Hormone Replacement Therapy for Women

Issues and Methods

What are your main issues?

Each person is an individual. That may sound obvious but modern medicine often ignores individual differences. I will go over options of the various ways hormones are administered and how individual variations may affect your choices. To begin, however, it is first important for us to understand what you hope to accomplish with hormone therapy. For some women, hot flashes are their main complaint, or perhaps sleep disturbance from night sweats. Maybe just poor sleep in general and waking up tired. Bleeding problems, fibroids, cramps, pain with sex, or loss of libido may be among your biggest problems. For other women, dry skin, dry eyes, vaginal dryness and infections are most disturbing. Long term issues like osteoporosis, Alzheimer’s and heart disease are important. A family history of breast cancer may be a concern, or perhaps you are a breast cancer survivor yourself. Your confidence and comfort with hormone replacement therapy and the specific method you are using is extremely important. It makes no sense to get a prescription that you don’t like, don’t want or are afraid to use.

Let’s find out what your hormones are doing now.

To begin, we need to get a complete medical history. Past gynecologic issues are important. Hormone problems can affect the whole body. Weight changes, allergies, autoimmune diseases, bowel habits, migraines, and psychological issues can all be related to your hormones. A physical examination gives clues to female hormone status and also male hormones that women produce, as well as thyroid hormones, adrenal gland and pituitary gland function. I usually get a basic set of blood work evaluating the ovary, thyroid and adrenal gland. If indicated, additional tests are obtained evaluating special issues of the pituitary, thyroid, adrenal, liver, and cholesterol or diabetes.

Blood tests, saliva tests and urine tests: Some doctors exclusively use saliva testing or 24 hour urine collections. I have found blood testing to be more consistent and reliable than saliva in most cases. In addition, it is usually covered by insurance. Progesterone tends to be concentrated in saliva and may give falsely high readings. Urine is an excretion product and may not reflect what is happening in the blood. Cortisol from the adrenal gland changes throughout the day, making blood testing difficult. For this and other special needs, saliva or urine may at times have an advantage and can be ordered. These tests are less likely to be covered by insurance and may need to be paid by the patient.

How do we begin?

With the history, physical and laboratory data, we can now assess where your hormone problems lie and begin to correct them. Some women tend to retain medication or absorb it very efficiently and a little goes a long way. Other women metabolize or excrete their medication rapidly or do not absorb it well. They may need larger or more frequent doses. I usually start with low doses. If your estrogen level is very low, starting with too high a dose can be a shock to the system and cause hot flashes and PMS like symptoms. Over a few months, we can get you to a comfortable level. After six to twelve weeks of therapy, we will obtain blood work. You will return to the office two weeks or so following the blood draw to discuss your hormone levels and how you feel. Adjustments or changes are made as needed and in two or three months we will repeat the process until you are comfortable. One of the major advantages of bioidentical hormones is the ability to measure your levels. This ensures that the levels are sufficient but more importantly, that they are not too high. Overdoses are more dangerous than too low a level.

What choices of therapy do we have?

Some commercial skin patches and creams contain bio-identical estrogen and can be effective.

Compounding pharmacies buy the various hormones in powder form. The pharmacist will carefully weigh out the proper amount. These powders can then be combined with a carrier and placed in a capsule or tablet to be swallowed. Other tablets and troches are made to dissolve under the tongue.

Hormones can be blended into creams or gels to be rubbed onto the skin or placed in the vagina.

Suppositories can be made for vaginal or rectal use.

Special solutions also exist to give hormones as drops under the tongue or as rub-on liquids.

Some women absorb hormones through their skin very efficiently. Other women, especially if their skin is tanned, only absorb small amounts. If the skin (topical) preparation isn’t working, changing to vaginal, sublingual (under the tongue) or the oral (swallowed) route may be more effective.

Should I avoid “First Pass” through the Liver?

Orally swallowed estrogens lower bad cholesterol and raise good cholesterol, affording some protection from heart attack. However, all estrogens, natural and synthetic, encourage the liver to make more blood clotting factors. Both of these effects are stronger if medicine is taken by mouth, because all food absorbed by the intestines goes directly through the liver. Clotting is a more important issue in older women who may be at higher risk of heart attack or stroke. If they have been off hormones for many years, they may have damaged arteries and veins. It is also important in smokers. Smoke damages the lining of arteries. In general, younger women require higher doses of replacement hormones and also have healthier arteries and veins. I tend to reserve oral estrogens for younger women to meet their higher hormone needs. I use topical or vaginal applications in older women, where I am more concerned with the risks and needed levels are lower.

How patient should I be if I have a problem?

If you have a reaction to one of the medications or think you are having a side effect, stop the medication and contact the office. If you don’t feel any change, have some patience. To keep safe, we are usually starting with a low dose and it may take a while to feel the improvement.

Follow up visits

Blood work and follow-up visits will continue every two or three months until the ideal levels of your hormones are achieved. Once you are stable, we may only need to do a recheck once or twice a year.

What if things have changed?

Especially in women in the perimenopause transition, the output of the ovaries is changing. Estrogen excess may decline and even become an estrogen shortage. If you feel that things have changed, we may need to retest your hormone levels. Proper therapy requires meeting your current needs, not last year’s needs.

Long term therapy

Hormone balance can be of benefit throughout a woman’s life. For young women who have had their ovaries surgically removed or lost function prematurely, I am trying to restore age appropriate levels. In later life stages, I find that lower levels of estrogen are needed for the patient to remain comfortable. Progesterone levels must be in proportion to estrogen to maintain proper balance. Progesterone therapy, therefore, is adjusted to the estrogen level. Since target estrogen levels generally decline with age and blood clotting risk increases with age, I tend to move from oral to topical forms of therapy in older women. I have found testosterone levels to be fairly steady across a wide range of ages. Many 20 year olds and 70 year olds have similar levels. If Testosterone is needed, a number of replacement methods are available. (Also see Why Should Women Take Replacement Hormones? The Benefits of Hormone Therapy.)