Bioidentical Hormone Replacement Therapy Fundamentals

What is BHRT (Bioidentical Hormone Replacement Therapy)?

Medically supervised, bioidentical hormone replacement therapy (BHRT) is a safe and effective solution for women seeking relief from symptoms related to hormone fluctuations and imbalances. BHRT uses hormones that are chemically identical to the hormones naturally produced by the human body. These are usually derived from plant sources such as yams or soybeans, and are FDA-approved commercially available products or compounded in a pharmacy to create a personalized treatment plan for each patient.

What causes hormone fluctuations and imbalances?

Significant hormone imbalances in women can occur at any age due to a variety of medical conditions and medications. These can include premenstrual syndrome (PMS), polycystic ovarian syndrome (PCOS), endometriosis, premature ovarian failure (POF), antidepressants, steroids (prednisone/cortisone), and chemotherapeutics. However, most women begin to experience significant hormone imbalances as they enter perimenopause. Perimenopause, menopause, and postmenopause are all phases of a woman’s life that are characterized by hormonal changes that can lead to a range of physical and emotional symptoms. While these terms are often used interchangeably, they each refer to specific stages in the hormonal changes you experience in life.

Perimenopause typically begins in your 40s and can last for several years before menopause occurs. This is a transitional period when the levels of estrogen and progesterone in your body begin to fluctuate. Perimenopause ends when you have gone 12 consecutive months without a period, at which point you formally enter menopause. At this stage, the ovaries stop releasing eggs and production of estrogen and progesterone decrease significantly. Menopause typically occurs in your late 40s or early 50s, but can occur earlier or later depending on a variety of factors. Menopause is a natural part of aging, but can also be induced by certain medical treatments, such as surgery to remove the ovaries or chemotherapy. Common symptoms of perimenopause and menopause include:

Hot flashes & night sweats
Fluctuating hormone levels can cause sudden and intense
feelings of heat, sweating, and flushing.
Mood swings
Hormone fluctuations can affect the levels of neurotransmitters
in the brain, leading to mood swings, irritability, and anxiety.
Decreased sex drive
Fluctuating hormone levels can decrease libido, or sex drive.
Irregular periods
Hormone fluctuations can cause changes in menstrual cycles,
including heavier or lighter periods, or periods that are closer together or farther apart.

Vaginal dryness
As estrogen levels decline, the vaginal tissue may become thinner, drier, and less elastic, leading to discomfort during sexual activity.
Fatigue
Hormone fluctuations can cause feelings of exhaustion and fatigue, making it difficult to complete daily tasks.
Sleep disturbances
Hormone fluctuations can disrupt sleep, leading to insomnia or waking up frequently during the night.

Postmenopause refers to the period of time after menopause has occurred. During postmenopause, the symptoms of perimenopause and menopause typically subside, but the effects of decreased estrogen and progesterone levels can lead to long-term health risks, such as osteoporosis and heart disease. Postmenopausal women may also experience vaginal dryness, discomfort during sexual activity, and urinary incontinence.

While each of these phases is characterized by hormonal changes, there are some key differences between perimenopause, menopause, and postmenopause. Perimenopause is a transitional phase that can last for several years before menopause occurs. During perimenopause, hormone levels fluctuate, leading to irregular periods and a range of physical and emotional symptoms. Menopause marks the end of your reproductive years and is defined as the point in time when you haven’t had a period for 12 consecutive months. At this stage, the ovaries stop releasing eggs and production of estrogen and progesterone decreases significantly. Postmenopause refers to the period of time after menopause has occurred and is characterized by long-term health risks associated with decreased estrogen and progesterone levels.

A thorough understanding of these different phases and the hormonal changes that occur during each stage is critical in managing your symptoms and maintaining your overall health and wellbeing. With proper management, you can navigate these hormonal changes and continue to live healthy, fulfilling lives.

What are the indications for BHRT?

Severe vasomotor symptoms
This is just a fancy way of saying hot flashes. When these occur at night, they cause night sweats and have significant impact on sleep quality.
Osteopenia
This is typically diagnosed with a DEXA scan T-score of -1.1 to -2.4.

Severe genitourinary symptoms
This includes painful intercourse, vaginal dryness, painful urination, and recurrent urinary infections.

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Which women are not good candidates for BHRT therapy?

Those with active liver disease or cirrhosis.
Those with current, past, or suspected breast, ovarian, or endometrial cancer.
Those who have had a previous blood clot in legs or lungs without precipitating cause (i.e. trauma, surgery)
Those with undiagnosed genital bleeding or endometrial hyperplasia
Those with a rare skin condition called porphyria cutanea tarda

What are the benefits of Bioidentical Hormone Replacement Therapy?

As women age, their risk of osteoporosis increases. BHRT can help maintain bone density and reduce the risk of fractures. Estrogen is important for maintaining bone density, and BHRT can help restore estrogen levels and prevent bone loss. A study published in the Journal of Women’s Health found that women who received BHRT had a significant increase in bone density compared to women who did not receive BHRT.

The decline in estrogen levels that occurs during menopause can cause vaginal dryness, pain during intercourse, and decreased libido. BHRT can help alleviate these symptoms and improve sexual function. A study published in the Journal of Sexual Medicine found that women who received BHRT had improved sexual function, including increased desire and decreased pain during intercourse.

Estrogen also plays a role in maintaining cardiovascular health, and declining levels of estrogen during menopause can increase the risk of cardiovascular disease. Studies have shown that bioidentical hormone replacement therapy can improve cardiovascular health in menopausal women by reducing cholesterol levels, improving blood vessel function, and reducing inflammation.

Research has shown that estrogen replacement therapy may reduce the risk of colon cancer in women. A study published in the New England Journal of Medicine found that women who received estrogen replacement therapy had a significantly lower risk of colon cancer compared to women who did not receive estrogen replacement therapy.

Estrogen plays a crucial role in maintaining cognitive function, and the decline in estrogen levels that occurs during menopause can lead to memory problems and other cognitive issues. BHRT can help restore estrogen levels and improve cognitive function. Research has shown that BHRT can improve cognitive function, including memory and attention, in women who have undergone menopause.

Urinary incontinence is a common problem for menopausal women, and declining estrogen levels can contribute to this issue. Bioidentical hormone replacement therapy can help to improve urinary incontinence by increasing muscle tone and reducing inflammation in the bladder and urethra.

The decline in hormone levels that occurs during menopause can cause a variety of uncomfortable symptoms, including hot flashes, night sweats, vaginal dryness, and mood swings. BHRT can help alleviate these symptoms by restoring hormone levels to more normal levels. Research has shown that BHRT can effectively reduce the severity and frequency of hot flashes and night sweats, as well as improve sleep quality and reduce vaginal dryness.

Mood changes, including anxiety and depression, are common in menopausal women. Bioidentical hormone replacement therapy may help to improve mood disorders by increasing levels of estrogen and progesterone, which have been shown to have a positive effect on mood.

What are potential side effects and risks of BHRT?

All of these risks and side effects are readily managed with appropriate patient screening, active monitoring, and medications adjustments as needed.

Vaginal Bleeding
BHRT can cause irregular vaginal bleeding or spotting.
Mood changes
BHRT can affect mood, causing changes in emotions and mood swings.
Nausea
Nausea is a potential side effect of BHRT.
Blood Clots
Estrogen therapy, including BHRT, has been shown to increase the risk of blood clots, which can be serious.

Skin Irritation
BHRT products may cause skin irritation, itching, or redness.
Fatigue
BHRT may cause headaches in some women.
Bloating
Some women may experience bloating or water retention while using BHRT.
Breast Tenderness
Women who use estrogen therapy, including BHRT, may experience breast tenderness or enlargement.

What are the different delivery mechanisms for medications?

Creams and gels are a popular option for BHRT delivery. They are typically applied topically to the skin, and the hormones are absorbed through the skin into the bloodstream. Creams and gels are often preferred by women who are uncomfortable with taking pills or who have difficulty swallowing. They also offer the advantage of allowing for a personalized dosing regimen, as the amount of cream or gel applied can be adjusted based on the individual’s needs. Creams and gels can sometimes get a little “messy”. They also carry a mild risk of transfer to others. Hormones can be transferred to others through skin-to-skin contact, so women using creams or gels should be careful to wash their hands after application and avoid close contact with others until the hormones have been fully absorbed.

Transdermal patches are another delivery option for BHRT. Patches are typically applied to the skin once or twice a week and deliver a steady dose of hormones over a 24-hour period. Patches are convenient and easy to use, and they offer the advantage of a consistent dose of hormones. One potential disadvantage of patches is that they can be irritating to the skin for some women.

Pellets are a newer delivery option for BHRT. Pellets are small, rice-sized pellets that are inserted under the skin, typically in the buttocks. The pellets slowly release hormones into the bloodstream over a period of several months. Pellets offer the advantage of convenience, as they only need to be inserted a few times a year, and they deliver a consistent dose of hormones. A disadvantage of pellets is that they require a minor surgical procedure to insert, which can be uncomfortable or inconvenient for some women. Additionally, pellets are not easily adjustable, so women who experience changes in hormone levels may need to have them removed or replaced.

Pills and capsules are a traditional delivery option for hormone replacement therapy. They are typically taken orally, and the hormones are absorbed into the bloodstream through the digestive system. Pills and capsules are convenient and easy to use, and they offer the advantage of allowing for a personalized dosing regimen. A potential disadvantage of pills and capsules is that they may not be as effective as other delivery methods. Hormones taken orally must pass through the digestive system and the liver before they can enter the bloodstream, which can reduce their effectiveness. Additionally, oral hormone replacement therapy has been linked to an increased risk of blood clots, stroke, and breast cancer.

Injections are another delivery option for BHRT. Hormones can be delivered via intramuscular injection, typically in the buttocks or thigh. Injections offer the advantage of a consistent dose of hormones and a longer duration of action than pills or capsules. One potential disadvantage of injections is that they can be painful or uncomfortable for some women.

Besides BHRT, are there any other treatments for menopausal symptoms?

BHRT is widely used to manage symptoms related to hormonal changes during mid-life. However, some women prefer non-hormonal medical therapies and others aren’t good candidates for hormones due to medical reasons. Non-hormonal treatment options include:

Antidepressants are a class of medications that are commonly used to treat depression, anxiety, and other mood disorders. They work by altering the levels of certain brain chemicals called neurotransmitters, which can help to alleviate some of the symptoms of menopause, including hot flashes and mood swings. Antidepressants that are commonly used to manage menopausal symptoms include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and paroxetine, and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine. These medications are generally well-tolerated and have few side effects, but they may take several weeks to reach their full effect.

Gabapentin is an anticonvulsant medication that is also used to manage neuropathic pain and anxiety. It has been shown to be effective in managing hot flashes and night sweats in menopausal women. Gabapentin works by binding to a specific type of calcium channel in the brain, which reduces the release of certain neurotransmitters that can trigger hot flashes. Gabapentin may cause dizziness, drowsiness, and other side effects, but these are generally mild and transient.

Clonidine is a medication that is commonly used to treat high blood pressure. It has also been shown to be effective in managing hot flashes in menopausal women. Clonidine works by binding to a specific type of receptor in the brain, which reduces the release of certain neurotransmitters that can trigger hot flashes. Clonidine may cause dry mouth, drowsiness, and other side effects, but these are generally mild and transient.

Vaginal dryness and discomfort are common symptoms of menopause due to the decline in estrogen levels. Vaginal moisturizers and lubricants can help to alleviate these symptoms by providing moisture and lubrication to the vaginal tissues. Vaginal moisturizers are applied regularly to the vagina to provide long-term moisture, while vaginal lubricants are applied during sexual activity to reduce friction and discomfort. These products are available over-the-counter and do not require a prescription.

Cognitive-behavioral therapy is a type of talk therapy that focuses on changing negative thought patterns and behaviors. It has been shown to be effective in managing depression, anxiety, and other emotional symptoms of menopause. CBT can help women to develop coping strategies for dealing with the challenges of menopause, and to improve their overall quality of life. CBT is generally safe and well-tolerated, although it may not be suitable for women with severe mental health conditions.

Exercise and a healthy diet are important components of overall health and wellness, especially during menopause. Regular physical activity can help to reduce hot flashes, improve mood, and promote better sleep. A healthy diet that is rich in fruits, vegetables, whole grains, and lean protein can help to reduce the risk of chronic diseases such as heart disease, diabetes, and obesity. Women should aim to get at least 30 minutes of moderate-intensity exercise per day, and to eat a balanced and nutritious diet.

While there are several non-hormonal therapies that have been shown to be effective in managing menopausal symptoms, there are also several commonly used therapies that do not have good evidence to support their use. These therapies are often referred to as complementary or alternative therapies, and while they may be appealing to some women, it is important to understand that they may not be effective for all women and may even pose some risks.

Black cohosh is an herbal supplement that is often used for managing menopausal symptoms, particularly hot flashes. While some studies have suggested that black cohosh may be effective for reducing hot flashes and other menopausal symptoms, the evidence is again mixed and conflicting.

One of the main issues with black cohosh is that it can vary widely in its content and potency, making it difficult to determine the optimal dose for managing menopausal symptoms. In addition, black cohosh may interact with certain medications and its safety and effectiveness for long-term use are not well understood.

Soy and phytoestrogens are often marketed as natural alternatives to HRT for managing menopausal symptoms. Soy products such as tofu, soy milk, and soybeans contain compounds called isoflavones that are structurally similar to estrogen and may have estrogen-like effects in the body. While some studies have suggested that soy and phytoestrogens may help to reduce hot flashes and other menopausal symptoms, the evidence is mixed and conflicting.

One of the main issues with soy and phytoestrogens is that they can vary widely in their content and potency, making it difficult to determine the optimal dose for managing menopausal symptoms. In addition, soy and phytoestrogens may interact with certain medications, and their safety and effectiveness for long-term use are not well understood.

Red clover is another herbal supplement that is often used for managing menopausal symptoms. Like soy and phytoestrogens, red clover contains compounds called isoflavones that may have estrogen-like effects in the body. While some studies have suggested that red clover may help to reduce hot flashes and other menopausal symptoms, the evidence is again mixed and conflicting.

Like soy and phytoestrogens, red clover may interact with certain medications and its safety and effectiveness for long-term use are not well understood.

Evening primrose oil is a supplement that is often used for managing menopausal symptoms, particularly vaginal dryness. Evening primrose oil contains a type of fatty acid called gamma-linolenic acid (GLA), which is thought to have anti-inflammatory properties.

While some studies have suggested that evening primrose oil may help to reduce vaginal dryness, the evidence is weak and conflicting. In addition, evening primrose oil may interact with certain medications and may pose some risks, particularly for women with a history of seizures or bleeding disorders.

These therapies are often marketed as natural alternatives to HRT, but it is important to understand that natural does not always mean safe or effective. It is also important to note that non-hormonal therapies may take longer to produce noticeable effects and may not be as effective as hormone therapy for severe or persistent symptoms. At Asymmetric Health, we recommend speaking with one of our providers before starting any non-hormonal therapy for menopausal symptoms to determine if the therapy is appropriate for you and to discuss any potential risks or interactions with other medications or health conditions.

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References

Citations

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