The cost, benefit and promise of hormone replacement therapy.
I almost accidentally careened my car into the icy waters of the Ohio River after driving past a billboard the other day. The cause of this near-tragic automobile accident was in response to the message of the advertisement: “Are you over 35 with a waning libido, expanding waistline and suffering from lack of sleep? Maybe it's hormonal.” Hormonal? Clearly, I misread.
Well, it's possible some assemblage of those questions may elicit a personal "yes" in reply, but still, isn't 35 kind of young for hormone issues? Don’t I have a few years before menopause and having to worry about hormone replacement therapy?
WHAT IS HORMONE REPLACEMENT THERAPY?
According to the Centers for Disease Control, hormone replacement therapy (HRT) has been prescribed to women to ease the symptoms of menopause since the mid-1930s.
During menopause (and perimenopause), the ovaries reduce their production of female hormones leading to hormone withdrawal symptoms such as hot flashes, loss of libido, mood swings, hair loss, weight gain and more. HRT supplements the waning progesterone and/or estrogen levels with synthetic compounds absorbed through pill, patch or cream form to help your body cope with the reduction.
In addition to easing the pain of menopause, HRT has also been widely viewed as an anti-aging treatment thanks to the 1960s book Feminine Forever, written by Dr. Robert A. Wilson, which praised synthetic estrogen therapy as an effective way to stay youthful and feminine. It also couched menopause in terms of an estrogen deficiency illness that could be managed with HRT rather than viewing it as a normal stage in the life cycle. The perceived added benefit of "youthfulness"greatly increased the demand for HRT and brought it into the popular consciousness as an anti-aging treatment.
Today, Suzanne Somers is the pop culture equivalent of Dr. Wilson. She is one of the most outspoken supporters of using HRT to “reverse the aging process” with books similar to Feminine Forever touting the benefits of hormone replacement therapy. In her book, Ageless, she claims HRT is an “inspiring, medically validated approach to reversing the aging process and maintaining a healthy, vibrant, mentally sharp, sexually active life.” And, with the support of influential figures like Oprah, she’s been telling American women to look to hormonal imbalance for many of their physical and emotional problems. Her twist? Instead of synthetic hormones, she supports bioidenticals.
Bioidentical Hormone Replacement Therapy (BHRT) is a different breed of hormone therapy that has become increasingly attractive to consumers in reaction to the debate over the safety of conventional hormone therapies.
Dr. Amy Brenner, a board-certified gynecologist whose West Chester practice specializes in BHRT, defines bioidenticals as: “An exact replica of the hormones that are produced in your body.” The thinking goes that since bioidentical hormones, unlike synthetic hormones, are metabolized identically to those made in the body, BHRT is “better for you” than conventional hormone therapies.
So if you're experiencing with Dr. Brenner refers to as “The 40s Syndrome” — brain fog, fatigue, dwindling sex drive, mood swings, et al. — she'll test your hormone levels for imbalance and then devise a treatment plan.
In order to discern what BHRT treatment is recommended for patients, the body’s current levels of progesterone and estrogen must be assessed. The method preferred by Dr. Brenner and the lion’s share of bioidentical providers for ascertaining these values is a saliva test: You spit into a vial and they ship it to a lab.
Why spit, you ask? The argument is that blood-test values can only assess an extreme absence or overabundance of hormones rather than the more-subtle fluctuation levels bioidentical practitioners are looking to tweak. Therefore, spit is preferable to blood as it allows for finer distinctions.
This is a contentious testing method, though. Many experts point to the fact that hormone levels vary widely throughout the day making such subtle values difficult to interpret. Also at issue is the fact that the lab that runs the test and sells the spit kit, ZRT Laboratory, is the lab that decided what the “correct” hormone values should be.
Along with Dr. Brenner, The Happy Hormone Cottage is another local agency that will help administer and interpret your spit kit. The Happy Hormone Cottage acts as facilitator, counselor and educator for clients seeking BHRT.
“We believe education is key and gives women the confidence to dialogue with their doctor and educate them on the benefits [of hormone therapy],” says Lyn Hogrefe, the executive director of The Happy Hormone Cottage.
When The Happy Hormone Cottage gets the results of your spit kit, the information goes to a compound pharmacist affiliated with the Happy Hormone practice. The pharmacist then draws up a recommended plan of action based on your imbalance for you to bring to your doctor who would then (upon approving the regimen) submit the prescription back to that compound pharmacy to be filled.
A compound pharmacy crafts prescribed medication customized to a patient allowing for a more individualized dosage rather than providing pre-configured medication dosages (.25 mg, .5 mg, etc.) like a regular pharmacy. The individualization of the treatment based on personal test results is a benefit touted by supporters of BHRT. (But detractors would point out that compound pharmacies are under scrutiny by the FDA because of a sterile injectable issues last year that caused a fatal outbreak of fungal meningitis.)
Like traditional hormone replacement therapy, BHRT is administered through creams, pills, gels, vaginal rings and transdermal patches with your personal regimen of hormone therapy determined by your doctor and the test results. For example, every day Somers puts an estrogen cream on her left arm, injects two milligrams of estriol (an estrogen typically only produced in significant amounts during pregnancy) into her vagina and then, for two weeks a month, puts a progesterone cream on her right arm. The regimen, which she revealed on an episode of Oprah, sounds complex and kind of odd, but testimonials of satisfied customers abound.
With BHRT, women report an increase in energy, better mood stability, better sleep and improved cognitive functioning in addition to relief from common menopausal symptoms. Studies also show that visible skin aging, including wrinkles caused by low estrogen levels, can be reversed with increased estrogen. BHRT can even make your hair more lush, weight easier to lose and can increase your vocal richness.
And it’s not just the patients who love it. In fact, Dr. Brenner and Hogrefe are such enthusiastic supporters of BHRT that they are on the program themselves. And they both look fantastic. (Sorry, had to be said.)
With all of these benefits, it’s completely reasonable to wonder why our doctors are not handing out prescriptions for hormone replacement therapy along with our annual flu shots. And it’s because not all minds concur on the risk of either HRT or BHRT, and more data would be nice, too.
After the immense commercial success of Feminine Forever — whose author was later revealed to be in the pocket of hormone-producing drug companies — and subsequent increase in demand for HRT, people began to wonder what, if any, damage the synthetic hormones were doing to women's bodies. In the 1970s, HRT's synthetic estrogen was shown to elevate the risk of endometrial cancer, causing an uproar. But then, in the 1980s, HRT got back into good graces when the hormones were shown to protect against osteoporosis and maybe heart disease. Today, the risk-benefit ratio is again in question.
The National Institutes of Health's Women’s Health Initiative conducted the first large scale, double-blind, placebo-controlled clinical trials of HRT in healthy, post-menopausal women in 1991. The study was slated to continue for 15 years but was stopped prematurely in 2002 when it found statistically significant increases in the rate of breast cancer and vascular disease among test subjects who received Prempro (a synthetic estrogen and progesterone compound). The threat of heart disease, stroke, blood clots and cancer outweighed the possible good of HRT, so they shut down the study.
And while the same large-scale tests have not been conducted on BHRT, the thought is that the molecular difference between bioidenticals and synthetic hormones is not enough to discount the risks found in the Women’s Health Initiative study. (Although one study has suggested that hormone patches and creams favored by bioidentical providers do no carry the same risks for blood clots as do the more traditional HRT pill delivery system).
Unfortunately, while proponents of bioidentical hormones assert there are no risks with the therapy like there are with conventional HRT, the lack of information on how the body interacts with the two hormone formulas differently is a problem. The view of the medical establishment is to assume the risks are the same for both, but Hogrefe disagrees, saying that since her program doesn't use synthetic estrogens or progestin (synthetic progesterone), they aren't concerned. But Dr. Brenner, who fully supports BHRT, won't allow women with a personal history of breast cancer to undergo bioidentical hormone therapy.
Today, before starting any type of hormone replacement therapy, your doctor should evaluate your particular set of health risk factors in conjunction with the severity of your symptoms when devising a treatment plan. The current, accepted treatment practice for any hormone therapy is to take the lowest dose of hormones for the shortest amount of time possible to achieve the desired outcome — although women on bioidenticals commonly undergo hormone therapy for an indefinite number of years with periodic testing and hormonal cocktail adjustments.
Despite the fact that we don't know all of the risks involved with traditional HRT or bioidentical therapy, there are undeniable perks of hormone replacement therapy that both sides recognize: It lowers your chances of colorectal cancer, has therapeutic advantages for those suffering from menopause symptoms and can help prevent osteoporosis.
TO YOUR HEALTH
With a bunch of promises and a bit of risk, there’s ground to be gained with hormone therapy and the parting thought is this: All of these professionals are there to help you. Doctors, educators, pharmacists, all of them, will work with you and with one another to devise a comprehensive strategy — and possibly a payment plan — particular to your personal story to help you take charge of your physical health and well being.
While many of the opinions out there may differ, the unifying and sincere drive to better women’s health is leading the discussion.