Hormone Replacement Therapy
Controversy Demystified

Menopause can be a scary time in a women’s life.  Not everyone will experience the jarring transition, but all women feel a change of some kind.  Going from a hormone level of 100 to 0, is like a race car coming to a screeching halt. Just this week, a colleague of mine lost a patient of his to suicide, a 51 year old mother of a teenage son, with a tiresome case of major depressive disorder.  I asked whether she had hit menopause, he said yes but many years ago.  What started her downward spiral though was the change in her skin since the onset of her menopause.  Her once beautiful face began to look aged and she became very self conscious, developing an obsession with her appearance.  The thought of her, a mother, wife, partner in the prime of her life, who suddenly felt the world was too much to bear, saddens me deeply. Especially since there may have been a simple solution. Enter: Hormone Replacement Therapy.

Menopause is a period in a woman’s life, where ovaries fail to produce estrogen.  They are done, irreversibly done.  There are estrogen receptors on practically every cell of your body, and its decline sets a ripple effect from your inner most core to the outer most skin.  There are even estrogen receptors in men, with an important function of managing the libido.   In the exam room, we often speak of treating the obvious symptoms of menopause: hot flashes, weight gain, memory fog, sleep disturbances, skin changes, diminished libido, vaginal dryness, joint pains, hair loss, and depression.  We have many drugs and potions to address single symptoms, or a myriad of symptoms.  However, the reasons which compel me to use hormone replacement therapy are for the not so obvious conditions; cardiovascular disease and breast cancer.  While there are many studies that have proven the benefits of hormone replacement therapy on prevention of, or slowing progression of heart attack and breast cancer in post menopausal years, there are equally as many refuting it.  Why there is so much controversy blows my mind.  Perhaps the reason being the male dominated world of medicine oversimplifies the health issues of women who tend to be complex creatures.  Whatever the reason, it cannot be overlooked.

The consensus amongst breast cancer and menopause experts is that the longer the exposure to estrogen, the higher the chance of breast cancer.  They base it on knowledge that beast cancer increases by about 3% if you are 55 or older when you reach menopause.  Then surely hormone replacement therapy sounds very scary to a menopausal woman who’s been told by her doctor to start estrogen and progesterone as a means to ward off uncomfortable hot flashes and vaginal dryness.  Unfortunately, what we don’t fully appreciate is that estrogen levels start declining a decade before you even reach menopause.  And it’s the rate of change that leaves the breast cells hungry for more estrogen to stay alive and vibrant as menopause strikes.   Breast cells soak up their receptors with any type of estrogen like compound they can find, whether it’s one of 50+ natural estrogen metabolites, phytoestrogens (found in plants such as soy), or xenoestrogens (found in environment, BPA and other harmful hormone disruptors).  What the hungry cells don’t consider is that not all activating hormones are alike, and some lead to abnormal proliferation which can lead to cancer.

In essence, it’s not the longer the exposure to estrogen that raises the risk of breast cancer, but the longer your breasts are starving for natural estrogens.

My theory in treating women as they begin the process of ovarian failure, is to mitigate the decent, thereby reducing activation of estrogen receptors with potentially harmful estrogen metabolites.  I can say without a shadow of a doubt, that no study has shown treatment with bio-identical estrogen and progesterone increases risk of breast cancer in post-menopausal women.  If you read carefully for yourself the golden study of HRT and breast cancer, The Women’s Health Initiative published in 2002, you’ll find that the culprit was progestins (synthetic progesterone) in raising risk of breast cancer.  Even then, the risk of aggressive breast cancers was less in treated groups, and more interestingly, the equine conjugated estrogen-only arm actually reduced incidence of breast cancer. Again pointing to the fact that it’s better to have some estrogen and progesterone around than none at all.

As for cardiovascular disease prevention, the story is similar.  When you compare the incidence of heart attacks in men and women, you see a graph like this.  The risk begins doubling after menopausal years and approaches that of men.  

hormone replacement

With judicious use and careful monitoring of preferably bio-identical hormones replacement therapies BHRT, our aim is to mitigate the decent of estrogen and progesterone in a heart that was once protected with these hormones.   A recent Danish study showed a whopping 50% reduction of heart disease and death after 10 years on hormone replacement therapy begun at onset of menopause without  any increase in risk of cancers, including breast.  This contrasts with the Women’s Health Initiative study where hormone replacement was started a decade after menopause.  Here in the United States, medical societies do endorse HRT for menopausal symptoms, but suggest further investigation is needed before they recommend bio-identical hormones.   In response to the growing demand of consumer preference of natural over synthetic hormones, Mayo Clinic initiated a study on direct comparison of BHRT with commercially available natural estrogens.  Dr. Kenna Stephenson’s  2013 landmark study on BHRT showed favorably significant effects on cardiovascular outcomes, depression scores, and menopausal symptoms.

The British Menopause Society endorsed superiority of regulated bio-identical hormones over synthetic estrogen/progestin in their 2013 Consensus Report on HRT for management of menopausal symptoms.  The data is out there, but our respectable, albeit stagnant societies are not willing to accept just yet.

Our knowledge of hormone replacement therapies in post-menopausal women is rapidly expanding.  New studies are emerging which prove that with proper use of hormone replacement therapies, in my opinion mainly with regulated bio-identical hormones, we are able to effectively and safely offset not only the obvious symptoms of depression, hot flashes and youthfulness, but more importantly the deleterious heart disease and breast cancer in women.  

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When a woman approaches the nonproductive years, it’s as if evolution saw no reason to exist.   All the signs of beauty, youth, and reproduction are driven by estrogen.  Without it, we are doomed.

Further Reading:
Bioidentical Hormone Therapy. (n.d.). Retrieved July 24, 2016, from https://www.menopause.org/publications/clinical-practice-materials/bioidentical-hormone-therapy
HRT: Benefits and risks – what you should know | Women’s Health Concern. (n.d.). Retrieved July 24, 2016, from https://www.womens-health-concern.org/help-and-advice/factsheets/hrt-know-benefits-risks/

Get in touch with Seaside Medical Practice
to schedule a HRT consultation with Dr. Yazdani

(310) 393-5000