentical natural formulations would have resulted in a different outcome...
- The manner in which you administer the hormone
Should Women in Medical Menopause Use Estrogen?
Just last year, the US Preventive Services Task Force updated its recommendations on hormone replacement therapy6 based on review of the available evidence, advising women over the age of 50 to avoid HRT—either estrogen alone, or in combination with progestin—for the purpose of preventing heart disease, osteoporosis, and cognitive decline. The recommendation to avoid HRT does not apply to women younger than 50 who have undergone surgical menopause or who are taking hormone therapy to manage menopausal symptoms such as hot flashes.
Once you undergo a hysterectomy before menopause, it is highly likely you need to replace the hormones lost since your body can no longer produce them on its own. So yes, most women in surgical menopause would be well advised to consider HRT. The issue at that point is more a matter of selecting the most appropriate form of hormone replacement. Many experts believe the bioidentical hormone estradiol is all you would really need.
Unfortunately, doctors have, and still often do, prescribe an HRT regimen that includes the completely unnatural progestin. Progesterone is made by a woman's ovaries, and helps balance the effects of estrogen. Bioidentical progesterone, which is completely natural, can be created from certain oils in yam and soy plants. Your body recognizes this bioidentical formulation, which helps prevent adverse reactions, as long as it's prescribed and administered appropriately and in the correct dose. However, natural progesterone cannot be patented, which is where progestin comes in. Progestin is a synthetic form of progesterone that mimics the actions of progesterone, and when it comes to medicine, patent is king, since without it, there's not much profit to be made by the pharmaceutical companies.
Beware of Synthetic Hormone Replacement
Synthetic progestins (like Provera) are responsible for many, if not most, of the detrimental side effects of HRT. For example, one meta-analysis published in the British Medical Journal in January 20057 found that synthetic HRT is linked to an increased risk of stroke, typically ischemic (caused by blockages of blood flow to your brain). In fact, synthetic HRT boosts your risk of stroke by almost one-third, and your risk of fatal or disabling stroke by more than half.
One of the trials reviewed in that meta analysis also linked synthetic HRT with higher risks of both breast cancer and heart attack. The trial (which included almost 17,000 women over 50), also found taking HRT for five years doubled your risk of life-threatening blood clots. Other potential side effects of HRT include:
- High blood pressure
- Vaginal bleeding
- Skin rashes and acne
- Weight gain
Ideally, Use Bioidentical Hormones
Premarin (the most popular estrogen replacement) comes from horse estrogens and is not bioidentical. While it may sound “natural,” I recommend avoiding animal estrogens for hormone replacement, as there are excellent human bioidentical estrogen hormones easily available through any compounding pharmacist. Your body recognizes these as “normal” and virtually identical to the hormones produced in your body, which makes them far safer than synthetic prescription versions.
There are three types of estrogens commonly used in bioidentical hormone replacement therapy: estrone, estradiol, and estriol. A common mixed formulation known as Tri-est includes 80 percent estriol with 10 percent each of estrone and estradiol.
Estradiol is the primary human female hormone found in all premenopausal women, whereas estriol is produced in significant amounts during pregnancy. Estriol is considered the safest of the three and is the most commonly prescribed. It has been used safely for decades, and I believe it's particularly useful when you've had a hysterectomy.
Unfortunately, there is still much unnecessary concern about bioidentical estrogen supplementation. What the FDA, most doctors, and patients do not realize is that bioidentical hormone supplements can actually optimize your health. That said, your hormone levels should ideally be monitored by either blood, urine, or saliva, to ensure they reach a target level that corresponds to the reference ranges for healthy young women. I also believe that menopausal hot flashes that do not resolve with phytoestrogens such as black cohosh, are another valid indication for short-term estrogen use. However, if estrogen is used, it is nearly always wise to use it in conjunction with natural progesterone.
The Best Way to Administer Bioidentical Hormones
Keep in mind that when it comes to administering bioidentical hormones, some delivery methods are clearly superior to others. Oral supplementation is perhaps your worst option, as your liver processes everything in your digestive tract first, before it enters your bloodstream, which will metabolize most of the swallowed hormones to inactive and potentially harmful derivatives. Any method that bypasses your liver will therefore be more effective.
Hormone creams are one common alternative that achieves this. However, since hormones are fat-soluble, they can build up in your fatty tissues and lead to having too much in your body. This in turn can disrupt other hormones. It's also near impossible to accurately determine the dose when using a cream. Sublingual drops can be a good option, as it enters your blood stream directly and will not build up in your tissues like the cream can. It's also much easier to determine the dose you're taking, as each drop is about one milligram.
In the 90s, I prescribed transdermal progesterone cream based on the now deceased Dr. John Lee. That worked well for most of the women but after 3-6 months most started to lose the benefits. However, I now believe the ideal delivery method is via trans mucosal administration. For more information about this, please listen to my interview with Dr. Wright. Administration methods are discussed toward the end of this interview.
Educate Yourself on the Risks and Benefits of HRT
As you can see, HRT is a very complex subject where it's virtually impossible to make blanket statements covering a majority of women. The risk versus benefit ratio is likely to shift depending on which camp you're in here. Factors to take into consideration are:
- Have you had a hysterectomy?
- Are you pre- or post-menopausal?
- And are you considering HRT for prevention of chronic disease, opposed to treating symptoms of menopause?
Keep in mind that treating hormone imbalances requires a holistic approach; the best approaches are often preventive and involve diet, exercise and other lifestyle-based strategies. For instance, both estrogen and progesterone are necessary in the female cycle, and their balance is key for optimal health. Many women have an imbalance of these hormones, regardless of their age. And if you have insufficient levels of progesterone to counter excessive estrogen, this imbalance can be further exacerbated by chronic stress.
So your answer—provided you're not in surgical menopause due to hysterectomy—might not necessarily lie in using hormones, but rather in addressing your stress levels so that your body can normalize your hormone levels naturally... Refined carbohydrates, processed and heated fats, empty foods -- and too much of them -- all serve to raise your estrogen to abnormal levels, as much as twice the normal, which are maintained for the better part of the adult lives of most American women. This is a MAJOR contributing cause of menopausal symptoms in the first place.
For some women, consuming phytoestrogens (plant-estrogens), such as licorice and alfalfa, before menopause can also help moderate your day-to-day estrogen levels so that when menopause comes, the drop won't be so dramatic. (Beware, however, that soy is not a good option here.) You'll also want to make sure your vitamin D levels are optimized, as this is a must for gene regulation and optimal health.
Certain polyphenols have also been shown to have some HRT-like benefits without the drawbacks, and are associated with a lowered risk of heart disease. Royal Matcha seems to be an amazing adaptogenic herbal solution for menopause that has helped many women. Be sure to avoid the inexpensive varieties, as they typically don't work. If you choose this option, make sure to obtain the authentic version from Japan. You'll also want to get plenty high-quality animal-based omega-3 fats, such as krill oil, and Black Cohosh may help regulate body temperature and hot flashes.
If you're in medical menopause, avoiding HRT due to fears about side effects could be a mistake. I recommend discussing your individual situation with an endocrinologist well-versed in bioidentical hormone replacement to discuss risks and benefits and devise an appropriate treatment plan.