Hormone Replacement

A study done over 20 years ago, the Women’s Health Initiative, changed the landscape of hormone replacement therapy forever. Or… well… for a while. Safety considerations were incompletely understood which prompted many clinicians to stop or decline starting hormones for women suffering with menopausal symptoms. In addition, initiation of hormonal therapy requires an in-depth conversation and assessment of patients. And time is not always something a busy provider has the luxury of in today’s healthcare environment, unfortunately. But today, with much more research, data, and knowledge, we can make safe and effective recommendations to our patients with confidence. You are not alone.

Hormone replacement therapy, otherwise known as menopausal hormone therapy, is an effective treatment for peri and post-menopausal vasomotor symptoms (hot flashes and day or night sweats), vaginal dryness, emotional changes associated with hormonal fluctuation, among other symptoms.  It has also been shown to reduce bone loss and prevent fractures.

In addition, symptoms sometimes assumed to be hormonal are not. Individuals should have a thorough assessment followed by a thoughtful treatment plan.

When it comes to assessing hormone status in pre, peri, and post menopause, many patients are surprised to hear that there is no role for blood work, saliva tests, or any other methods of measurement.  That is because symptoms are not associated with specific levels and those levels do not, therefore, prompt dose adjustments.  It is the patient and her symptoms that may prompt adjustments in therapy over time.

Lab work may be suggested to test for other problems that can masquerade as a menopausal symptom, however, such as anemia, thyroid disorder, diabetes, among others.

Bottom line: “I want to know where I’m at” with hormones, is not as easy as getting bloodwork.

The term bioidentical hormones is one that refers to the chemical structure of hormones naturally found in the human body.  It is not a scientific or medical term, otherwise.  Marketing efforts and lack of an evidence-based approach to hormone replacement can falsely reassure women that using bioidentical hormones is the best and safest approach.  However, studies are lacking to demonstrate superior efficacy and safety over a wide range of pharmaceuticals that have, by contrast, undergone approval for safety and efficacy by the FDA. 

Estradiol and progesterone are available in pharmaceutical products (as opposed to compounded products)  and have the same chemical structure as is found in the human body and have been approved by the FDA. The choice of which hormonal or non-hormonal treatment to alleviate menopausal symptoms should always be made between clinician and patient, taking many factors into account. 

Other estrogens found in the female human body include estriol and estrone and are not felt to play a role in hormone replacement, according to evidence and safety data currently available.

It is growing practice in some areas of the US to get bioidentical topical, buccal or injectable pellets (typically under the skin of the gluteus) compounded in pharmacies.  These products are not approved by the FDA for safety and efficacy.  In fact, there are concerns that compounded products are less safe than those manufactured by pharmaceutical companies who use good manufacturing practices (GMP), a system for ensuring that products are consistently produced and controlled according to quality standards designed to minimize risk to patients.  GMP is regulated by the FDA.

There are also concerns that hormone pellets that are injected under the skin may contain supraphysiological doses of hormones such as estrogen and testosterone which would be potentially harmful.

For additional information on compounded hormones, click in this short video:
https://www.youtube.com/watch?v=IXyfdus-uDU

Prescribed compounded products should be limited to cases where no good pharmaceutical option is available.

Topical estrogen in combination with any other “bioidentical” hormone that is compounded has not been shown to be more effective or safer than other hormone options, nor are they approved by the FDA for safety and efficacy.  Further, estrogen used topically in women with a uterus must be in combination with oral progesterone (or a progesterone IUD) to prevent uterine cancer.  The use of a topical progesterone cream has not been demonstrated to effectively accomplish this, potentially putting women at risk for developing uterine cancer.

Testosterone should not be used in most women for hormone replacement therapy. The exception to this is in women suffering from a mental health disorder known as Hypoactive Sexual Desire Disorder defined by “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity” that causes “marked distress or interpersonal difficulty.” Additional criteria also must be met for this diagnosis.

Otherwise, testosterone in women has not been demonstrated in clinical studies to have long term safety or efficacy for menopausal symptoms and can contribute to developing acne, hair loss, hair growth (where you don’t want it), clitoral enlargement, anxiety, deepening of the voice.

A position statement on the use of testosterone to treat women in pre, peri, or post menopause has been created to this point and endorsed by the following medical societies:

The International Menopause Society
The Endocrine Society
The European Menopause and Andropause Society
The International Society for Sexual Medicine
The International Society for the Study of Women’s Sexual Health
The North American Menopause Society
The Federacion Latinoamericana de Sociedades de Climaterio y Menopausia
The Royal College of Obstetricians and Gynecologists
The International Society of Endocrinology
The Endocrine Society of Australia
The Royal Australian and New Zealand College of Obstetricians and Gynecologists.

 Ask us for a copy of this position statement if you are interested.

There are multiple options to treat menopausal symptoms when a woman prefers this option or when hormonal therapy is contraindicated.  The choice of medication is dependent upon a number of factors unique to a woman’s health, risk factors and preferences.

Supplements that claim to improve menopausal symptoms lack evidence and the FDA does not regulate the supplements industry.  Therefore, precise ingredients are not known, claims can be misleading, and safety is not guaranteed. There are very few supplements that our practice recommends and none of them are for menopausal symptoms or to enhance hormone replacement for any reason. Caution should be used when supplements are recommended to the public and awareness of profit motive potentially associated with those recommendations.

Your journey with us begins with a complimentary meet and greet to determine if our goals are in alignment.  If so, you may join our program we call Women’s Health & Wellness at TLJ. We begin with a thorough health history, physical examination, and laboratory work, if indicated.  Risks and benefits of a variety of treatment options are discussed and, together, we embark on a path of better health, prevention, and optimal well-being.

Because we cannot separate you from your hormones, we take a holistic approach to your entire self and body.  The core of our practice is Internal Medicine., primary care.  We can either function as your primary care provider (preferably) or we can work together to compliment one you already see.

 At TLJ Aesthetics MD, we are caring for you, inside and out.

Women’s Health & Wellness at TLJ is a concierge model of primary care. Insurance is billed for your office visits.  A small monthly, semi-annual or annual fee is also charged for benefits not billed to your insurance including after hour availability to your provider for urgent matters, periodic news communications, as a few examples. This enables our team to provide ample time to our patients where they never feel rushed or unheard.

Of course, this would be our preference, as we’d like to take care of “all” of you now and in the future.  However, if you are a member of an HMO and cannot choose a primary provider outside that system, we are more than happy to supplement the primary care provider you already have.