Hormone Replacement Therapy in Perimenopause & Menopause

Today we talk through some of the things you are likely considering to help you feel better. 

None of this is medical advice - always consult with your healthcare provider before starting anything, even supplements that you can purchase without a prescription. 

Things we cover: 

• The difference between standard hormone replacement therapy and bioidentical hormone replacement therapy
• The importance of progesterone even if you no longer have a uterus (because it does more for us than just protect the uterus)
• Testosterone in BHRT, things to consider, and some of the controversy you might see around it
• Breast cancer risk in HRT
• The actual goal of HRT in easing through perimenopause
• Some consideration for determining how long you might need to be on HRT, and things to consider when it is time to wean off
• Our thoughts on a better, more accurate term to describe what we are actually doing with HRT because the term is really confusing and misleading
• Accessibility of BHRT compared to HRT
• HRT tidbits for consideration in the highly sensitive population

Chapters

00:00 Understanding Hormone Replacement Therapy (HRT)
04:26 Bioidentical vs. Conventional Hormones
11:07 Breast Cancer Risk and Hormone Therapy
20:48 Accessibility and Affordability of Hormone Treatments

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We would also love to know what is on your mind. If you were to join us, what would we be talking about? Email us at messymidlifepodcast@gmail.com or message us on Instagram or TikTok @messymidlifepodcast.

Transcript

SPEAKER_00 0:01

Real women.

SPEAKER_01 0:02

Real talk.

SPEAKER_00 0:04

Real messy.

SPEAKER_01 0:06

This is Messy Midlife. Hi, everybody, and welcome back to Messy Midlife. Good morning, ladies. Good morning. Good morning. So we ended our last conversation talking about all the things like the basics, establishing the basics for hormones, and then talking a little bit about lab testing and where they come into play, the way we need to consider it, all of the things. And so I would like to sort of wrap up this ultra-medical part of our conversation where we're making sure that we have context for everybody on the things that we talk about when we just go into our doctor space and forget that maybe people are listening who don't know what we're talking about, by talking about some of the things that we can do to address the hormones when they're not going well. So there's things that people really need to understand about HRT that I need to understand better thanks, and I'm starting to understand better thanks to some conversations we've had about HRT, the different options that we have, and then the things that can be used when HRT is just not available to you for lots and lots of different reasons. So hopefully we can have that conversation today and then maybe take a little bit of a break for a little bit, a few more check-ins, like our normal stuff, and then get back to some of our other highly requested topics. What do you guys think? Sounds good. I'm very cool. So let's just dive right in first and foremost. What is HRT? I'll take this one, Karen.

SPEAKER_03 1:34

Or so HRT, right, hormone replacement therapy. And that can be, it's kind of a blanket, right? That can be for men, for women, and it's looking at replacing the hormones that we're naturally making as we age and as that hormone production goes down. HRT can also be used in younger women. It's not happening as frequently, but things like a premature ovarian failure where the ovaries aren't making any of the hormones, and younger women are having some pretty terrible symptoms from having really low hormone levels, it can be used there too. But I think in general, especially in our age range, we're talking about replacing some of those hormones that have been decreasing or declining over the years. And the tough thing is, you know, it's not linear, right? It's not like we have this like nice, beautiful linear line on a graph. It can be all over the place. Hormones can go up and down and all around. So we can have different symptoms at different times because of those hormonal fluctuations.

SPEAKER_00 2:33

I love that you mentioned that, Aliza, because just like with everything at this stage, it's not a, oh, right, I've got my plan and it's set. And so that collaboration with your provider and the own your own introspection and logging your symptoms and getting a sense of when you're needing certain shifts in those hormones or herbs or whatever it is you're taking.

SPEAKER_03 2:56

So in the integrated medical space, we often hear BHRT, which is bioidentical hormone replacement therapy. So that's where we are using hormones that have a similar, well, identical, not just similar, but identical makeup to the hormones that we're making. It can be estrogen, progesterone, testosterone, DHEA, pregnanolone, anything within that, that hormone cascade.

SPEAKER_01 3:20

Why is that important?

SPEAKER_03 3:21

It's important to have bioidentical hormones because they are the hormones that are exactly like the hormones that we are making in our bodies in structure and in function. We're not putting something totally foreign into our bodies. There can be a lot of talk about natural and bioidentical, but natural doesn't always mean bioidentical. So one of the estrogens that was used for years and years is called premarin. And premerin is natural because it's made from pregnant horse urine. So it's natural. I mean, totally disgusting in my opinion, but um it's natural. It is not bioidentical. It is not identical in structure to the hormones that we as humans make. And can be therefore very problematic. Yes. So I think it's really important to, like we were saying, work with a hormone-literate doctor who really understands those differences and understands the nuances, even with different types of bioidentical hormones and different combinations.

SPEAKER_01 4:22

What is the difference then between the bioidentical hormones that you hear of in the functional, integrative, naturopathic medical space and the hormones that somebody might get from their very conventionally trained endocrinologist or gynecologist? That's a great question.

SPEAKER_03 4:38

Do you remember our last episodes we were talking about three different types of estrogen, right? Estrone, estradiol, estriol. We don't touch estrone anymore. It's it's a very problematic, potentially carcinogenic form of estrogen. So we naturally make it, but we certainly don't give ourselves exogenous estrone. Estradiol alone. So 100% estradiol E2 is what's conventionally used alone. Sometimes with progesterone, sometimes not. Um, I've seen it both ways. When we're talking about what is the safest, most effective way to do hormone replacement therapy, and by waydenical hormone replacement therapy, it's doing a combination of estradiol and estriol together that you're using systemically. So typically in perimenopause, menopause, uh, again, conventional would be 100% estradiol. Bioidentical would be only 20% estradiol, and then 80% of that very protective estriol. We're always bringing in progesterone as well. The progesterone that you can get conventionally has tons of fillers and junk added into the formula. Typically, bioidentical progesterone is very clean, no fillers, no funky oils. And the great thing about it is that it can be done in a slow release capsule. So we take progesterone orally at night before bed because it's a really inhibitory hormone and helps us with sleep. When we do those bioidenticals, we can have it done in a slow release form. So it's releasing over a four-hour time period and staying in your body for up to 10 hours as opposed to being released and used right away.

SPEAKER_01 6:30

So what I'm likely to be recommended by my gynecologist at the VA when I have my hysterectomy soon is I'm likely to be recommended estradiol and that's it. Yes, that is typically what's done in a patch form. Okay. And it is the only thing that makes it not bioidentical is not how it's prepared, it's how it what it is paired with. Is that correct?

SPEAKER_03 6:55

So the Minvel patch is plant derived. Um, and it says chemically identical.

SPEAKER_00 7:00

Oh, that's interesting.

SPEAKER_03 7:01

Yeah. Because it contains the seven beta estradiol, but it doesn't have any of the estriol in it, which I guess is the big difference.

SPEAKER_01 7:09

So the bigger bigger concern. So it is more about not how it's prepared, but what it's paired with that makes it more bioidentical. Yes.

SPEAKER_03 7:16

And I think even with so even with things like, okay, maybe a woman had a hysterectomy, and then you know, the doctor would say, Oh, well, you don't need progesterone because you don't have a uterus.

SPEAKER_01 7:29

So we don't need to protect the uterus.

SPEAKER_03 7:31

So we don't need to protect against endometrial hyperplasia or uterine cancer, but um, but progesterone is still super important because we still we still need progesterone, even if we're had have had a hysterectomy, progesterone is still a really important hormone in paramenopause and menopause. I mean, it's an important hormone throughout life, but just simply saying, oh, you don't have a uterus, you don't need it, I don't think that's really fair to women. It doesn't give the opportunity for them to feel as good as they could.

SPEAKER_01 8:02

Right. Because it goes. We're talking about hormones beyond just preventing another problem. We're talking about hormones to recognize that it is also a problem when you don't feel well, even if it's not because of cancer that you don't feel well.

SPEAKER_00 8:16

And the role, and the role they play in our mental health and our sense of ease. It's so much more than just baby stuff, right? Like it's so beyond the uterus. Hormones beyond the uterus.

SPEAKER_03 8:31

Well, you are for so many women. I mean, I would say 90 to 95% of my patients have had trouble sleeping prior to starting hormone replacement therapy. And even those that have had a hysterectomy. So it's just important to look at all of the pieces, and it's not it's not so much, well, you don't have this, so you don't need this, and you just do this, and not that it doesn't really work that way. You have to look at the person as a whole, but their symptom picture is.

SPEAKER_01 8:59

How often is testosterone included in prescriptions for BHRT?

SPEAKER_03 9:04

Pretty often. So I would say, you know, obviously the dosing that we're doing for women is far less than we're doing for men, right? Just because our levels are so drastically different. And it really depends on how how women do with testosterone and how we also how we metabolize it from DHEA. So DHEA turns into testosterone and then testosterone turns into estrogen. So some women can actually take DHEA and it can be very, very effective turning into testosterone. As we age, for a lot of women, that doesn't work as well. And so we can take DHEA, but we don't necessarily see it converting to testosterone. Um, but everyone's metabolizing things differently, too. And so some people with testosterone therapy, I always start at a super, super low dose with everything. But even at low doses, I can see where it can start, testosterone can start having issues with like facial hair growth or like acne, oily skin. So we just have to watch how the patient is doing with that low dose and making sure it's safe and effective to increase it.

SPEAKER_00 10:06

I did want to mention that in the naturopathic world and in the functional medicine world, testosterone is for sure prescribed frequently. There is a big conversation in the conventional gynecological world of is this appropriate? Is this a male hormone and the role that it has played in uh gender-affirming therapy and how that can become a problem with certain providers. And I just wanted to mention this because I have had people come to me who have had providers be very, very resistant to prescribing testosterone, and it happens and know that you can find someone else, if that's the case, who will absolutely listen to you and uh treat you appropriately.

unknown 10:54

Yeah.

SPEAKER_03 10:54

And the dosages too are very different, right? So the dosages we would do for a woman in peramenopause versus somebody who needed that gender affirming care and really needed those higher levels is very, very different.

SPEAKER_00 11:07

Yes.

SPEAKER_01 11:07

Are there things I should have asked you or that your patients frequently ask you about HRT that I haven't already asked you before I go into all my other questions that I have for you guys?

SPEAKER_03 11:16

I mean, I think that the big one is, you know, breast cancer risk with hormone replacement therapy. And I think that's where this idea that there's this high risk or that that causes breast cancer is not necessarily true. But what I will say with my oncologist hat on is we never know what's going to spark a process in our body, right? And so I will never say that there is one thing alone that causes cancer or anything like that. There there really isn't. Um it's a conglomeration of all of these different things that like happen to come together in the perfect storm. So it's not just one piece. So I think I said before, you know, I've had women who have had breast cancer that have never been on a hormone in their life. And I have women who have been on hormone replacement therapy, bioidentical hormone replacement therapy for 10 years and have no issues, right? So it's really there's there's so much individually that we have to take into account. But I don't think it's as simple as this substance causes this cancer.

SPEAKER_01 12:26

Is it more likely or a greater risk if you're doing the non-bioidentical?

SPEAKER_03 12:31

Well, you don't have, I don't think we have those statistics, right? We don't have randomized controlled trial um showing biased, you know, estradiol and estriol versus just a patch, which is estradiol. But theoretically, right, that estriol is protective against breast cancer. So I think it's an important piece to be added in just to reduce any potential risk. Even if I have patients on the patch, I say, great, let's do like a little tiny squirt of estriol, also there's ways that we can configure it.

SPEAKER_01 13:02

So it's a 20% for the estradiol and 20 and 80% estriol. Yes. But isn't estriol predominantly present in a pregnancy?

SPEAKER_03 13:13

It is, but we also, so it's high, we have higher levels of estriol in pregnancy. But we're also we're making estriol. We convert estradiol to estriol.

SPEAKER_01 13:23

I guess I'm just confused if where the bioidentical part is, if we're having 20% E2 and 80% E3 in something that is bioidentical, that is not, that's not necessarily what our body's making, right? Bioidentical just means the molecular structure is the same. Okay. So it could still be bioidentical, as we've said earlier, if not necessarily how it's paired, but how it's prepared. So it could be bioidentical E2. Yes, like a like a patch, like a Minville patch. Okay.

SPEAKER_04 13:53

Yeah.

SPEAKER_01 13:54

But then the pairing with the E3 is not necessarily to mimic what our hormones look like before we started into perimenopause. It's because of the desire for extra protection. Protective benefits.

SPEAKER_03 14:07

And this is you said something mimic our levels prior to. So there are protocols that do that, right? I personally don't believe that they're safe, but some doctors do. And so they will have women in perimenopause and menopause doing higher levels of estrogen, progesterone, testosterone that are mimicking those levels that we had in our 20s and 30s and actually cycling them, like as you would through, you know, a menstrual cycle. My feeling is let our bodies age and give the support that's needed, as opposed to trying to be pushing a 50 or 55-year-old woman or 60. I've seen it 60, 65, you know, pushing women of an older age into hormone levels from when they were younger. I think that there is a risk there because our bodies are naturally evolving to have lower levels. Yes, we can support that with a little cushion, but we don't want to be pushing back to levels that we had 30 years ago.

SPEAKER_01 15:06

What you are describing is really an important piece for people to understand. So bioidentical hormone replacement therapy is not necessarily about matching where we were. It's about, as you said, cushioning to get us through the transition. So that to me says that this is not a permanent thing. It's not something that you will be on for the rest of your life. So, how do people eventually wean off?

SPEAKER_03 15:31

So it I think it really depends on what dose you start on, right? So I typically start at low doses because that's what also what research shows is that we do not have to have high doses of particularly estrogen to get the benefit from estrogen. We can still maintain bone density. We can still have symptom management with hot flashes and night sweats and things like that with lower doses of estrogen. And I don't think it's ever a good idea to chase any of those symptoms with more estrogen when you're going up to a higher level. There can be other things at play that can cause those symptoms as well. So, yes, it's in my opinion important to give us those lower levels. So then when we do go off, it's not this like crash and burn, right? And it's really depending on each woman and their symptoms, right? Are they somebody who has osteopenia and a pretty strong family history of osteoporosis where we know that they're likely going to need some more estrogen longer term? It's not necessarily that being on it for a long time is terrible at all if it's making you feel better as well. We're balancing, you know, family history, your personal history, your symptom picture, your other health markers too.

SPEAKER_01 16:49

Okay.

SPEAKER_03 16:49

And I think it's it's fair to say that it can be safe to be on very low doses longer term. And if you are going to eventually stop, you're just you're not stopping cold turkey. Right. I have a lot of patients that do that because they've had a breast cancer diagnosis or an endometrial cancer diagnosis and they stop cold turkey. And yes, in those cases, that's typically what needs to be done. But otherwise, it's like tapering off slowly that you're not putting your body into like a oh my God, what just happened state?

SPEAKER_00 17:24

That's my motto with everything that I do is comfort and quality of life through everything. And I do work with some people that are like, I just need to stop this and move on with my life. And you know, we do what we can to support them through that. But it's especially in perimenopause, like it's there's enough complexity and and beyond that we can choose to support either with the taper or additional supplementation to make it not miserable. Because it's something that we can actually control to not be usually to not be miserable.

SPEAKER_01 18:01

So another way that it's not really hormone replacement and not exactly bioidentical, even though that's the word that those are words that are used. I wish we could change this that was more precise, more accurate. It's like hormone transition therapy instead, right? And so one of the things that you're you're saying that is also not the same unless you were doing one of those protocols, which I have also seen people do it, especially in medical school, where women who had not had a period for 10, 15 years are having periods again because of the hormones that they're taking. Um, but so we're not gonna be doing the stagger with the when we take which hormone, when we're in this, what ri maybe really should be called hormone transition therapy. Uh, not transitioning genders, but just transitioning from you know one stage of life to the next to just give a little bit more ease. Flow therapy, you know?

SPEAKER_03 18:52

While you're when you're not flowing, I don't know. We're gonna come up with this. We'll trademark it.

SPEAKER_01 18:57

Yes, we will get a new, better, more accurate term. So if you're using all of these different hormones, it's not gonna be at different parts of the cycle. It's gonna be just consistent. Yes. Every day, you're taking the same dose at the same time every day, not progesterone half the month, estrogen half the month, testosterone throughout, or anything like that.

SPEAKER_03 19:17

Nope. Every day and depending on the dose, sometimes lower doses, sometimes a little bit higher depending on the hormone, but not having those fluctuations like you would when you were cycling and getting your period.

SPEAKER_00 19:30

Jen, I think you're really onto something with this because part of the reason we're doing this is the confusion around hormone replacement therapy, even for those of us in the medical world, you know, who had extensive, we all had extensive hormone, well, gynecological courses. And yet, as we've discussed, I mean, I've had to pursue so much extra continuing education. But the just the title of it, it is not replacement. And for a long time, it's supplementation to your own, you know, your physiologically produced hormones. So it's in addition to, you're not replacing anything until you stop menstruating. And at that point, at least the word becomes more relevant. But prior to it's not, it's not aptly labeled.

SPEAKER_01 20:19

Right. Which I think is part of the big confusion. And because there's so many different types, and I I got the basics of the training, but it is not my area of expertise. I've never once written a prescription for any of those types of hormones, any sex hormones. And I've never managed anything with this. So it is, it's not something that I know how to do effectively. So uh there's definitely people who are going to be just as bamboozled by some of this stuff as I feel like I am. Okay, so moving on from this, unless there's anything else about the hormone replacement or inappropriately named hormone replacement, hormone flow therapy, hormone cushion therapy.

SPEAKER_00 20:57

Cushion like that, yeah. There's one thing I wanted to circle back to. I agree with you, Elisa, on the additives and ickiness of conventionally produced hormones. And in terms of accessibility, affordability, bioidentical hormones are almost, I think they're pretty much 100% compounded. Yeah. And therefore out of pocket. And because of that, the one thing that I have noticed with highly sensitive people is progesterone, uh, prometrium tends to be the better tolerated, certainly more so than estrogen. That's the one that I really, if you're gonna spend money and we need to, the estrogen bioidentical options are definitely better tolerated for sensitive people. And testosterone is not available for women conventionally that I know of. I don't know if it is in California for women.

SPEAKER_03 21:53

No, I mean the the dosage, the one that is that is conventionally produced is made from home. Yeah.

SPEAKER_00 22:00

Dose is so high. Yeah. Yeah. There's no so far, and that might change because things are shifting, it's not available through a conventional prescription through your pharmacy for women. So that's a required bioidentical. But progesterone is. And that is one that, although it does have fillers and, you know, I'd want to say peanut oil, it is some obviously that's a problem if you have a sensitivity to that. But it is pretty well tolerated by sensitive people. It's a little bit more affordable because it is covered by insurance. And it's something to consider. You don't get the added benefit of the extended release, which is really nice. But if you're having to pick and choose what you can afford, that's something to consider. That it is pretty well tolerated. Agreed.

unknown 22:42

Right.

SPEAKER_01 22:42

And so that's something that people could ask their doctors about, even if it's not the standard that they're just offered estrogen, if they, like me soon, had a hysterectomy that they could even ask about it, may or may not actually get it prescribed. But if you're not working with somebody out of pocket or who's willing to go a little bit outside of the formulary for the system that they work in.

SPEAKER_03 23:04

And I think that's exactly that's what it really depends on is if your doctor has a familiarity with compounding pharmacies, if they use compounding pharmacies, if their requirements in the healthcare system they're working in allow them.

SPEAKER_00 23:21

Right. Right. Like Kaiser is notorious for having very strict guidelines of how they prescribe, how they order labs, and even just what you mentioned, Jen, if it's if it's a progesterone prescription, are they willing to think outside of their very, you know, neat and tidy box and consider all of the different ways, like what Elisa was saying earlier, all of the different ways that hormones have impact us as women. I have collaborated with so many conventional doctors to help them understand that this person's insomnia is not a deficiency of, you know, sleep medication. It's just that their progesterone is starting to drop and they need that extra support. And that is mind-blowing to many conventional providers. And oftentimes they are not willing to do that because that's not the quote unquote gold standard. So finding the right provider for you, once again.

SPEAKER_01 24:16

So, ladies, I'm wondering if it would be wise just for the sake of our attention deficit ladies who listen to us and people who got all the stuff going on because they're talking to people in midlife and going through perimetopause. If we should pause here and have our next conversation be on the non-hormone-based ways to support your body through it, just so that people can pick and choose what they want to listen to and give themselves a break if they need it in between. What do you think? I think that's great.

SPEAKER_03 24:44

I just go to the ADHD first. Gotta look out for our poops.

SPEAKER_01 24:50

So we'll be back with another likely shorter on the shorter side episode to just give you some thoughts on things that can be used if HRT is not available to you. So stay tuned for that. Uh until then, take care, everybody, and love you, ladies.

SPEAKER_00 25:06

Love you. See you next time. If our messy is your kind of messy, we'd love for you to rate, review, and follow or subscribe wherever you get your podcasts.

SPEAKER_02 25:16

We'd also love to know what's on your mind. If you were to join us, what would we be talking about? Email us at messy midlifepodcast at gmail.com or message us on Instagram or TikTok.