Bioidentical Hormone Replacement Therapy (HRT)

At midlife, a healthy lifestyle can help manage menopausal symptoms and reduce your risk of serious health conditions, like breast cancer, heart disease, and osteoporosis (thinning bones).

Hormone replacement therapy is an option to treat the symptoms of menopause and perimenopause. Because there can be risks associated with the use of hormone replacement therapy, we encourage an individualized consultation with your provider to determine what is best for you.

Hormone replacement therapy (HRT) is medicine to treat symptoms of menopause, such as hot flashes, vaginal dryness, and sleep problems. It replaces the hormones that drop at menopause. Most women get relief from these symptoms within weeks of starting HRT, though occasionally it may take 6-8 weeks for full effect.

HRT most commonly contains two female hormones, estrogen and progesterone. HRT may come in the form of a pill, a patch, or a vaginal ring. A vaginal cream or a vaginal ring that contains a much lower dose of estrogen may be used to relieve vaginal dryness only.

Bio-identical hormones are plant-derived hormones that are chemically similar or structurally identical to those produced by the body. Bio-identical HRT is not felt to be any safer than conventional HRT. Bio-identical hormones include commercially available products approved by the U.S. Food and Drug Administration (FDA), such as micronized progesterone and estradiol, as well as compounded preparations that are not regulated by the FDA. Examples of commonly prescribed compounded hormones include Biest (biestrogen) and Triest (triestrogen) preparations. Both of these more common compounded products contain estriol. The FDA has not approved any drug that contains estriol as it does not have evidence to confirm that estriol is safe and effective. Unlike FDA approved products sold in standardized dosages, compounded preparations can be custom-made for a patient according to a health care provider’s specifications. Advertised advantages of compounded hormone therapy compared with FDA-approved conventional therapy include greater dosage flexibility and greater choice of routes of administration. The hormones may be placed in a rectal suppository, a cream, a gel, an under the tongue tablet, or under the skin pellet. While the estrogen and progesterone may be government approved, the mixtures are not. The big disadvantage of compounded hormone therapy is the lack of FDA oversight. The mixtures have not been studied to confirm proper or predictable absorption of the hormone or to ensure safety of the products. The purity, potency and quality of compounded preparations generally are considered to be inferior to FDA approved conventional HRT.

The goal of treatment is to alleviate symptoms with the lowest dose of HRT rather than to treat to a specific blood level. The lowest dose of hormone that relieves your symptoms is felt to be the safest dose for an individual. There is insufficient data to support increased efficacy or safety for individualized hormone therapy based on salivary, blood or urinary hormone levels and testing. There is no evidence that hormone levels in saliva are meaningful.

Talk with your provider about whether HRT is right for you. Follow-up care is a key part of your treatment and safety. Be sure to have regular checkups with your provider and call your provider if you are having problems.

Why might you take HRT?

  • HRT reduces symptoms of menopause, such as hot flashes, mood swings, and sleep problems.
  • The estrogen in HRT helps to prevent thinning bones and may lower the chance of colon cancer.
  • HRT helps keep the lining of the vagina moist and thick, which can reduce irritation.
  • HRT helps protect against dental problems, such as tooth loss and gum disease.

What are the risks of taking HRT?

  • Some women who take HRT may have vaginal bleeding, bloating, nausea, sore breasts, mood swings, and headaches. Talk to your provider about changing the type of HRT you take or lowering the dose, which may help to end these side effects. If you have having unexpected vaginal bleeding, you definitely should call your provider.
  • Taking HRT can affect your risk for heart disease, breast cancer, blood clots, and stroke.

You should not take HRT if you:

  • Could be pregnant.
  • Have a personal history of breast cancer, endometrial cancer, pulmonary embolism, deep vein thrombosis, heart attack, or stroke.
  • Have vaginal bleeding from an unknown cause.
  • Have active liver disease.

What can you do to reduce the symptoms of menopause?

  • Losing excess weight by eating a low-fat diet filled with fruits, vegetables, and whole grains can help reduce and even eliminate menopausal symptoms
  • Eat healthy foods and get regular exercise. This also will help to maintain strong bones and a healthy heart. Call the Kaiser Permanente Physical Activity Helpline is 1-888-680-BFIT for help increasing your physical activity.
  • Do not smoke. If you smoke, you can reduce hot flashes and long-term health risks by stopping. If you need help quitting, talk to your provider about stop-smoking programs and medicines. These can increase your chances of quitting for good. The Kaiser Permanente’s Smoker’s Helpline is 1-888-883-STOP.
  • Practice daily breathing exercises (meditation) to reduce hot flashes and mood swings.
  • Limit the amount of alcohol you drink to reduce symptoms of menopause and long-term health risks.
  • Keep your home and office cool.
  • Use a vaginal lubricant, such as Astroglide, Replens, Wet Gel Lubricant, or K-Y Jelly.
  • Do pelvic floor (Kegel) exercises, which tighten and strengthen pelvic muscles. To do Kegel exercises:

    Squeeze the same muscles you would use to stop your urine. Your belly and rear end (buttocks) should not move. Hold the squeeze for 10 seconds, then relax for 10 seconds. Repeat the exercise 10 to 15 times a session. Do three or four sessions a day. You should not regularly do these while urinating but rather do at other times during the day.

When should you call for help?

Watch closely for changes in your health, and be sure to contact your provider if:

  • You have unexpected vaginal bleeding while taking HRT.
  • Your symptoms do not improve.

Suggested reading material for this problem as well as other issues common in perimenopause and menopause are on our Orange County’s Women’s Health Services website, the American College of Obstetrics and Gynecology Patient website or the North American Menopause Society website. At these sites, you can learn more about the changes to your body and your feelings at this time in your life as well as get unbiased and consistent evidence-based recommendations to help you optimize your health and well-being.

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