I saw a popular OBGYN give a talk on hormone replacement…here are my takeaways:
Last week I had the opportunity to listen to Dr. Mary Claire Haver, a popular OBGYN who is raising awareness about the medical treatment of menopause and perimenopause. I first listened to her speak on a popular podcast that a friend shared with me. After listening to that interview, I was struck by her intelligence and charismatic speaking presence and was compelled to see her in person when the opportunity arose. Here are my impressions:
I think Dr. Haver is wonderful and is doing such important work. One key takeaway from her talk, and what patients need to know, is that hormone replacement was largely condemned and feared by the medical community until very recently. A study called the Women’s Health Initiative was published in 2002 and showed an increase in breast cancer incidence in the premarin (conjugated murine estrogen, not used much anymore) plus progestin arm of the study, which was not statistically significant. The publication sent shockwaves through both the medical and patient communities, with media headlines abounding, claiming that estrogen replacement caused breast cancer. Because of this study, hormone replacement was considered a last-ditch, risky effort in treating menopause symptoms like hot flashes, mood changes, fatigue, and body composition changes (think abdominal fat gain), and was rarely used for essentially two decades.
In recent years, however, more studies have been done (and so many more are needed) showing the benefit of estradiol, what the average patient knows to be bioidentical estrogen, replacement for menopause symptom relief, bone health as people who experience menopause age, and even cardiovascular health. We also have narrowed our criteria for who really cannot have hormone replacement, increasing the number of patients who are good candidates for hormone therapy. While any treatment of any kind comes with risks, benefits and alternatives, hormone replacement is looking safer and more beneficial than it ever has for many patients.
The medical community at large has not been taught how to manage or replace hormones in perimenopausal and menopausal patients due to the relatively recent evolution of this perspective, leaving many patients without great options for adequate and responsible hormone replacement. This isn’t to say that we should blame the doctors - we genuinely believed that hormone replacement was dangerous and were taught based on the best evidence we had at that time. But it does put undue burden on menopausal and perimenopausal patients to advocate for themselves when they ideally shouldn’t have to do this. Dr. Haver and other doctors, like myself, are working to bring awareness to the importance of hormone replacement therapy for perimenopausal and menopausal folks.
Other important takeaways from the talk and my thoughts:
Estrogen, progesterone, and other hormone testing can be helpful but is not always necessary or useful in estradiol and progesterone hormone replacement.
While other testing can be beneficial to rule out other causes of fatigue, abnormal menstrual cycles, and sometimes vague symptoms of perimenopause and menopause, the hormone changes that happen especially in perimenopause can be difficult to capture with conventional lab hormone testing and can actually prevent patients from getting hormone replacement promptly when lab tests look normal. Symptoms guide hormone replacement therapy with estrogen and progesterone, not lab tests, so hormone testing throughout treatment is rarely needed or of use. There are instances where testing these hormones, including LH and FSH, can be beneficial (especially in cases where we suspect premature ovarian failure), but this is not always the case.
It’s important to rule out other causes of symptoms that can present in perimenopause and menopause.
Thyroid abnormalities, inflammation, and other conditions can mimic some of the symptoms of menopause. Having a basic lab panel before hormone replacement, again maybe or maybe not including estrogen, progesterone, LH and FSH, can be useful for your doctor to rule out other conditions that need to be treated first before going right to hormone replacement.
Hormone replacement should be adjusted based on symptoms, not lab tests
Hot flashes, mood swings, sleep disturbances, and many other symptoms should be used as our markers for successful or suboptimal hormone replacement therapy with estrogen and progesterone. Dr. Haver lists 50+ symptoms that can come with these huge hormone shifts as we age. It doesn’t matter if your labs are perfect if you’re still not feeling like yourself. This is standard of care, and more practitioners and patients need to be aware of this.
Hormone replacement can be standardized, prescription-based, and affordable
I attended an advanced-practice module for hormone health through the Institute for Functional Medicine a few years ago, and it turns out that the standard of care for functional and conventional models for hormone replacement is the same, despite how many functional medicine providers practice. Estradiol patches are preferred, as estradiol (estrogen) is safest when administered through the skin and is a way to get a stable, steady-state dose of estrogen which can be helpful for mood stabilization among many other symptoms. Progesterone pills are cheap and bioidentical and should be taken at night to support sleep and balance the effects of estrogen on the uterus and breast tissue. Testosterone is available via prescription as well, though no testosterone formulations exist that are formulated for testosterone deficiency in women, so we use the men’s formulation and dial the dose way down to more accurately achieve healthy levels in women. Whether your doctor is conventional or more holistic, like me, these are standards across the board. Compounded hormone replacement can be useful for some folks, but it’s difficult to ensure a standardized dose unless the compounding pharmacy is excellent and that can be hard to find. Compounded hormones also tend to be much more expensive and less accessible than pharmaceutical hormone replacement, which is a barrier to care for many patients.
Testosterone replacement is important for some patients, and needs to be monitored more than estradiol and progesterone replacement
This is where lab testing can be very helpful to confirm the diagnosis of low testosterone. While it isn’t required to start testosterone therapy (low libido and other symptoms can help us to establish a clinical diagnosis without testing), it is best practice to monitor testosterone levels when starting and continuing testosterone therapy. It’s easy to overtreat and excessively high testosterone levels can increase various health risks. I monitor levels of my testosterone-taking patients of all genders, along with periodic blood counts, liver function tests, and cholesterol tests.
We deserve to thrive after menopause
Estrogen receptors exist all over our body, and the benefits of hormone replacement are linked to positive cognitive effects, better bone health, and improved cardiovascular risk profiles in addition to improved quality of life when peri- and postmenopausal symptoms improve. This is HUGE. Women tend to live longer than men, but our quality of life as we age is drastically reduced in comparison. Not everyone can take estrogen, and there are other things to be aware of to thrive as we age, like nutritional status, increasing skeletal muscle strength and bone strength with resistance training, avoiding weight fluctuations and being underweight as we age, and stability and balance practices. Increasing awareness on this topic as a whole, even in people who are not candidates for hormone replacement, will allow physicians and patients to have better awareness of healthy aging practices and increase quality of life in aging women.
“Big muscles, big bones”
Dr. Haver grew up in a time where being thin was considered healthy, and she admitted to dieting much of her life in order to attain this aesthetic. One of the most important and impactful parts of her talk for younger folks who have not yet encountered these steep hormone changes was to focus on building muscle when you are young. Our bone density is at its highest when we’re around 25 years old. Dieting, overexercising without building skeletal muscle through heavy weight training, and undernourishing our bodies with a lack of adequate calorie intake can result in osteoporosis, increased fractures with aging, and lower quality of life as we age. Being adequately nourished, including being “overweight” by medical standards like BMI calculations which are actually not meaningful health indicators, has been shown in many large research studies to be health protective. She tells her daughters to have “big muscles, big bones, and bigger bodies” to age well and support their vitality in their older years. I can’t think of a more important thing to hear as a younger woman. Not buying into body image norms will quite literally save your life.
Some additional thoughts about hormone health from a functional and integrative medicine, primary care perspective:
DUTCH testing
I use the DUTCH test judiciously in my practice, and admittedly use it less often for perimenopausal and menopausal folks. I find it to be a really useful tool, particularly for younger patients with irregular cycles, severe premenstrual symptoms, fatigue, PCOS, sleep issues, and other concerns. It’s a dried urine hormone metabolite test, and while more research needs to be done to prove that it is reproducible and clinically useful from a conventional standpoint, it has given me many useful insights into my own and my patients hormone health that conventional testing absolutely lacks the capability to identify. It’s so useful for the many women who are passed from doctor to doctor, who have “perfectly normal” conventional labs but inexplicable hormone-related symptoms. I have personally used the DUTCH test to identify and treat my own hormone abnormalities, despite multiple lab tests being totally normal and not indicating any obvious hormone issues, and have had enormous success using it on myself and my patients.
Oral DHEA use
Dr. Haver uses vaginal DHEA but not oral DHEA in her hormone replacement plans. She did note that DHEA, an adrenal hormone, is converted to testosterone and estrogen and is the source of 50% of circulating testosterone in women, and noted that we can extrapolate that if vaginal DHEA is useful, that oral likely is too. She prefers to go directly to the source and treat estrogen in perimenopausal women, but I personally also like to check and treat DHEA if it’s low. Replacing an adrenal hormone that is converted into a sex hormone is a way of treating a root cause, rather than a branch after-effect, and is lower risk than replacing estrogen and testosterone (both of which can be low risk and responsibly done with the help of a skilled doctor). I use it as an adjunct to hormone replacement, which allows me to use lower effective doses of estrogen and testosterone when indicated. I also use it in younger non-perimenopausal women who are low, as it’s been used and studied from a fertility perspective and has been found to be safe and beneficial.
Men’s hormone health with aging is often overlooked as well
Okay, Dr. Haver has a big valid point that men have it easier than women for the most part when it comes to aging. She also is an OBGYN, so it is completely understandable that it was overlooked in her talk, which focuses on women’s health and aging. As a primary care doctor who sees everyone of all genders, men’s hormone replacement is also emerging as an undertreated area of medicine that can have cardiovascular benefits and improve vitality, or quality of life, with aging. It’s another topic of which awareness should be spread and more testing and treatment should be done. I hope more doctors can seek additional training like I did to feel comfortable and competent to identify and treat hormone deficiencies and gender-affirming care in any gender.
Overall, the talk was captivating, largely accessible for patients without much medical knowledge, and important. We deserve to thrive, as Dr. Haver stated multiple times in her talk. It is encouraging to see more awareness being spread about caring for yourself and seeking appropriate treatment for the hormone shifts that happen with normal aging. It is so important to know what to look for, and to have a trusted physician steering the ship, as treatment is individualized and can be adjusted to fit your needs and optimize your health.
