Regardless of the wider debate that surrounds the treatment options for menopausal symptoms, there can be no doubting the fact that for as many as 80 per cent of the women who experience them the menopause is extremely challenging both mentally and physically.
Physical discomfort comes in the form of, among other symptoms, hot flushes and sweats, weight gain, vaginal dryness, foggy thinking, hair loss, loss of libido and fatigue.
Emotional challenges come from anxiety, lack of sleep, depression, mood swings and irritability.
So, it’s hardly surprising that many women seek help through Hormone Replacement Therapy (HRT).
In early treatments it was believed that oestrogen replacement alone would be enough to tackle the symptoms, but it then emerged that oestrogen-only forms of HRT contributed to increased incidence in uterine cancers.
To protect the uterus, doctors realised that progesterone needed to be included in HRT treatment.
In 2002 a new danger had emerged as a Women’s Health Initiative study revealed that there was an increased risk of breast cancer, heart disease, DVT and stroke associated with HRT treatments where oestrogen was combined with synthetic progestogens, leading many women to abandon their HRT treatment.
Not long afterward, a study published in The Lancet showed that while oestrogen alone marginally increased the risk of breast cancer and DVT, the risk was increased significantly in the combined use of oestrogen and some synthetic forms of progesterone, such as progestins.
Conversely, this and other studies also demonstrated that combining oestrogen with natural unadulterated progesterone did not increase the risk of breast cancer or DVT.
A key learning for the medical community should have been that the physiological effects of progesterone and progestins are markedly different. Read my fully-referenced article on this subject for a more detailed understanding of the scientific evidence.
This poses a problem for the manufacturers of HRT: unable to patent natural progesterone, commercial advantage is only possible through patenting synthetic progestins. Profits are therefore placed at risk by growing awareness of the different biological effects of natural progesterone versus synthetic progestins.
Awareness of these differences has not yet reached all corners of the GP community, but where it has, those GPs tend to be inclined, ethically, to prescribe oestrogen with bio-identical natural progesterone.
The main three oestrogens are oestriol, oestrone, and oestradiol, all of which are produced naturally in the body and all of which have a physiological effect.
These oestrogens have a number of benefits in how they tackle menopausal symptoms such as hot flashes, sleeplessness, cognitive function, mood swings and skin and hair heath.
They can also maintain pelvic health, protect against colon cancer and macular degeneration, prevent atherosclerosis, hypertension, improve insulin sensitivity, prevent osteoporosis, prevent osteoarthritis.
However, the beneficial anti-ageing effects oestrogens can have in the improvement of tissue function is often ignored due to fears over the long-term risks mentioned earlier in this article.
There is, however, some key science around oestrogens that needs to be highlighted. The three main oestrogens differ in potency, with oestradiol being 12 times more potent than oestrone and 80 times more potent than oestriol.
Recent studies have shown that oestriol is the dominant oestrogen in non-pregnant pre-menopausal women and seems to be breast protective. Studies also suggest that oestriol is not associated with increased risk of breast or uterine cancers.
Furthermore, in over 40 years of oestriol use there hasn’t been a single report to the FDA of an adverse event from treatment.
So, although oestriol has traditionally been considered the weaker of the oestrogens and had been thought previously to play no significant role outside pregnancy, research now suggests it may play an important part as a more protective oestrogen and as a regulator of its more potent sisters.
My companion article to the progesterone article referenced at the beginning of this piece “Not All Estrogens are Created Equal” adds scientific weight to this area of the debate.
There is much conflicting public opinion in the debate around conventional HRT and bioidentical HRT (BHRT). However, in publishing those opinions there’s a responsibility for doctors and others to ensure they’re based on ethical and established science rather than ill-informed conjecture.
Let’s deal with some of the popular mis-selling that appears to be perpetuated in the HRT argument:
BHRT is highly ineffective, expensive and puts women at risk of cancer
More than three decades of use have demonstrated the effectiveness of BHRT and it is preferred by many women who have tried both. As already outlined, there’s no increase in the risk of cancer when oestrogens are used with natural progesterone.
BHRT doses are often a best guess and delivery methods haven’t been properly developed
BHRT doses are based on many years of experience – and doctors prescribing BHRT know the delivery methods are proven because they measure hormone levels before and after prescription.
There’s a danger that errors in dosing can lead to endometrial cancer
Again, the combined use of oestrogen with natural progesterone reduces this risk and there is no evidence of a link between BHRT and endometrial cancer.
Dosing errors mean women may not get enough protective progesterone
This is a risk that is purely theoretical and not based on any scientific evidence. Furthermore, BHRT doctors measure progesterone levels post-prescription in order to confirm correct dosing.
The Women’s Health Initiative study was misleading and presented in a way that frightened women
There are now multiple studies to demonstrate the link between increased cancer risk and the combined use of oestrogens with synthetic progestins.
There are already several bioidentical approved products available, including HRT
Although true, there are very few and the reality is that these are very rarely prescribed by GPs and unlike BHRT, will not address other hormone deficiencies that may be present
Approved HRT products are tried and tested, and the doses approved by medical research
HRT assumes a fixed dose is suitable for everyone, which is not the case since absorption varies greatly from person to person. And, as we’ve already established, BHRT doctors measure the hormone levels in their patients – something that does not routinely happen in conventional HRT treatment.
Both HRT and BHRT are synthetically made
This is correct, although all the evidence suggests their physiological effects are very different because BHRT have a structure that’s identical to the hormones produced within the body.
It’s virtually impossible to tailor BHRT treatment to individual patients
This is simply wrong. Every woman will have a different reaction to different doses of hormones. By measuring hormone levels pre- and post-prescription, we can ensure each women receives the optimum dose for her.
BHRT costs a lot more than HRT
This is true where the required hormone replacement is more comprehensive or complete. If only oestradiol and natural progesterone are used, the price of treatment should be similar.
BHRT is mainly delivered as a cream and progesterone isn’t absorbed through the skin
BHRT can be delivered topically, trans-mucosally and in the case of progesterone, orally. Progesterone is absorbed through the skin and we can prove that by measuring progesterone levels following treatment.
Because BHRT is unregulated, there’s a risk of overdosing patients with oestrogen
Again, measuring hormone levels in BHRT means this is actually more likely to occur in unmeasured conventional HRT treatments.
HRT is an approved product so it can be monitored
In fact, BHRT is monitored even more closely through regular testing and patient follow-up.
BHRT is mainly prescribed by GPs, despite the wider medical community condemning its use
If that’s true, then why is it true? Presumably because those doctors have been convinced by the available evidence that BHRT is in the long-term interests of their patients. As such they’re perhaps acting more ethically than the medical societies that have ties to big Pharma.
In summary, there is no evidence to support any claim that BHRT is unsafe. It is unfortunate, unfair and ethically unforgiveable that so much opinion attacking BHRT should be circulating without any credible supporting science behind it.
If those who seek to decry BHRT were minded to engage in a more sophisticated and informed debate on the subject, a great many women around the UK would be better informed about the best way for them to manage their own menopausal symptoms.
This blog is a simplified version of a more scientifically detailed article written by Dr Nyjon Eccles for the Alliance for Natural Health International. If you would like to learn more about the science and evidence that drives the debate around BHRT and HRT, you can read that article in full here.