Menopause and Hormone Replacement Therapy (HRT)
Menopause is such a hot topic right now, but it’s more than just a hot topic for myself and so many other women. For those who were left without hormone replacement in the 90s and early 2000s, it can even be a hurtful subject. The fallout from the flawed Women's Health Initiative (WHI) study was incredibly unfortunate and left countless women without access to the care they deserved and needed.
When speaking about the WHI study, Dr. Peter Attia put it plainly: “It’s hands-down the biggest screw up of the entire medical field in the last 25 years.”
Thankfully, the conversation around hormones is evolving. Women entering menopause today have access to more accurate information, better treatment options, and the ability to make empowered decisions about their health.
What Went Wrong with the WHI Study?
The WHI study, released in the early 2000s, dramatically changed the perception of HRT. The study used conjugated equine estrogens (derived from pregnant horse urine) and synthetic progestins (like medroxyprogesterone acetate) - hormones that are not chemically identical to the hormones our bodies produce. The study found an increased risk of breast cancer, heart disease, stroke, and blood clots in the women taking the equine estrogens plus synthetic progestins. Understandably, this raised concerns about the safety of HRT.
Today, we have safer, more effective options. Bioidentical hormones, derived from plants and structurally identical to our natural hormones. These bioidentical options have changed the game. These hormones help support strong bones, healthy hearts, and sharp brains, extending women's vitality well beyond menopause.
So How Can We Move Forward?
Estrogen, progesterone, and testosterone play crucial roles in women's health, especially when it comes to bone density, brain function, and cardiovascular health. When women lose those hormones at menopause, they are at increased risk for heart disease, dementia, and osteopenia/osteoporosis. There is a long list of other health issues that can come with loss of these vital hormones, but those are the heavy hitters.
Bioidentical hormones have become more popular because they are considered to be more natural and are thought to carry fewer risks than the synthetic forms used in older HRT treatments, like those used in the WHI study. The key is individualized care. Women need to work with providers who truly understand hormone therapy and can personalize treatment plans. That’s where Seaside Med comes in!
Hormone Replacement Options: What to Know
With so many HRT options out there, it can be overwhelming. There are some really great bioidentical options but not every bioidentical hormone is recommended, completely effective, and/or safe. For example, I don’t recommend Bi-Est or hormone pellets. That said, if you are currently using Bi-Est or hormone pellets, or have used them in the past, it’s okay. This is new territory and we’re all making decisions based on the information we’re given, and what we feel is best at the time.
Why I Don’t Recommend Pellets or Bi-Est:
About hormone pellets: Hormone pellets must be surgically inserted under the skin every 3-6 months. Over the years, this can lead to scar tissue. While convenient, they can cause unpredictable fluctuations and come with potential side effects like mood swings, hair loss, weight gain, and incision site complications. Everyone metabolizes hormones differently, making pellets hard to dose accurately. Testosterone pellets, in particular, can cause irreversible androgenic symptoms. More controlled and customizable options are available that offer precise dosing and fewer risks.
About Bi-Est: Bi-Est combines estradiol (E2) and estriol (E3). While estradiol is the most potent and essential estrogen during our reproductive years, estriol is far weaker and primarily associated with pregnancy. There’s limited research supporting estriol’s use in HRT, and it often adds unnecessary cost without meaningful benefit. For most women, restoring estradiol alone to premenopausal levels (at least 50–60 pg/mL for optimal bone health) makes the most sense, and it’s hard to reach those levels with Bi-Est.
So, What Are the Best Options?
I prefer to prescribe oral, topical, and injectable compounded medications. They offer flexibility, cleaner ingredients, and can be tailored to your exact needs. Insurance doesn’t cover compounded medications, but the cost is very manageable: Less than $4 a day for all 3 hormones: estradiol, progesterone, and testosterone.
If insurance coverage is a priority, estradiol and oral micronized progesterone are available as patches or pills. There are no FDA-approved testosterone options for women yet, so it always has to be compounded. I feel it’s important to make sure everyone knows the retail oral options insurance covers contain additives the compounded versions leave out. According to the FDA, retail oral estradiol products can contain: acacia, colloidal silicon dioxide, D&C Red No. 27 (aluminum lake), dibasic calcium phosphate, FD&C Blue No. 1 (aluminum lake), FD&C Yellow No. 5 (tartrazine) (aluminum lake), lactose, magnesium stearate, starch (corn), and talc. Retail oral progesterone ingredients can include: Peanut oil NF, gelatin NF, glycerin USP, lecithin NF, titanium dioxide USP, D&C yellow No. 10, FD&C red No. 40, and FD&C yellow No. 6. Still, the goal is to get hormones on board. I’m all about shared decision-making. I’ll support whatever path you feel most comfortable with.
Considerations When it Comes to HRT
Hormones can be dosed statically, rhythmically, or cyclically. It doesn’t have to be complicated. Find a provider who will work with you to find a plan that’s right for you. My preference for HRT is simple, effective, and supportive of your long-term health.
Sometimes, hormone therapy isn’t an option. While estradiol hasn’t been shown to cause breast cancer, it is a growth hormone, so it’s generally avoided in cases of active breast cancer. However, a history of breast cancer isn’t always a contraindication to hormone therapy. A thorough risk-benefit discussion, ideally with input from an oncologist, can help guide the decision about whether to use HRT after breast cancer.
Timing also matters, but it’s not always a hard no. Again, it comes down to individualized assessment. Many experts recommend starting HRT within 10 years of menopause. When started early, estradiol can help maintain vascular function, improve lipid profiles, and may slow the progression of atherosclerosis. But when more than 10 years have passed since menopause, atherosclerotic plaques may already be present. In those cases, introducing estradiol might destabilize those plaques, potentially increasing the risk of stroke or heart attack. When HRT is still desired in these situations, we typically start with a very low dose and increase slowly, allowing the body time to adjust.
We’ll take into consideration a history of uterine fibroids, endometriosis, blood clots, etc., when making the best decision about what form of HRT is best for you.
After weighing the benefits and risks of HRT, if you decide treatment isn’t right for you, that’s okay too! There are still meaningful steps we can take to protect your bones, brain, and cardiovascular health! Resistance training can help maintain bone strength and build muscle. The more muscle you have, the more you’ll be supporting your metabolic health as you age!
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If you're ready to take the next step, I’d love to support you on your journey. Our future health is a worthy investment, and the rewards are well worth it.
This link will take you to my electronic health record where you an book an appointment with me and we can get you started on a path to better health whether that means HRT, optimizing your metabolic health, or both! Book here!
Stay tuned! I’ll soon be sharing more about the powerful benefits of estradiol for both women and men, plus a deeper dive into perimenopause and the long (often bumpy) road to menopause.
