Hormone Replacement Therapy (HRT) and Hormone Optimization Therapy (HOT) are controversial due to the Women’s Health Initiative (WHI) study. The WHI was a large trial between 1993 and 2002 investigating hormone therapy on postmenopausal women. Flaws were found, such as the wrong cohort with underlying health issues and synthetic hormones that have been linked to adverse effects. Despite bioidentical hormone studies proving safety and benefits, the WHI’s findings are still applied to bioidentical hormones and women of all ages.
Through this series I hope to discuss the benefits of HRT/HOT in both women and men, and debunk some of the controversy surrounding HRT/HOT. The goal being to empower individuals to make informed decisions regarding their hormone health.
Menopause is the time when a woman’s body stops producing the hormones necessary for reproduction, causing menstrual periods to stop. The average age of menopause is around 51 years old, but it can occur earlier or later.
Perimenopause refers to the time leading up to menopause when a woman’s body undergoes hormonal fluctuations and changes in preparation for the cessation of menstruation. Perimenopause can last several years and is marked by irregular menstrual cycles and a decline in fertility. During this time, women may experience symptoms such as hot flashes, night sweats, mood changes, vaginal dryness, and sleep disturbances.
What are the benefits of hormone replacement therapy (HRT) for women?
HRT can improve bone health by regulating bone formation and reducing the risk of osteoporosis, which can lead to bone fractures, especially in postmenopausal women. A study showed that oral estradiol can increase bone density in women with osteoporosis.
HRT can also reduce the risk of cardiovascular disease by increasing good cholesterol (high-density lipoproteins) and decreasing bad cholesterol (low-density lipoproteins), which improves insulin sensitivity and reduces visceral fat. Studies have also shown that oral estradiol can halt the progression of atherosclerosis and even reverse plaque build-up in arteries.
HRT can improve cognitive function, particularly in verbal learning and memory. It can also improve mood and sleep by supplementing the decline of progesterone, which is known to affect mood and sleep in postmenopausal women.
Estrogen and progesterone have neuroprotective effects that can reduce the risk of Alzheimer’s disease and dementia. In fact, HRT use has been linked to a 29% lower risk of Alzheimer’s disease in postmenopausal women.
Finally, HRT can also reduce the frequency and severity of menopausal symptoms, such as hot flashes, night sweats, and vaginal dryness.
What are some misconceptions about HRT?
There are some common misconceptions about hormone replacement therapy (HRT) in postmenopausal women. One of these is that HRT can cause cancer. However, studies have shown that hormones are actually protective against certain types of cancer, such as breast, endometrial, and colon cancer. Hormones like estrogen and progesterone have been found to stimulate the production of proteins that can prevent abnormal cell growth and promote programmed cell death, which can prevent the formation of tumors. In fact, women who take combined estrogen and progesterone hormone therapy may have a lower risk of developing breast cancer than those who do not use hormone therapy.
Another misconception is that HRT can increase the risk of blood clots. While oral estrogen therapy has been associated with a risk of blood clots, topically applied estradiol does not carry the same risk. This is because topically applied estradiol is absorbed directly into the bloodstream through the skin, bypassing the liver where it can cause changes in clotting factors. In women without risk factors for blood clots, oral estradiol should be considered to achieve the cardioprotective benefits of estradiol.
Finally, some women who have had a hysterectomy wonder if they still need progesterone. The answer is yes, even in women who have had both their uterus and ovaries removed, progesterone is still necessary for various functions in the body, including bone health, cardiovascular health, and brain function. Low levels of progesterone have been associated with an increased risk of various health conditions, including osteoporosis, cardiovascular disease, and cognitive decline. Therefore, even after a hysterectomy, it is beneficial to receive progesterone therapy to maintain adequate levels of this important hormone.
What about Men?
Andropause, also called male menopause, is a condition that affects men as they age. It’s caused by a decline in testosterone, a hormone that’s important for male physical and sexual characteristics, as well as overall health. Symptoms of andropause include decreased libido, erectile dysfunction, fatigue, and mood changes.
Andropause is a natural part of the aging process, but testosterone replacement therapy (TRT) may be considered for men experiencing symptoms that affect their quality of life. Testosterone is important for both men and women’s health, and low levels can lead to health problems such as osteoporosis, cardiovascular disease, and depression. Testosterone replacement therapy can help men and women with low testosterone levels.
What are the benefits of testosterone for both men and women?
Testosterone is a hormone that is present in both men and women, although it is often associated more with men. It has several benefits for both sexes, including improving bone density. Studies have shown that testosterone replacement therapy can increase bone mineral density in men with low testosterone levels, which can help reduce the risk of fractures and improve overall bone health. Testosterone stimulates the production of new bone tissue and helps to maintain existing bone mass by acting on bone cells called osteoblasts, which are responsible for bone formation.
In addition to improving bone density, testosterone can also increase muscle mass, strength, endurance, and recovery. Studies have found that testosterone replacement therapy can increase muscle mass and strength in men with low testosterone levels. It also appears to enhance muscle recovery after exercise by enhancing muscle protein synthesis. This can be particularly beneficial for older men with low testosterone levels.
Testosterone has also been shown to have a beneficial effect on body composition by reducing visceral fat. Visceral fat is the fat that surrounds internal organs and has been linked to an increased risk of metabolic disorders such as type 2 diabetes and cardiovascular disease. Testosterone replacement therapy has been found to decrease visceral fat mass in men with low testosterone levels, and higher testosterone levels have been associated with lower visceral fat accumulation in both men and women. Testosterone appears to influence body fat distribution by regulating the activity of lipoprotein lipase, an enzyme that is involved in the storage of fat in adipose tissue.
In addition to physical benefits, testosterone can also enhance mood. Studies have found that men with low testosterone levels are more likely to experience symptoms of depression. Testosterone replacement therapy has been shown to improve mood and reduce symptoms of depression in men with low testosterone levels.
Testosterone therapy has also been shown to improve sexual function in both men and women with low testosterone levels. In men, testosterone therapy can improve sexual desire, erectile function, and overall sexual satisfaction. In women, testosterone therapy has been found to improve sexual desire and arousal in postmenopausal women.
Furthermore, testosterone replacement therapy has been studied for its potential cardiovascular benefits. Low testosterone levels have been associated with an increased risk of cardiovascular disease, and testosterone therapy has been associated with a reduced risk of major adverse cardiovascular events such as heart attack, stroke, and death in men with low testosterone levels. It has also been found to improve cardiovascular risk factors such as blood pressure, cholesterol levels, and insulin resistance in men with low testosterone levels. However, it is important to note that testosterone therapy should only be used in men with confirmed low testosterone levels who are carefully monitored for potential side effects.
Finally, testosterone replacement therapy has been shown to have positive effects on skin health, including improvements in skin thickness, collagen production, and overall skin texture. In men with low testosterone levels, testosterone replacement therapy has been found to improve skin thickness and collagen density.
Risks of Testosterone: Debunking Myths
Testosterone replacement therapy (TRT) has some risks associated with it, but many of the commonly perceived risks are actually myths. One concern is erythrocytosis, which is an abnormally high number of red blood cells. However, this can be easily managed by monitoring blood work and adjusting testosterone levels accordingly. Another myth is that TRT can cause prostate cancer, but this is not true. TRT can increase PSA levels, but it’s a physiologic increase and does not cause prostate cancer. TRT can, however, aggravate an existing prostate cancer, so it’s important to have a baseline PSA before starting TRT.
TRT can also impact fertility by suppressing the hypothalamic-pituitary-gonadal (HPG) axis, leading to a decrease in sperm production and testicular size. However, the effects on fertility are not absolute, and some men may still be able to conceive with TRT. Men who wish to preserve their fertility should discuss the potential impacts of TRT with their healthcare provider and consider alternative treatment options.
Excess levels of testosterone can contribute to acne and exacerbate hair loss in some men by increasing the conversion of testosterone to dihydrotestosterone (DHT), which can cause hair follicles to shrink. However, the impact of TRT on hair loss is not universal, and some men may not experience any change in hair loss with TRT. In women, excess testosterone therapy can exacerbate hair growth resulting in hirsutism or excessive hair growth on the body.
What should I expect during a “Hormone Optimization” Consult? During a hormone consult, you will discuss your concerns with a Physician or Nurse Practitioner. Your provider will take a detailed history and obtain blood work. Blood work is often advised to be done in the morning given the physiologic changes of testosterone. After the initial consult, you will be asked to come back and review your test results and discuss a plan of care for hormone optimization. I don’t have symptoms of menopause, should I still consider HOT or HRT?
The current guidelines state that HRT should be used to treat symptoms and not used to prevent or treat chronic conditions, this is something that should be discussed with your provider and individualized. As discussed above there are many benefits of HRT & HOT beyond treating menopausal symptoms and therefore individualized and informed consent regarding treatment is advised.
Is there a time frame for HOT/HRT? Have I missed the “window’?
While we know with synthetic hormones, the research suggests the risk of adverse events increases after 63, the same has not been shown with bioidentical hormones. Bioidentical hormones do not have a specific window where they are deemed “safer” to be prescribed.
How are Hormones Replaced or Optimized? As discussed, there are bioidentical and synthetic options. Given the safety profile, the preference is to use bioidentical hormones. 1. Estradiol: This is a bioidentical version of estrogen and is available by oral and topical preparations. 2. Progesterone: This is best given orally, as topical preparations often do not provide enough of an increase in systemic levels to provide adequate uterine protection. 3. Testosterone: Testosterone is available in intra-muscular and subcutaneous injections, topically, intranasally and by pellets. An individualized consultation at Preventous can help determine what is best for you.