Considering Hormone Replacement Therapy? Here are The Facts You Need to Know

Considering hormone replacement therapy? There's so much confusing and contradictory information out there. We've gathered together facts, based on science, that you need to know including: What is hormone replacement therapy?, The differences between standard HRT and bioidentical HRT, how to find a menopause specialist, some of the many misconceptions about hormone replacement therapy, and a personal story of what it's like to start hormone replacement therapy.

Hormone Replacement Therapy. Everyone's got an opinion about it, it seems, and everyone's opinion is different. Your aunt says not to take it because your family history precludes it. Your girlfriend says bioidentical hormones are the only way to go. Your Facebook Friend wrote that Big Pharma is lying to you about commercial HRT and it's made from horse urine and is that what you want in your body? Your doctor only has fifteen minutes to talk to you and says whatever you decide is fine with him.

As I said, everyone's got an opinion, so if you're considering hormone replacement therapy or if you would just like to know more information about it, here are some facts - backed by science - that you should know.

This is part of an on-going series on Midlife Rambler, Real Talk about Menopause. Too many of us (including myself) don't fully understand what's happening and don't know where to go to for accurate information. I am not a doctor and this is not medical advice but I'm hoping to provide some of the information I wish I had known when I went through menopause and give you some resources to check out if you want to learn more. 

More Real Talk About Menopause

What is Hormone Replacement Therapy?

Simply put, hormone replacement therapy uses hormones (either synthetic or bioidentical) to supplement or even replace the hormones your body is no longer making. If you're considering hormone replacement therapy, you have several options available to you depending on:

• The symptoms you want to alleviate
• Your current hormone levels
• Other existing health conditions you may have

Signs Hormone Replacement Therapy May be Right for You

If menopausal symptoms such as hot flashes, night sweats, sleep difficulties, or vaginal dryness are severe enough to affect the quality of your life, you could be helped by hormone replacement therapy.

You don't need to be fully menopausal to start HRT; many women start HRT during perimenopause.

Types of Hormone Replacement Therapy

So much of the information about hormone replacement  is confusing and contradictory. You'll hear the terms bioidentical, synthetic and natural thrown around, for example, but there can be overlap between all those categories.

Broadly speaking, hormone replacement therapy can be broken down into two types:

Standard Hormone Replacement Therapy - These are FDA-approved medications, available in standard dosages and prescribed by doctors, containing either Estrogen, Progestin or a mix of Estrogen and Progestin. 

Compounded BioIdentical Hormone Replacement Therapy - Compounded Bioidentical Hormone Replacement Therapy is a customized prescription made for an individual patient. Typically, the prescriber will conduct a series of lab tests before creating a customized prescription which is then created by a compounding pharmacy - a pharmacy which specializes in creating medications that aren't commercially manufactured.

Common Misconceptions About Hormone Replacement Therapy

Again, there is soooo much confusing, contradictory and misleading information out there. Here's just a few of the misconceptions about HRT.

Misconception #1: You Should Avoid Hormone Replacement Therapy Because It Could Give You Cancer

This common misconception is still prevalent even among some doctors because of all the publicity around a 2002 study of the risks and benefits of hormone replacement therapy which was halted because the researchers found an increased risk of invasive breast cancer.

But what about that study that had to be halted because it showed HRT caused an increased risk of blood clots and stroke? It turns out that the study, which took place in 2002, was poorly designed. More than 70% of the women in the study were over 60, long past the age when most women go through menopause and are having hot flashes. When these women were removed from the study and only the results from  women ages 50-59 were evaluated, the study results did indeed show that HRT caused a decrease in heart disease.

(As a side note, this is the perfect example of why we need more women in the sciences. I can just see the study designers thinking to themselves, "All women over 50 are old, right? So, we'll just study all women over 50.")

Misconception #2: All Women in Menopause Can Benefit from HRT

I call this the Suzanne Somers Theory of HRT as she has famously said, "When the brain perceives you are no longer reproductive because your hormones are out of balance, it tries to get rid of you, and it usually activates the cancers in perimenopause."

That's actually not true and what's more, current guidelines state that HRT isn't right for you if you've had breast cancer, ovarian cancer, endometrial cancer, blood clots in the legs or lungs, stroke, liver disease, or unexplained vaginal bleeding. 

These conditions have proven links to the amount of estrogen in a woman's body so it makes sense to not add additional estrogen if at all possible. You're typically discouraged from HRT if you have a close family relative with a history of these conditions as well.

This applies to both standard hormone replacement therapy and compounded bioIdentical hormone replacement therapy, by the way. Anything that adds estrogen to your body can increase your risk in these cases. I read this horror story recently:

Pinkerton tells of a 65-year-old patient whose naturopath put her on an estrogen product and an alternative anti-aging protocol for years. What the naturopath apparently didn't factor in was the patient's breast cancer history, which had been a large, node-positive, estrogen-positive cancer. Pinkerton checked the woman's blood and found very high levels of estrogen. "If she had any cells that escaped [her breast cancer treatment] she could be feeding them," Pinkerton says.

This whole article is excellent. If you have questions about standard HRT vs compounded HRT, I encourage you to read it.

Speaking of Standard HRT vs compounded HRT, they have their own set of misconceptions that should be addressed.

Misconception #3: Bioidentical Hormone Replacement Therapy Means Compounded Bioidentical Hormone Replacement Therapy

Bioidentical hormones simply refer to hormones that are chemically identical to the hormones created by your own body. In theory, at least, your body should react to these hormones just as it does to these hormones when they are produced by the body.

We tend to think of bioidentical hormone replacements as those natural hormone supplements touted by celebrities such as Suzanne Sommers and Oprah Winfrey, but the truth is standard hormones prescribed by doctors can also be bioidentical. For example, the HRT supplement I take, Activella, contains a bioidentical form of estrogen (estradiol) and non-bioidentical form of progestin (norethrindrone acetate). The FDA recently approved Bijuva, which consists of a bioidentical form of estrogen and a bioidentical form of progestin.

Bioidentical is considered a marketing term, not a medical term and it's often used interchangeably with "natural," which brings us to our next misconception.

Misconception #4: If Something is Natural, then It's Good for You

You may also hear some hormone replacement therapy solutions referred to as "natural." The word natural simply means that the source of the hormone is either plant- or animal-based. Technically, the hormone everyone loves to hate on, Premarin, is a "natural" hormone since it's derived from the urine of pregnant mares. However, it is then processed in a lab so it's classified as a synthetic hormone. The bottom line - the word "natural" doesn't mean that  a choice is necessarily better for you than any other choice.

Misconception #5: Compounded HRT is Safer than Standard HRT

You might hear that a compounded HRT option is safer than Standard HRT but there's certainly no proof that's the case. HRT from a compounding pharmacy may not come with the same list of side effects and other warnings that you receive from HRT you pick up at your local CVS but that's only because these individually prepared compounds do not have FDA approval. There's no testing to verify that the amount of hormone listed on the label is what's actually in the drug.

Additionally, compounding pharmacies are required to be licensed by their state boards but they receive no other oversight. In 2012, a large outbreak of meningitis was eventually traced back to steroid injections created by The New England Compounding Center. Sixty people died. 

This doesn't mean that there aren't cases where compounded HRT is better for you than standard HRT. My doctor, for example, offers both options. Just be sure to discuss all the pros and cons with your doctor.

What To Do if You're Considering Hormone Replacement Therapy

If you're considering hormone replacement therapy and you don't already have a relationship with a physician specializing in women's health, then I would encourage you to visit The North American Menopause Society's website and find a menopause clinician near you. As we've seen, there are so many misconceptions about hormone replacement therapy that even conventional doctors still believe so you're really best served by finding a specialist with the most up-to-date knowledge and training.

Real Talk about Hormone Replacement Therapy: My Story

Everything I've written in this article so far can be found on the Internet, although not all in one place. Some of it can only be found with great difficulty, believe me. But I have seens almost no real-life stories where women share their own experience with hormone replacement therapy so I wanted to share mine.

Perimenopause was a breeze for me. I had almost no symptoms except for occasionally having some issues sleeping and sometimes feeling like I was a little hot. No heavy bleeding, no never-ending periods, none of that. Instead, my periods went from every month on the dot to every couple of months, every three months, every six months, and then finally I realized it had been a year since my last period.

Best menopause ever!

Until the night I woke up drenched in sweat.

And just like that, every night turned into a battle between my body and me. It really felt like never-ending ocean waves or birth contractions. I could feel the heat rising in my body, I'd start to sweat and throw off the blanket, the heat would continue to  build until finally it peaked. I could feel the heat subsiding, like a contraction easing, and then I'd be damp with sweat and freezing so I'd pull the blanket back on me and wait for it to happen again. 

I have no idea how many times a night this would happen. It felt like 1000, but I honestly do think it was at least once an hour. I wasn't sleeping obviously so I had no energy during the day and I couldn't concentrate. I really felt like I was going through a form of torture.

I think it was less than two weeks before I made an appointment with my doctor and I remember her laughing because I had had my annual visit less than two months earlier and had told her that everything was just fine. That's how fast everything happened.

We talked through all my options and, with her help, I chose standard hormone therapy as I have no risk factors precluding this and I'm the type of person who is more reassured than concerned by FDA-approved medications. She prescribed the lowest dose of Activella, which contains both estrogen and progestin, and we scheduled a follow-up visit to check my hormone levels and see how I was doing.

I'd love to tell you that I filled the prescription and felt back to normal from that moment on, but the truth is more complicated. Hormone surges tend to make me nauseous; I used to always get sick when I started birth control pills and I won't even discuss my experiences with morning sickness during pregnancy just in case the memory makes me sick again.

So I spent a good two weeks in the worst of both worlds: the hot flashes continued but now I was also sick to my stomach all day long. I was backing out of my driveway one day on the way to work when it suddenly occurred to me that if you're feeling sick because of a new medication, that still counts as being sick. I pulled back into my garage and went back to bed.

That was a turning point for me. I started feeling better almost immediately. Unfortunately, while my hot flashes did ease up a bit, they still continued so my doctor increased my dose at our next visit. 

She also continued to monitor my hormone levels. At our next follow-up visit, I reported that my hot flashes were mostly gone but I still suffered from an extreme lack of energy. She considered prescribing testosterone, but decided against it because my testosterone levels were well within the normal range. I'm glad she didn't because I eventually started feeling more like myself again without adding any additional hormones.

I've been on my current HRT regimen for five years now. Some doctors believe that you shouldn't take HRT any longer than five years, but many others believe that it's fine to stay on the regimen as long as it seems to be helping and you're not experiencing any health issues. I'm sure we'll reevaluate the issue sometime soon, but considering that hot flashes can last for years, I'm happy to stay on it until she believes I need to stop.

Lessons You Can Learn from My Story

• Find a doctor you trust, one who is comfortable giving you options and making you a partner in your care. Check the North American Menopause Society's website for a list of menopause specialists if you don't already have a relationship with a doctor.
• Be patient with the process. You may not feel "back to normal" right away and your doctor may need to tweak your prescription along the way.
• Continue to follow-up with your doctor until you're happy with how you feel.

What's your experience with HRT? Share in the comments!

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