BHRT for Menopausal Women

Written by Ellie Kroeger

What is it?

BHRT is the supplemental administration of molecules that are identical to human sex hormones; the most commonly prescribed are estrogen, progesterone, and testosterone. These hormones can be administered topically (transdermal), orally, intravenously, or intra-vaginally.


Why consider HRT?

When women begin menopause, their estrogen and progesterone levels drop. This can lead to a variety of frustrating symptoms such as weight gain, night sweats, irritability, sleep disturbances, brain fog, hair loss, dry skin, hot flashes, depression, and decreased libido. In the long term, low levels of estrogen can also increase the risk of Alzheimer’s, atherosclerosis, and osteoporosis by accelerating aging.


Why topical vs oral?

Although there are many possible forms of administration, topical and oral administration of estrogen, progesterone, and testosterone are the most common. Topical estrogen is often recommended, which can be absorbed into the skin to act both locally and systemically. Topical administration avoids first-pass metabolism in the liver, rendering lower doses as effective as higher oral doses, and transdermal absorption may be safer than oral estrogen because less estrogen may be converted to estrone (an unfavorable estrogen linked to cancer). However, further studies are needed.

Topical estrogen can be combined with topical progesterone in one convenient cream, but oral progesterone may more closely mimic the natural oscillations of progesterone in the body due to its longer half-life and circulation in the blood.


What can exogenous estrogen do?

Replacing the lack of estrogen in the body when it is no longer being released in normal quantities and restoring it to pre-menopausal levels can reduce menopausal symptoms and slow the rate of aging.

Some benefits that might result from taking estrogen during menopause:

  • Increased skin elasticity
  • Increased vaginal lubrication
  • Increased libido
  • Weight loss
  • Hair growth
  • Improved wound healing
  • Menopausal symptom relief (i.e. hot flashes, night sweats, sleep disturbances)
  • Reduced risk of atherosclerosis (as long as HRT is started peri-menopausal and not years post)
  • Reduced risk of Alzheimer’s and dementia
  • Reduced risk of osteoporosis (which is the loss of bone tensile strength, NOT of bone density, which is why calcium is not beneficial)


Because HRT is replacing hormones, when the HRT is stopped and estrogen levels return to menopausal levels (very low to nonexistent), the expected rate of aging will return. The cognitive and atherosclerotic protection will be negated.


What are the three types of estrogen, and why are they administered in different percentages?

E1- estrone : this is an unfavorable form of estrogen, the “carcinogenic” estrogen also secreted by adipose tissue, as well as the only type naturally produced by the body after menopause.

E2- estradiol : this is the most potent and biologically active form of estrogen, especially during reproductive years.

E3- estriol : this estrogen is least likely to be converted to estrone (because it first must be converted to E2 and thus would take two steps). It is less biologically active than estradiol and rises naturally during pregnancy.

A typical prescription usually indicates a ratio of E3 to E2. Often, it is 50/50,  80/20, or 90/10. Although there may be a lower chance of conversion to estrone with a higher ratio of E3 to E2, a higher dose may be required to have an effect on the body, because E2 is the more biologically active, potent, and effective at mitigating menopausal symptoms.


How does estrogen improve my symptoms?

Estrogen is a hormone that acts systemically and binds to receptors all over the body. Hormones interact widely in various signaling pathways within the endocrine and neuroendocrine systems. Maintaining the hormone range correspondent with that of a younger female can slow the rapid increase in oxidative stress and aging associated with a drop in estrogen.

For example, menopause leads to a decrease in skin thickness, as well as reduced collagen content. Estrogen counteracts this, increasing skin thickness and collagen content.


How is estrogen broken down?   

Estrogen gets broken down in the liver into three metabolites: 2-hydroxyestrone, 4-hydroxyestrone, and 16-hydroxyestrone. 4-hydroxyesteone is largely a metabolite of conjugated estrogens. The ratio of 2-hydroxyestrone to 16-hydroxyestrone is ideally high, although some 16-hydroxyestrone is necessary. 2-hydroxyestrone is considered to be a more favorable estrogen metabolite, while the other two metabolites can lead to abnormal cell growth (cancer) when in high quantities. There are a variety of foods and lifestyle changes that can increase 2-hydroxyestrone (i.e. lignans in flaxseed, cruciferous vegetables, omega-3 supplementation, lowering body fat percentage).


Do I need to take progesterone if I am also taking estrogen?

If you have a uterus, yes. Taking progesterone with estrogen lowers the risk of endometrial cancer by lowering the risk of the uterine lining growing too thick (hyperplasia). If you do not have a uterus, progesterone is often still recommended due to its calming effects.


What can exogenous progesterone do?

Progesterone is known to increase GABA synthesis and promote sleep. It is often considered a relaxing hormone. It can reduce anxiety and help menopausal symptoms, alongside exogenous estrogen. However, progestins - synthetic progesterone found in birth control – lead to a slightly higher risk of breast cancer than progesterone, perhaps due to their potential to bind androgen receptors.


What about DHEA?

DHEA is a hormone produced by the adrenal glands. It is a precursor to estrogen and testosterone, and it does not require a prescription. It is often touted as a more “natural” means to increase sex steroid levels and optimize their ratios (because under different conditions and enzymes, it can be converted to either estrogen or testosterone). It has been shown to improve skin, treat osteoporosis, reduce erectile dysfunction, and increase libido, likely due to its ability to increase estrogen and testosterone levels. Its production is drastically reduced as we age.


Why BHRT vs synthetic hormones?

Bio-identical hormone replacement therapy, as the name implies, uses chemicals that are molecularly identical to human hormones. They are extracted from plant sources and then modified in a lab. BHRT requires a compounding pharmacy that can personalize the dose for each patient’s unique needs and hormonal profile.

Synthetic hormones, on the other hand, come in standard doses. They may be metabolized differently in the liver and/or lead to different ratios of metabolites.


Why are people against HRT?

Lots of misinformation exists on HRT. Some studies report slight relative increases in breast cancer risk; however, most of these are not statistically significant.


What are the other risks?

HRT may increase the risk of blood clots, as well as increase the risk of cardiovascular disease if a patient begins HRT when she already has advanced atherosclerotic plaques and calcification.


What is DIM?

DIM is a dietary supplement often used to assist liver detoxification, especially increasing the detoxification of estrogen into favorable metabolites (i.e. 2OHE) to be cleared from the body.


What are other naturopathic ways to improve menopausal symptoms or increase my hormone levels?

There are a variety of over-the-counter plant extracts and supplements that have been shown to improve menopausal symptoms and/or increase hormone levels, such as black cohosh, Vitex, maca, Pueraria mirifica, and other phytoestrogens. Lowering cortisol can also be beneficial, in addition to maintaining adequate levels of vitamin D, magnesium, and zinc. Resveratrol, another phytoestrogen, may also offer cognitive and oxidative protection for post-menopausal women.


How is HRT different from birth control?

Oral contraceptives contain ethinyl estradiol, which impacts and is impacted by liver metabolism differently than natural estradiol; hence, this is why ethinyl estradiol/oral contraceptives have been linked to liver complications and changes in hepatic function.

Birth control and HRT also typically have different doses of estrogen and progesterone, with birth control pills usually containing more estrogen than HRT. Similarly, hormone replacement therapy is prescribed to women with low to non-existent concentrations of estrogen, whereas oral contraceptives are often prescribed to women during their reproductive years when they are concurrently secreting estradiol. This may account for the different side effects and risks between birth control and HRT.


Is it unnatural to take HRT? Is menopause a natural part of aging?

In a way, BHRT could be argued to be the most natural means possible of addressing menopausal symptoms to improve quality of life. Rather than take a cascade of pharmaceuticals to relieve a variety of symptoms that stem from the same root cause, HRT can address that root cause and offer increased youth.


As science advances and clinical trials continue, the best practice in medicine rapidly changes. It is important to form your own opinions on hormones  by reading medical literature and taking note of how YOUR body responds to various hormones and dosages. Intuition in medicine should never be neglected.


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