You have decided on bio-identical hormone replacement and are excited about the prospect of improved energy, libido, concentration, bone density, and muscle mass. When you come to us for consultation on bio-identical hormone replacement, one of the first questions you might have is, “what is the best method?” There is no one size fits all answer to this question which can be frustrating when deciding.
Adding to the confusion are media reports about the harmful effects of estrogen, the oral form of estrogen in particular. Even your primary healthcare provider may be reluctant to sign off on some or any forms of estrogen replacement since they are relying on outdated or erroneous research studies that look at traditional estrogen and not the bio-identical form.
Bio-identical hormones are different from those used in traditional hormone replacement therapy (HRT) in that they’re identical chemically to those our bodies produce naturally and are made from plant estrogens. The hormones used in traditional HRT are made from the urine of pregnant horses and other synthetic hormones.
Estrogen
The continuing controversy over hormone replacement in general, and estrogen in particular, can be confusing for patients. There is a debate on oral vs. topical (aka patch). This is where it gets sticky. Topical is safe in every study for blood clots. So this is why some hormone providers only do topical. But if you look at the research, there is no study that the bio-identical oral estradiol causes an increase in blood clots.
Premarin studies do show an increase in the risk of blood clots. But even some of the hormone providers lump this into the category of 'estrogen.’ Research articles may say hormone replacement therapy that includes Premarin and is not bio-identical.
When we look at studies with only oral estradiol and not Premarin, there is no risk of blood clots. And many studies suggest that oral estradiol does better for improving cholesterol and arterial plaque, therefore, reducing the risk of heart disease better than topical. In fact, studies show that estrogen replacement therapy reduces cardiovascular disease in women. Remember, estrogen levels have to be at a certain level to provide bone, brain, and heart protection.
Oral
Pros
Many studies suggest that oral estradiol does better for improving cholesterol and arterial plaque, reducing the risk of heart disease better than topical.
More consistent blood levels to determine dosage. With pills, it is easy to adjust dosages based on blood levels
Cons
Other methods might give greater peace of mind to women who have concerns about oral despite the current research.
Some women may not like taking pills, and compliance can be an issue.
Patches
Pros
Convenience. Patches are changed once or twice a week.
Lower risk of side effects and higher safety profile.
Cons
Absorption. The skin is a barrier to absorption, and some women do not absorb enough estrogen to benefit. In those cases, other delivery methods like oral or pellets will deliver more consistent dosages.
Irritation at the site. For some, a patch will irritate the application site.
Compliance. With the patch, you have to remember to change on a regular schedule.
Creams
Pros
The risk profile may be lower with creams, therefore a more appropriate choice for some.
Can be applied vaginally to improve vaginal health and as a treatment for atrophy.
Cons
Compliance and convenience. With creams, you have to remember to apply it daily. Daily application of a cream can be messy and inconvenient.
Absorption. Again the skin acts as a barrier to absorption, and levels may not be accurate. Also, you have to use great caution not to wash off the cream before it has had a chance to deliver a precise dose.
With creams, you have to be careful that other people in your household don’t come into contact with the cream site. Otherwise, the estrogen could pass to other people.
Pellets
Pros
Pellets provide the most accurate and consistent blood levels once the dosages are determined.
Compliance is very high since the pellets remain in the skin for 3-4 months.
Convenience. Pellets require no effort on your part. They are in and the only thing you have to remember is to have them replaced in 3 months.
Testosterone can be inserted via pellets and eliminate the need for topical or injectable testosterone with the patch and creams.
Cons
Slight risk of infection at the insertion site.
Slight risk of extrusion of pellets, and a need for replacement.
Once the dosage is in, there is no way to change it. For example, if you have vaginal bleeding the estrogen dose can’t be adjusted until the next pellet insertion.
Testosterone and Progesterone
Testosterone
Testosterone can be added to pellets providing consistent absorption and levels. For women who opt not to use pellets, the choices for testosterone are creams or injections. The same problems with estradiol creams apply to testosterone- absorption, compliance, and the risk of passing testosterone to others in your household.
The disadvantage of injections? Some people don’t like needles! Plus, injections have to be given either daily or weekly. However, injections eliminate the problem with possible contamination of other people.
Progesterone
Progesterone can be taken orally, sublingually, or vaginally. Unfortunately, progesterone is not available in pellet form. For women who are particularly sensitive to progesterone, vaginal inserts are an option.
How to Decide on the Best Bio-Identical Hormone Replacement
As you sift through controversies, research studies and consider what your primary care provider says, talk with us about your concerns and options. Your comfort level is an important consideration when making these decisions, and at Optimal Hormone Health, we can provide you with all the information you need to move forward.
Sources
“Estrogen in the Prevention of AtherosclerosisTrial.” American College of Cardiology. https://www.acc.org/latest-in-cardiology/clinical-trials/2010/02/23/19/03/epat
“Effect of hormone replacement therapy on cardiovascular events in recently postmenopausalwomen: randomised trial.” BJM. https://www.bmj.com/content/345/bmj.e6409
“Early use of postmenopausal hormone therapy may prevent heart disease.” Science Daily. https://www.sciencedaily.com/releases/2016/03/160330184238.htm