NATUROPATHIC DOCTOR IN ONTARIO
The 3 Things You Need To Know About Hormone Therapy In Menopause
Is it safe? Is it right for you?
Hormone Therapy In Menopause
Bioidentical hormone therapy in menopause is both “so hot right now” in the community and on social media, but is ice cold in your doctor’s office. Details of bioidentical hormone therapy seem illusive. You are hearing about all of the amazing benefits online and through your friends, and yet your doctor is “not comfortable prescribing it”? Why this mismatch?! Let us explain the complicated nuance of hormone therapy in the 2020s, and why it seems appealing and at the same time, unattainable for many women.
3 Things You Need To Know About Hormone Therapy In Menopause
1) How hormones are shifting in perimenopause and menopause and why this causes symptoms
2) The history of hormone therapy and why many patients and practitioners shy away from it
3) The current research and standards of care, including specific dosing and safety assessment
Why You Might Want Hormone Therapy in Menopause (and Perimenopause)
The ovaries are little functioning factories that pull ingredients out of the bloodstream, build them into hormones, and release them back into the bloodstream to flow towards other tissues and organs where they link with hormone receptors and activate pathways in those cells.These ovaries are organic, responsive, flexible, and hard-working! They are constantly on alert, awaiting their signal to spring into action.
Just as you can imagine, any functioning factory will have disruptions in output as it navigates the logistics of start-up (puberty) and at closure (menopause). There is not always a smooth ramping up of operations in teenagehood, nor always a gentle decline into retirement in perimenopause. These hard-working ovaries tend to fit and spurt creating irregular undulating hormone levels at the edges of the reproductive life cycle.
In perimenopause, estrogen levels can swing wildly, whereas progesterone begins its progressive decline from often the age of 35 onwards. For some women this is a gentle slope, for others there is very much a rapid plummet. When estrogen and progesterone are not paired in a balanced way (as is standard in the reproductive years), a woman is more likely to be experiencing symptoms of perimenopause (such as hot flashes, insomnia, mood disturbances and cognitive changes).
Historically, estrogen alone was prescribed to manage these perimenopausal symptoms. But, you ask, how would adding MORE estrogen to a fluctuant estrogen and a declining progesterone picture help? Really it’s like drowning out background noise. By introducing higher estrogen levels consistently, it smooths out the many hormone change messages that the brain is receiving.
From a naturopathic perspective, a better option is to first boost the low progesterone levels. This improves hot flashes and sleep quality in most women. If there is still room for improvement, then we consider adding in bioidentical estrogen to support mood and improve long-term risks of both osteoporosis and cardiovascular disease.
Bioidentical hormones are only ever prescribed after a thorough risk-benefit assessment, and the treatment is very much uniquely tailored to that particular patient. The treatment also gets altered over time as the woman progresses through perimenopause into menopause. As her own estrogen production continues to decline, we increase the dose of bioidentical estrogen to both maintain wellness and a symptom-free state, as well as mitigate long-term disease.
The History of Hormone Therapy
Hormone therapy has been around since the early 1940s. The primary source of hormone supplementation was the urine of pregnant horses (CEE, Conjugated Equine Estrogen – PreMARin) as it was relatively easily sourced, and bioidentical hormones were not yet commercially freely accessible. Progesterone was not prescribed.
Many women valued the symptom relief CEE provided, and it was somewhat commonly prescribed. But in the 1970s an association was found between estrogen hormone therapy for menopause and an increase in endometrial cancers. Then in the early 1990s, a large study measuring the safety of estrogen therapy demonstrated an increased risk of breast cancer as well. It did however show a reduction in osteoporosis and cardiovascular disease. Another large study, concluding in 2002, found an increased rate of breast cancer, coronary artery disease, stroke, dementia, and thromboembolism, and a decreased rate of hip fractures (osteoporosis), colorectal cancer, and diabetes. These results were widely publicized and are what is commonly believed to be the whole truth about hormone therapy.
The big problem with this study is that the women included were mostly not recently menopausal (the average age was 62, where the average age of menopause is 51). When the data was analyzed with age segmentations, it showed that for women aged 50-59 there was a reduction in all-cause-mortality, and therefore the concept of an appropriate timing window was accepted. We also learned that, if a woman still has a uterus (aka, a woman who has not had a hysterectomy), it is mandatory to prescribe progesterone in tandem with estrogen to balance its effects on the uterus and prevent endometrial cancer.
After this study hormone prescriptions to menopausal women declined by 80%, and is now only prescribed to 3-4% of perimenopausal and postmenopausal women (whereas prior to this study was prescribed to 25-30%). To be clear, this does not mean that fewer women are suffering from perimenopausal symptoms, they are just going untreated, or treated with other medications that in turn have their own risks and side effects (for example antidepressants, and bisphosphonates for osteoporosis).
From those studies we learned that timing, dose, and route of administration are all very important when considering the safety of bioidentical hormones. When all of the current research is compiled, as it is supported by various international medical menopause societies, the data confirms that the benefits of hormone therapy (when prescribed at the right time, in the right dose, and the right route) outweigh the risks for most women. This is definitely the case for women who are suffering from perimenopausal symptoms (hot flashes, insomnia, and mood changes), but the benefits of hormone therapy in the prevention of cardiovascular disease and osteoporosis may be indicated even in some asymptomatic women, depending on their risk factors (for example, a woman at high risk of osteoporosis would benefit from estrogen therapy even in the absence of perimenopausal symptoms).
TWO MOST IMPORTANT RISK MITIGATORS FOR HORMONE THERAPY
- HORMONE THERAPY CAN ONLY BE INITIATED WITHIN 10 YEARS OF YOUR LAST PERIOD
- IF YOU HAVE A UTERUS, PROGESTERONE MUST BE PRESCRIBED ALONG WITH ESTROGEN
If these two factors are addressed, the increased risk that may come with the use of hormone therapy in menopause and perimenopause are extremely minimal, and usually outweighed by the short-term quality of life measures as well as long-term health benefits for most women.Calculating your individual risk is easy to do, and will allow you to make a fully informed decision about if hormone therapy is the right choice for you.
Take Home Message About Hormone Therapy
To summarize; the current consensus of the medical research community is that hormone therapy in menopause is safe and effective, but as always, there is a lag between research and clinical application. Many family doctors are still operating from old information and fear prescribing hormones to even the most symptomatic perimenopausal women.
If this is your case, the best option is to help give your doctor the confidence that you are fully informed and this is a safe medical decision you are making by providing them reference to the appropriate menopause societies documentation. We will also be creating a “Doctor Information Package for Menopausal Hormone Therapy” to facilitate this for you if you are outside of Ontario and cannot see us as patients directly. For our patients, naturopathic doctors in Ontario can order any necessary lab testing to rule out other causes of the hormonal symptoms, and then safely prescribe hormones as indicated for each patient. For other patients, we support them by setting them up so that they can have an informed discussion with their family doc.
The current research and standards of care, including specific dosing and safety assessment:
As said, we are putting together a proper education module to flesh out the specifics, but in the meantime here are links to some online resources to point you in the right direction:
Dr. Janna Fung | Naturopathic Doctor
Dr. Janna Fung is a licensed naturopathic doctor with a special interest in dermatology and women’s health. She has a passion for evidence based preventative medicine and strives to empower patients with the knowledge to achieve their optimal health. She understands collaborations is the only way to develop realistic sustainable health/wellness results and strives to develop individualized health goals with patients.
Dr. Elizabeth Miller | Naturopathic Doctor
Dr. Miller completed her doctor or naturopathic medicine degree at the Canadian College of Naturopathic Medicine, and holds a Master’s and Bachelor’s of science in Human Health and Nutrition from the University of Guelph. Her extensive knowledge of nutrition and her strong foundation in scientific research allows for a very thorough approach to your care. She is licensed and registered as a Naturopathic Doctor in Ontario by The College of Naturopaths of Ontario (CONO) and is a member of the Canadian Association of Naturopathic Doctors (CAND) and the Ontario Association of Naturopathic Doctors (OAND).
She is passionate about teaching holistic health to help women understand their bodies and get to the root cause of their health issues. Her areas of special interest include women’s health, hormonal health, gastrointestinal health, and pediatrics.
Dr. Sarah Goulding | Naturopathic Doctor
Dr. Sarah Goulding is a licensed naturopathic doctor in Ontario and has a BSc in neuroscience and biology from Dalhousie University (2004), and did her 4-year naturopathic training at the Canadian College of Naturopathic Medicine (2010). She’s since accumulated over a decade of clinical experience, and refined her practice to focus on women’s health and digestion. She is licensed and registered as a Naturopathic Doctor in Ontario by The College of Naturopaths of Ontario (CONO) and is a member of the Canadian Association of Naturopathic Doctors (CAND) and the Ontario Association of Naturopathic Doctors (OAND).
Dr. Sarah Goulding blends science and compassion, and acts as a personal health researcher to help you navigate your health. Tools that she uses include nutrition, supplements and botanicals, bioidentical hormones, and lifestyle modifications. The closer you get to the root cause, the gentler the therapies needed to resolve the issue.
