“The goal of using bioidentical hormone replacement therapy is to relieve the symptoms of menopause, decrease risk for disease such as heart disease and osteoporosis and improve quality of life.”

“The availability and customization possible with bioidentical hormones makes them a wonderful tool in the functional medicine tool kit. When they are a good fit and used properly, bioidentical hormones are life changing!”

Treatments for menopausal symptoms and achieving optimal health are moving away from the traditional hormone replacement therapy pharmaceuticals and towards bioidentical hormones. 

In my view, natural hormone replacement therapy, combined with a functional medicine approach is a winning combination for women as they move through their perimenopausal years and into their wise menopause years.  

If you haven’t read Part 1 of my series on hormone replacement therapy, please do in order to learn about the difference between traditional options and bioidentical HRT as well as some of the fascinating history that explains our cultural hesitation with the use of hormones. 

In today’s article, I’m going to cover:

• What to expect with estrogen, progesterone and testosterone bioidentical options
• The importance of follow up testing 

Let’s dive in right away!

What to Expect with Bioidentical Hormone Replacement Therapy

The goal of using bioidentical hormone replacement therapy (BHRT) is to relieve the symptoms of menopause, decrease risk for disease such as heart disease and osteoporosis and improve quality of life. 

BHRT is available in a variety of forms including:

• Oral pills
• Transdermal patches
• Transdermal creams or jells
• Injection  
• Pellet insertion

Your provider will help you determine what bioidentical hormones, what dosage and what delivery method are best for you.

Now, let’s talk through some details for each bioidentical hormone: estrogen, progesterone and testosterone. 

Bioidentical estrogen

Low estrogen is a hallmark of menopause. While estrogen levels may fluctuate and even be high showing symptoms of estrogen dominance during perimenopause, eventually levels fall to a much lower level than when a woman was cycling. 

Bioidentical estrogen therapy is typically the estrogen called estradiol, or E2. Replacing estrogen may be helpful for hot flashes, mood changes and other symptoms of declining hormones. 

The safest form of estrogen replacement therapy is a bioidentical estradiol transdermal patch or a vaginal bioidentical estrogen cream.

Remember that it’s important for estrogen and progesterone to be balanced for a comfortable cycle and fertility. In menopause, estrogen is safest when used in conjunction with progesterone. 

For a menopausal woman who still has her uterus, progesterone needs to be used along with estrogen to protect the endometrial lining. Estrogen used alone is associated with uterine cancer. This is one example of bioidentical hormones and cancer risk, if used improperly. 

Some women who use bioidentical estrogen and then decide to discontinue use at some point, may experience a period of increased symptoms (such as hot flashes or mood changes) as they go through the withdrawal of estrogen and move to a new, lower baseline level. 

Bioidentical progesterone

Bioidentical progesterone is the preferred form of progesterone. Much of the available progesterone HRT is actually progestin, the same synthetic hormone used in birth control. Progestin is associated with some of the risks of HRT, but without the benefits. 

Progesterone needs to be used in conjunction with estrogen replacement therapy for a woman with her uterus. However, progesterone can be prescribed on its own for a woman with or without a uterus. 

Symptoms of estrogen dominance including insomnia, night sweats and heavy periods are more common during the perimenopausal years. As a woman begins having cycles where she doesn’t ovulate, she doesn’t have the progesterone she needs to balance with estrogen. Bioidentical progesterone can be a lifesaver in this circumstance!

Bioidentical progesterone is the most prescribed HRT in the United States with 21 million prescriptions per year! 

Since transdermal progesterone options might not deliver a high enough dose of progesterone for endometrial protection, oral preparations are preferred, specifically oral micronized progesterone capsules. 

Previous studies showed that only synthetic progestin protected the endometrium, but a more recent trial called REPLENSIH suggests that bioidentical progesterone is as effective, with possibly lower side effects when used in the correct ratio. 

Bioidentical testosterone 

We typically think of testosterone as a male hormone, but testosterone in women is important as well and low levels of testosterone may contribute to symptoms of menopause. Sufficient levels of testosterone are required to maintain (and build) lean body mass, which is important for metabolism and body composition as we age. In addition, low testosterone may contribute to fatigue, bone loss and low libido. 

DHEA is the precursor to testosterone (and estrogen too) that is largely made in the adrenal glands. The adrenal glands become particularly important for hormone production in menopause as the ovaries cease to produce hormones. I’ve written in detail about the benefits of DHEA supplementation for women (read Part 1 and Part 2 of my series for more information). 

I mention DHEA because it is often a good option for supporting testosterone levels in women. In addition, testosterone may be used directly for certain women as a cream or pill. I prefer the troches or a cream that is used transdermally on the labia. 

Importance of Hormone Level Testing 

If you know me, you know my motto is why guess when you can test? And testing for hormones is no exception. In fact, it’s incredibly important. 

Many hormone imbalances produce similar symptoms. How do we know if your fatigue is related to low testosterone or if it’s a symptom of low cortisol, low thyroid or even insulin resistance? This is why testing to understand your unique baseline hormones is so important. It’s how we address your root cause so you feel better over the long-term.

In addition to baseline testing prior to prescribing bioidentical hormone replacement therapy, I always recommend ongoing testing as well, at least annually. Since all hormonal systems are connected, it’s possible that we may need to adjust your prescription if you go through a period of high stress, have new symptoms develop, are diagnosed with a new condition or another factor that arises. 

The availability and customization possible with bioidentical hormones makes them a wonderful tool in the functional medicine tool kit. When they are a good fit and used properly, bioidentical hormones are life changing! 

References

1. Mirkin S. (2018). Evidence on the use of progesterone in menopausal hormone therapy. Climacteric : the journal of the International Menopause Society, 21(4), 346–354. Full text: https://www.tandfonline.com/doi/full/10.1080/13697137.2018.1455657 
2. Gersh, F. L., O’Keefe, J. H., Lavie, C. J. (2021). Postmenopausal hormone therapy for cardiovascular health: the evolving data. Heart. Published Online First: 22 February 2021. Full text: https://heart.bmj.com/content/early/2021/02/22/heartjnl-2019-316323.full?ijkey=aaPB4xO8RYmwoi7&keytype=ref&fbclid=IwAR1OClPqG56jsuWiqH0SaaeJy6YDBENQxMHABm2yQn6M4cbZtj5PQiBb1xM