Struggling through perimenopause? Wondering if bHRT (bioidentical hormone replacement therapy) is for you? The TOG team has gotten a lot of IG queries about if bHRT is “safe” and what to consider if you’re in this stage of life. So, we asked Dr. Cassie Wilder, NMD, to break it down for us.
By: Dr. Cassie Wilder, NMD
IN THIS POST:
- What IS bioidentical hormone replacement therapy?
- Goals of bHRT
- A holistic perspective on bHRT
- Why you might consider bHRT
- What makes bHRT unsafe
- Birth control masquerading as bHRT
- If bHRT is a HARD no
- Final thoughts on bHRT
What IS bioidentical hormone replacement therapy?
The term “bioidentical hormone therapy” (or bHRT, which we’ll be using as a shorthand) began as a marketing term for custom-compounded hormones. Now, it usually refers to compounds that have the same chemical and molecular structure as hormones that are produced in the body, the definition that The North American Menopause Society uses.
So what hormones are actually used with bHRT?
A birds eye view of this means we’ll be talking A LOT about estrogen here, however it’s important to note that bHRT is NOT just estrogen. It requires an individualized balance of replacement hormones, depending on symptoms, tolerance, medical history and more.
For persons with a uterus and ovaries, adding in progesterone for example, is required to maintain safety of those organs while on estrogen therapy. (Even if you no longer have a uterus, I’d still consider talking to your doctor about the need for adding progesterone—not a progestin…an actual oral micronized progesterone—to your HRT). Estradiol (estrogen) is very hot, while progesterone is cooling/calming; without progesterone, adding a bunch of estrogen to someone’s system can cause them to feel other side effects.
There is also testosterone replacement therapy, which arguably is the most fun. Your ovaries also make a significant amount of testosterone and when they’re not producing hormones anymore, your testosterone diminishes…as will your sex drive, memory/cognition, muscle mass and did I say sex drive? Adding in testosterone to your bHRT can help combat these things and, with a little finesse, doesn’t have to cause side effects (like cystic acne, oily skin and hair loss).
A good prescriber can help custom create a formulation that addresses your specific needs.
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Goals of bHRT
The goal for bHRT for perimenopause or during menopause is not to pump you full of hormones in the same quantities you had when you were 25—it’s to provide symptom relief and maintenance of vital organs.
A holistic perspective on bHRT
Bioidentical hormone replacement therapy often gets lumped in with its predecessor, plain ol’ hormone replacement therapy, which traditionally utilizes synthetic or manufactured hormones. However, there are a few different things to consider that people who are wary of hormone replacement therapy should take note of. Let’s start there.
Your body produces these hormones naturally
And it’s also natural for perimenopause/menopause to happen as well. That makes the ‘putting unnatural things in our body’ argument moot. Many compounding pharmacies can utilize very clean bases to put hormones in, including coconut oil.
Our life expectancy keeps increasing
Just google “life expectancy over time graphs” and you’ll see that our overall life expectancy has been increasing dramatically over the years—we’ve never really lived this long. Some of these geriatric-based symptoms or conditions (including some of the effects of meno / perimenopause) are relatively new.
Researchers have also historically not included women in many research studies pre-1950s, so what we know about the impact of women’s hormones on women’s biochemistries as we age is also relatively new.
Put those two together and what you do get? A tiny slice of feminism: If taking bHRT can improve the quality of life for women as we age, is that not holistic? I’d argue it IS.
Doing bHRT is not required to survive
So you can do whatever you want. If it doesn’t feel right to do it, don’t. No judgment required.
As your levels of estrogens decrease, your estrogen receptors will start going down over time as well. So a few years into perimenopause, when your number of receptors has decreased, you might not need as much estrogen anymore.
It’s easy to quit
In general, there are really no repercussions if you start bHRT and then decide it’s not for you. Say you start bHRT, and feel like it’s not giving you the results you want or it’s too expensive or you just aren’t having terrible symptoms—you can stop, the hormones will detox out through your natural elimination pathways and then they’ll be gone from your system…no harm, no foul.
The length of time you decide to do bHRT is up to you (unless you develop a hard-no condition—see below). Some women stay on it the rest of their lives and some only do it through the transition of perimenopause and then stop! Most patients who find great benefit from it will generally continue the rest of their lives. Those who just felt like it was so-so will generally quit after the perimenopause symptoms go away.
Now, I do say this loosely because (as I explain below) there will be some prescribers who don’t take into account the totality of risk profile on the patient and make some mistakes there…and there might be repercussions.
Why you might consider bHRT
This transition period looks different for literally every woman. Your transition through perimenopause into eventual menopause is like turning down a dimmer switch—but that dimmer switch has a mind of its own. Day by day or even week by week, your hormones will go up and back down until that dimmer switch is finally shut off.
bHRT can help quell meno / perimenopause symptoms
I like to explain it this way: Your body has millions of estrogen receptors throughout the body, in your brain, uterus, heart, bones, etc. They’re all looking for estrogen to quench their thirst. During perimenopause as that dimmer switch gets turned down, those receptors still WANT that level of estrogen, but your body just isn’t producing it. So their thirst = your symptoms.
It’s this erratic nature of your hormones during this time that causes many of the uncomfortable symptoms that perimenopausal women feel, like:
- Weight gain,
- brain fog,
- vaginal dryness,
- hot flashes,
- loss of muscle tone,
- loss of collagen (can be seen dramatically in the skin over time!),
- and much more.
bHRT essentially replaces or makes up the deficit of what your body isn’t producing to satiate those estrogen receptors. It doesn’t delay menopause—once that train has started, it’ll keep going as it has more to do with how many eggs you have left in your ovaries than your hormone production, but bHRT can be used as symptom management.
Are there other natural options?
There are other things that can help to quench the thirst (like phytoestrogenic herbs and foods), but none as strong as the prescriptive kind. And if the phytoestrogenic herbs and foods quench your symptoms, should you just stop there and not do bHRT? Maybe, maybe not. That’s up to you and your provider to decide.
Other positive health effects of bHRT
Perhaps you’re okay with the symptoms (or maybe you didn’t get any!) of perimenopause. But there are a few health-related effects (vanity related and non-vanity related) that estrogen has on your body that may change your mind about doing bHRT therapy.
👉Estrogen helps keep the bones strong, and helps your body build new bones. Have a family history of osteoporosis? You might want to consider bHRT.
👉Estrogen helps the electrophysiology of the heart—have a family history of arrhythmias or just want to lower your risk of a arrhythmia starting (like PVCs or PACs)? You might want to consider bHRT.
👉Estrogen is integral in the creation of neurotransmitters and maintenance of a fatty brain—without estrogen, you have an increased risk of depression as well as brain atrophy (which could eventually cause dementia).
👉Estrogen helps with maintaining proper insulin sensitivity—low estrogen can cause insulin resistance and further metabolic disease such as diabetes.
👉Estrogen has SO MUCH beneficial effect on skin elasticity and collagen production. One of the reasons babies have such soft skin is all their subcutaneous fat (right below their skin). Lack of estrogen makes that fat go away and decreases collagen production, causing the hands to start looking like ‘my grandma’s hands’ (words I hear patients use often).
What makes bHRT unsafe
Like with any medical treatment, there are potential issues with bHRT. But the most common issues aren’t actually medical side effects—they have more to do with the provider and the patient than adverse health risks. (Remember my caveat from above?)
Poor knowledge / lack of time of the prescriber
Prescribing bHRT is more of an art form than a science. There are deeper questions that need to be asked, screening exams that need to be done and subtle nuances of the prescription that need to change when your symptoms change.
For patients who are particularly sensitive to estrogens in the first place, having control over that art form is necessary for me, as bHRT is more than just estrogen replacement therapy (remember it can include progesterone and testosterone too).
Many providers will tell their patients no for HRT without ACTUALLY knowing anything about HRT. They misquote safety studies (antiquated ones, usually), or dismiss the patient and tell them symptoms of perimenopause are “natural.” Sometimes these providers don’t feel they know enough to prescribe HRT, but instead of fessing up to it, they just decline the prescription and send the patient away. This is another reason to switch providers if you’re not getting the support you need.
It is also a good idea to do annual blood testing to determine how the dose of hormones you are on is affecting your hormone levels. We’re not going for an ‘optimal’ number here, just making sure you’re in safe ranges. Perimenopause/menopause in general can affect other aspects of your biochemistry, so this annual blood testing is good regardless! If your provider isn’t keeping you up to date on this bloodwork, consider it a red flag.
A provider also needs to have the time available to spend with you as a patient, support staff to handle quick questions and the resources to get help from other providers who have experience with bHRT. All of those can be hurdles to getting the care you need.
Lack of access to personalized prescriptions
You’re most likely used to swinging by Walgreen’s or CVS or Target to snag your prescriptions. But conventional prescriptions, like those available at your run-of-the-mill pharmacies, aren’t personalized to fit YOUR needs as you experience perimenopause symptoms.
On the flip side, when you use a compounding pharmacy, the prescriber has much more control of the dosing, frequency, route of administration, etc. Because these are personalized doses and medications, the cost is likely higher than at a conventional pharmacy (it depends on what your RX benefits are, but conventional pharmacies are more likely to be contracted with many insurance companies for at least partial coverage).
I prefer compounding pharmacies if they’re within the patient’s budget because of that control over the prescription. Naturally occurring estrogens have a balance between E1, E2, and E3 (that’s another can of worms…) and when you send prescriptions to a compounding pharmacy, you can specify the ratios of estrogens and how much of each you want. Generally speaking, when you send to a conventional pharmacy, you only get E2 (aka the Estradiol patch or pill in whatever predetermined dose forms are available for purchase).
A note about compounding pharmacies: Unfortunately, many prominent websites will post about the dangers of compounding pharmacies, making them out to be back-alley establishments that don’t mix safe or advertised dosing compounds. However that simply isn’t true. Many providers who work with compounding pharmacies have developed strong relationships with the pharmacy team and understand their process and compliance of the pharmacy with the Pharmacy state regulatory board. At least in Minnesota, where I practice, there are hospital systems that have their own compounding pharmacies that will make bHRT for patients.
Poor follow up of the patient
Another potential hazard of being on HRT of any form is that it requires effort on your (the patient’s) end. Getting regular screening exams such as mammograms, bone density scans and following up regularly with your prescriber are just as important to make sure that you are being safe with their hormone therapy.
That includes taking the medication as prescribed. With many medications, from OTC Advil to prescription codeine, people assume that if one pill is good, two is better and three is BEST. Don’t take this attitude unless you’ve been given the green light by your provider.
Along those lines, if you start noticing other changes to your body, new symptoms or adverse effects, you should speak to your provider ASAP—don’t just wait until your annual check in.
Birth control masquerading as bHRT
This is a whole separate topic, but I wanted to touch on it, as many patients will run into this in their search for relief in perimenopause: Many providers will utilize estrogen-based birth control (NuvaRings, oral contraceptives, etc.) or progestin-based birth control (IUDs, DepoProvera, Norethindrone) as “HRT” for menopause. THIS. IS. NOT. THE. SAME.
Birth control has different safety considerations, has different effects on your body (i.e. increased risk for blood clots), and cannot be compared to bHRT preparations. They’re totally different. If this is what your provider recommends, consider finding a different practitioner with more knowledge of the subject.
If bHRT is a HARD no
Just like with any medical treatment, there are going to be patients who are a hard no when it comes to HRT.
In general, females with a personal history of estrogen positive cancers are typically a no-go. If that’s you, you’ll likely already know you’re not a candidate. That said, it can be pretty nuanced even if you’re in that category.
For example, if you had uterine cancer (common E+ cancer) and they removed that uterus…you can be a candidate again.
Family history of estrogen-sensitive cancers does not 100% rule out bHRT, because many of those cancers aren’t genetic. And, you can’t rule out everyone with an estrogen-positive disease though (endometriosis, fibroids, etc.), because you can just alter their dose.
Other factors that make you a bad bHRT candidate? If you have a history of clotting disorders, strokes or heart attacks—but again, these don’t 100% rule out your eligibility, depending on the type and circumstances around your diagnoses.
If you’re in the hard NO category, there is an option for vaginal estriol creams to help with symptoms of vaginal dryness or atrophy. When the vagina doesn’t have estrogens (or lubrication), the tissue can start to get very thin and will tear, leading to pain and other increased risks of infection.
BUT, this vaginal estriol cream doesn’t help with systemic symptoms like the brain fog, weight gain, insulin resistance, bone loss and more.
Final thoughts on bHRT
So, is bHRT for everyone? No. Arguably, more people are good candidates for it than conventional medicine tells them. But declining hormones can be a personal preference—I just want it to be the patient’s preference, not just the provider’s preference.
Is bHRT the only option for perimenopause? No, but other natural therapies may not be as effective as warding off the bone loss, brain atrophy, etc. People don’t do bHRT all the time and is it 100% guaranteed that they’ll have all the perimenopause symptoms? No, but it’s also not 100% guaranteed that any form of HRT will prevent those symptoms either.
Do I think people should strongly consider doing bHRT if they feel comfortable? Yes.
Should you talk to someone who is an expert in bHRT prescribing (vs. just asking your PCP)? YES. If your PCP says no, I’d urge you to get a second opinion.
What else are you curious about surrounding bHRT?
Medical Disclaimer: While the author is a Registered Naturopathic Doctor with a Doctorate in Naturopathic Medicine, she is not YOUR doctor, and these recommendations are only guidelines for reference, not personalized medical advice. Please seek additional support or treatment from your primary care practitioner before acting on anything addressed above.