The Facts on BHRT in Menopause

​​Hormone replacement therapy has become an increasingly popular option for women seeking relief from symptoms occurring in menopause, menstrual irregularities, PCOS, amenorrhea and hypogonadism. Furthermore, people have been moving towards bio-identical hormones in hopes of a more biologically similar therapy with fewer risks and side effects. However, before embarking on hormone replacement therapy, it is important to understand the pros and cons of this form of treatment.

Signs of Shifting Hormones
As women age, estrogen and progesterone levels start to decline. The decrease in hormones can be the cause of a number of the following symptoms:
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• Irregular menstruation, particularly a decrease in the frequency of menstruation
• Thinning hair on the head and body
• Vaginal dryness
• Decreased libido
• Weight gain
• Significant decrease in energy and chronic exhaustion
• Hot flashes and night sweats
• Brain fog, reduced concentration, and other cognitive changes

 
Perimenopause — the period leading up to menopause — and menopause are often the culprits behind fluctuating hormonal balances and their resultant side effects.However, you do not have to be a middle aged adult to have hormone irregularities. Some women experience a lack of cycle (amenorrhea) in their mid 20s, following a birth control pill, or in cases of polycystic ovary syndrome (PCOS), endometriosis, or untreated thyroid conditions.
 
Risks and Benefits of BHRT
 
The use of bioidentical hormone replacement therapy has sparked intense debate. Like all compounded hormones, BHRTs are regulated medications made from Health Canada approved substances that require a prescription from a licensed professional. They are held to the same standards as pharmaceutical prescription substances.
 
The primary differentiation between HRT and BHRT is the biologically identical component of the compounded formula. The chemically synthesized structures of bioidentical hormones are identical to those produced by the human body, vs biologically similar chemicals found in HRT (fun fact: birth control pills are a form of HRT).
 
Molecular differences between synthetic progestins and progesterone result in differences in their pharmacological effects on breast tissue. Studies have found pro-carcinogenic effects of synthetic progestins on breast tissue, compared to data demonstrating ‘bio-identical hormones are associated with a lower risk of breast cancer and cardiovascular disease, and are more efficacious than their synthetic and animal derived counterparts’ (1,2). Furthermore, transdermal vs oral estrogen preparations have been considered less likely to pose risk for blood clots, stroke and coronary artery disease (3). Some studies even go as far as to say that bioidentical hormones are the preferred method of HRT when considering safety and efficacy (2).
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At the present moment, naturopathic doctors in Ontario have the ability to prescribed transdermal (topical) and suppository estradiol, estrone, estriol, progesterone, and oral natural desiccated thyroid.

The one biggest gap research for the safety of topical hormones is that bioidentical benefits of progesterone over progestins is shown with the use of oral dosing. Topical progesterone’s have not been show to increase blood serum values high enough to offset the impacts of estrogens on the endometrial lining, which when used in conjunction with estrogen replacement therapy (oral, topical, and transdermal), may increase the patients risk for endometrial hyperplasia and cancer. Therefore, I always advise working with the right team of doctors to ensure you’re on the most efficacious and safe BHRT for your concerns.
 
BHRT and Menopause: 
 
When diet and lifestyle measures fail, bioidentical hormone replacement therapy can be helpful in treating some of the side effects of hormonal imbalances caused by menopause.

• Hot Flashes, Night Sweats & Insomnia. When taken at bedtime, progesterone therapy has been shown to be significantly more effective than placebo at improving anxiety, reducing hot flashes and increasing quality sleep in as little as 4 weeks (4). Unlike estrogen and other vasomotor therapies, progesterone also does not appears to cause a rebound increase in hot flashes when discontinued.
• Increased Energy and Cognition. Lowering levels of progesterone and estrogen have been associated with decreased energy, more anxiety, impaired cognition, and lack of motivation. Progesterone when metabolized by the kidneys produces a byproduct know as a-Pregnanediol, which crosses the blood brain barrier and binds to GABA receptors, promoting a sensation of calm. Estrogen has impacts on the areas of the brain associated with learning, memory, and cognitive function. BHRT (when administered within the first 5 years of menopause) may help improve energy stores, promote happiness, and reduce the risk of cognitive decline and Alzhiemer’s disease (5-6).

• Improved Sex Drive. Its estimated that about 10-40% of women through menopause experience vaginal atrophy – thinning of the walls of the vagina – and dryness, having a significant impact of quality of life through this transitional period. Intravaginal estriol replaces lost estrogen in vaginal membranes, and helps alleviate symptoms associated with vaginal atrophy and dryness, with little to no side effects. Since Estriol is the weakest of our three estrogens, and has little affinity for breast and uterine tissue receptors (7), it makes is a safe and effective treatment for almost all women, with as little as 1-2 applications as week.
• Healthier Bones. Lower estrogen and progesterone levels can lead to an increased risk of developing osteoporosis. By restoring hormones levels, BHRT has been shown to significantly improve bone mineral density, and decrease the occurrence of osteoporosis or hip fractures (8).

 
Other Lifestyle Changes Can Improve Hormonal Health:
 
A healthy lifestyle, including regular exercise, can drastically improve overall health and help balance changing hormones.

• Reduce or eliminate unnecessary calories from refined sugars, grains, fried foods, pre-packaged products. Furthermore, limiting refined sugar improves insulin resistance and weight management through fluctuating hormones.
• Eat more fiber. Fiber not only helps regulate the gut microbiome, which can improve hormonal imbalances, but it also binds to hormonal metabolites and improves their elimination through the bowel. Always talk to your Naturopath about fiber if you are taking oral hormones.
• Eliminate caffeine and alcohol – both attribute to increase vasomotor symptoms (aka hot flashes!)
• Move your body. Getting at least 30 minutes of purposeful activity daily can improve your mood, reduce inflammation, and help maintain a healthy weight. A study in Sports Medicine showed that regular exercise can also help regulate hormones (10).

 
It is important to understand what is causing an imbalance in natural hormone production before embarking on a course of treatment. Oftentimes, simple changes in lifestyle can achieve positive results and provide most – if not all – of the same benefits of hormone replacement therapy.
 
To evaluate your hormonal health and to discuss your treatment options, please contact your Toronto Naturopathic Doctor, Dr. Courtney Holmberg at 647-351-7282 to schedule your appointment today.
 
 
References:

1. Constantine GD1, Kessler G2, Graham S3, Goldstein SR4. Increased Incidence of Endometrial Cancer Following the Women's Health Initiative: An Assessment of Risk Factors. J Womens Health (Larchmt). 2019 Feb;28(2):237-243.
2. Holtorf K. The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Postgrad Med. 2009 Jan;121(1):73-85.
3. Cobin RH, Goodman NF; AACE Reproductive Endocrinology Scientific Committee. American Association of Clinical Endocrinologists and American College of Endocrinology Position Statement on Menopause – 2017 Update.Endocr Pract. 2017 Jul;23(7):869-880.
4. Progesterone for hot flush and night sweat treatment–effectiveness for severe vasomotor symptoms and lack of withdrawal rebound. Prior JC, Hitchcock CL. Gynecol Endocrinol. 2012 Oct;28 Suppl 2:7-11. Epub 2012 Aug 1. PubMed
5. Daniel JM, Witty CF, Rodgers SP. Long-term consequences of estrogens administered in midlife on female cognitive aging. Horm Behav. 2015 Aug;74:77–85.
6. Herrera AY, Hodis HN, Mack WJ, Mather M. Estradiol Therapy After Menopause Mitigates Effects of Stress on Cortisol and Working Memory. J Clin Endocrinol Metab. 2017 Dec 1;102(12):4457–66.
7. Buhling KJ, Eydeler U, Borregaard S, Schlegelmilch R, Suesskind M. Systemic bioavailability of estriol following single and repeated vaginal administration of 0.03 mg estriol containing pessaries. Arzneimittelforschung. 2012 Aug;62(8):378–83.
8. Cano A, Estévez J, Usandizaga R, Gallo JL, Guinot M, Delgado JL, et al. The therapeutic effect of a new ultra low concentration estriol gel formulation (0.005% estriol vaginal gel) on symptoms and signs of postmenopausal vaginal atrophy: results from a pivotal phase III study. Menopause N Y N. 2012 Oct;19(10):1130–9.
9. Sarah Bedell Cook, ND. Bioidentical Hormone Replacement Therapy in Postmenopausal Osteoporosis: Is BHRT the key to prevention? Natural Medicine Journal. Aug 2014 Vol. 6 Issue 81.
10. Schubert MM1, Sabapathy S, Leveritt M, Desbrow B. Acute exercise and hormones related to appetite regulation: a meta-analysis. Sports Med. 2014 Mar;44(3):387-403.