Over the past 23 years, there has been a lot of fear about hormone replacement therapy (HRT) – especially during menopause. The Women’s Health Initiative originally reported a concern about breast cancer risk, and that led many women to avoid HRT. 

A newly updated report from the same researchers has completely changed the perspective on hormone replacement. The researchers are now stating that HRT is not increasing breast cancer risk the way they once feared. Instead, HRT can actually decrease disease risk, including by decreasing heart disease, dementia, diabetes, and osteoporosis. 

That is such essential information, and such a shift in what we’ve been hearing, that I wanted to cover this topic in detail. 

I’m Dr. Doni Wilson, a Naturopathic Doctor, Certified Professional Midwife, and Clinical Nutritionist with over 25 years of experience as a women’s health expert. I graduated from Bastyr University in the Seattle area and was trained in bioidentical hormone replacement therapy in the 1990s. I’ve been helping women with hormone replacement therapy throughout the years since then.

I continue to update my training through educational seminars and reviewing the research so I can give you and my patients the latest information to help you make this important decision. I think this is the most important decision women are making in their 40s and 50s because it can not only influence how you feel now, but also has the ability to influence how you feel, and your health, for the rest of your life.

Choosing hormone replacement therapy is a very individualized decision. It’s important to understand and think through your medical history and your health risk factors. It’s also important to work with a practitioner who understands the latest research. It is essential to individualize your doses and how hormones are delivered to your body (oral, cream, patch, etc). I’m going to cover how to find a practitioner who can guide you every step of the way.

Understanding Hormone Replacement Therapy

When we say “hormone replacement therapy,” we are referring to estrogen and progesterone, and in some cases testosterone and DHEA as well. 

During perimenopause, the ovaries decrease their production of estrogen and progesterone. Progesterone is usually produced when we ovulate. As the ovaries ovulate less and less, progesterone production decreases. When the ovaries stop ovulating all together, the period will stop coming. The definition of menopause is twelve months without a period. At that point progesterone production will be close to none. 

Over that same time period, estrogen can increase first, for some women, and then decrease over months to years. Sometimes estrogen fluctuates up and down for a period of time, triggering symptoms of menopause such as hot flashes, night sweats, and migraines. Eventually, when the ovaries decrease function, estrogen function decreases to very little, and the period stops coming.

The ovaries also produce testosterone and DHEA, and the levels decrease during peri and post menopause. A decrease in testosterone and DHEA can also cause symptoms associated with menopause. The decrease in testosterone and DHEA can vary from person to person, especially because these hormones are also produced by the adrenal glands. The impact on how you feel based on these changes is unique to you.

You might hear different terms for hormone replacement therapy: HRT, HT (hormone therapy), estrogen therapy, progesterone therapy, testosterone therapy, or bioidentical hormone replacement therapy. In this video, I’m focusing on estrogen and progesterone. There are three forms of estrogen – estrone, estradiol and estriol. When it comes to estrogen therapy, most of the research is on estradiol. 

When we say synthetic versus bioidentical or natural hormones, we’re referring to the difference between hormones produced in a lab—synthetic hormones that look similar to what our bodies make but are slightly different in their chemistry—versus hormone that look exactly like what our bodies make naturally. 

Synthetic hormones can provide some of the same effects as natural hormones but are more likely to cause side effects and maybe not have as many positive benefits as hormones that look the same as what our body makes. If it looks exactly the same as what our body makes, then our body thinks it came from our body.

Bioidentical hormones means the hormone is identical to our biological hormones, sometimes referred to as natural hormones. A synthetic progesterone is called a progestin, and synthetic estrogen and progestin are found in birth control pills. Some practitioners use progestin and equine estrogen like Premarin versus using natural bioidentical estrogen, which would be estradiol (E2), one of our natural estrogens, and progesterone, our natural progesterone.

Research shows that with natural or bioidentical hormones, there is more potential benefit for helping with symptoms and preventing health issues, with a lower risk of side effects. As a naturopathic doctor, I’m more supportive of bioidentical or natural hormones over synthetic hormones based on the research and my clinical experience.

Key Factors in Decision Making When Considering HRT

When you’re thinking about hormone replacement therapy, the first thing your practitioner will ask is: when was your last period? 

This helps us understand where you are in the window of peri to post menopause. If your last period was within the past year, that’s still considered perimenopause, and we may be less likely to add estrogen. If you’re still having a period, we might start with natural progesterone to help regulate your cycle, but we’re less likely to add estrogen until your period is becoming farther apart or has stopped.

The reason estrogen is not used until the period stops is because estrogen can stimulate growth of the uterine lining. Also, whenever we add estrogen to the body, if you have your uterus, we need to also add progesterone. 

Here’s the key: you can use progesterone by itself without estrogen, but you cannot use estrogen by itself unless you’ve had a hysterectomy. If you have your uterus and want to use estrogen, we need to balance it with progesterone because research shows if we only use estrogen, the uterine lining can buildup, leading to uterine bleeding, hyperplasia, or increased risk of uterine cancer.

If it’s been more than one year since your last period, you’re postmenopausal, and we could use estrogen and progesterone together. If it’s been more than five or 10 years since your last period, that can influence decision-making as well. Many practitioners follow research from the Women’s Health Initiative showing concern about whether waiting longer to start hormone therapy means fewer benefits or downsides (we’ll discuss more in a minute).

The 10-year window after your last period is the best timeframe for you to make a decision about adding estradiol and progesterone. At the same time, new research shows there it can still be beneficial to add HRT even if you’re past the 10-year window. If you’re over 60 and have never used hormone replacement, it’s important to talk to your practitioner about considering HRT based on your body, symptoms, and health risk.

How HRT Helps with Menopause Symptoms

If you’re having many symptoms related to menopause and have tried herbs, nutrients, and other approaches but still have symptoms, that’s a reason to consider hormone replacement.

For vasomotor symptoms—hot flashes and night sweats—using estrogen or estrogen with progesterone can decrease these symptoms by 75 to 95% based on research. If you’re experiencing severe hot flashes and night sweats, and even migraines, it is worth considering HRT because when symptoms are affecting sleep, it can lead to other health issues. If you’ve tried natural approaches and still get hot flashes and night sweats, that’s a good time to think about hormone replacement therapy.

Sleep issues (even without night sweats) can also be helped by hormone replacement therapy. Studies show HRT (estradiol and progesterone) can help with sleep. If you have trouble going to sleep, staying asleep, or you’re waking up, it’s worth it to consider adding hormone therapy.

Genitourinary symptoms of menopause (GSM) include vaginal dryness, pain with sex, pain with pap smears, and increased likelihood of bladder and vaginal infections, including high-risk HPV. These issues increase for women in menopause because of a reduced amount of estrogen vaginally. Estrogen helps keep vaginal cells healthy and prevents discomfort as well as infections, by supporting the vaginal microbiome.

Research shows vaginal estrogen use is so protective for GSM, that it’s considered essential for most women after menopause and for the rest of their lives. When using vaginal estrogen, not much circulates around your body—it mostly stays vaginal. You’re not required to use progesterone with vaginal estrogen because it is not enough to cause a growth of the uterine lining. Less than 10 to 15% goes out of the vagina. For that reason, vaginal estrogen won’t help symptoms elsewhere in your body or prevent disease risk. There are few cases where vaginal estrogen is not recommended, for example if you are currently being treated for breast cancer.

At minimum, if you’re postmenopausal, talk to your doctor about vaginal estrogen, then consider systemic oral or transdermal estrogen. Estrogen can help with sexual function by increasing lubrication and blood flow. For libido specifically, we often discuss testosterone replacement.

Estrogen therapy can also help with skin changes, wound healing, itchy skin, dryness, dry eyes, joint pain, and stiffness—symptoms related to lack of estrogen.

How HRT Can Prevent Diseases

Osteoporosis: The first two to five years after your period stops is when women have the greatest risk of bone loss. A holistic approach to preventing bone loss includes dietary changes, nutrients (calcium, vitamin D, vitamin K), and exercise. If you have an increased risk of bone loss or have a DEXA scan showing bone loss, that’s another reason to consider estrogen and progesterone replacement. Studies show a 34% reduction in hip fractures and clinical trials show women can increase bone density using HRT.

Diabetes risk, metabolic syndrome, and elevated blood sugar increase in postmenopausal women. Using estrogen and progesterone has been shown to decrease type 2 diabetes by 15-30%. If diabetes is in your health history or you have type 2 diabetes, it is worth considering HRT.

Weight gain is common in post menopause. Studies show mild benefits of HRT preventing weight gain. 

Many women experience low mood and anxiety. Studies show hormone replacement therapy can help to some degree, though research doesn’t show a huge benefit for mood. I find clinically that women often notice an improvement in mood, anxiety, and depression with hormone replacement therapy. I also help them to optimize cortisol and neurotransmitter levels using nutrients and herbs.

The research on cognitive decline and dementia risk is crucial. The Women’s Health Initiative showed that when women start estrogen therapy within the first 10 years of menopause, especially within the first five years, they have up to 50% reduced risk of Alzheimer’s and dementia.

New Studies Have Changed How We Think About HRT

We’ve been in fear of hormone replacement therapy increasing cancer risk because of what we were told when the Women’s Health Initiative first came out in 2002. The media scared us about increased breast cancer risk with estrogen. Now they’ve reevaluated the study with new information saying women should not avoid estrogen because of fear of breast cancer. When reevaluated, they found there was increase in one out of 1,000 women per year, and after four years of use, who had increased risk of breast cancer—much lower than originally reported. And that breast cancer risk was more associated with the synthetic progestin, not the estrogen (and not natural progesterone).

If you don’t have a history of breast cancer, hormone replacement therapy with natural or bioidentical hormones is not shown to increase your risk, and it may decrease risk (upcoming studies will tell us more). Even with a family history of breast cancer, hormone replacement is still an option. If you currently have breast cancer, or have a history of breast cancer, it’s best to work with your doctors to determine the best choice for you and your situation.

Because the incidence of dementia in women is increasing, the research showing that estrogen replacement therapy can decrease the risk of dementia, especially when used within the first 10 years after the period stops, is also driving a change in our decision-making about hormone replacement therapy. If you are beyond 10 years, it’s still worth considering HRT because new research shows women starting estrogen 10 years after the period ends are still able to benefit from a reduction in dementia.

Estradiol helps protect nerves, increase neuroplasticity, and prevent dementia by reducing amyloid plaque, enhancing glial cells, and helping glucose metabolism. Progesterone is also protective to the brain. 

For cardiovascular disease, when women over 65 take oral estrogen, there can be an increased risk stroke and blood clots. If over 65, it is considered better to use transdermal delivery of estrogen (cream or patch) because estrogen delivered through the skin doesn’t increase risk of blood clots and stroke.

More women die from cardiovascular disease than breast cancer. Women using estrogen therapy have 40-50% decreased heart disease risk than women who didn’t use hormone replacement. This was shown by the Women’s Health Initiative, Cochrane review, and other studies. Cochrane review showed 48% reduced coronary heart disease risk and 30% reduced all-cause death.

If the main condition causing death in women can be reduced by hormone replacement therapy, that completely changes the way we’ve been thinking about HRT. We need to be less worried about breast cancer risk and more concerned about preventing other health conditions in women, including heart disease, dementia, and diabetes. Estrogen replacement therapy also decreases colon cancer.

Doses and Delivery of Hormone Replacement Therapy

It’s important to work with a practitioner to help you find the best doses and delivery method for you. 

There are some bioidentical hormones, both estradiol and progesterone, available through pharmaceutical companies as pills or patches that you can get at a regular pharmacy. They come in set dosages. An MD or gynecologist is likely to prescribe the pharmaceutical version, and it might be covered by your health insurance (check with your insurance). 

It is important to be aware that pharmaceutical capsules contain other ingredients. I recommend looking up the ingredients prior to taking any product in case you might be allergic to an ingredient or prefer to avoid them. 

Compounding pharmacies make formulas that are not available from pharmaceutical companies and not covered by insurance. They can make individualized hormone creams with dosing specific to you. They can provide estradiol and progesterone in a cream or oral capsule form without other ingredients. The hormones can be combined together into one formula. 

You’ll need to work with a practitioner who is trained to work with a compounding pharmacy to make a formula for you, and then to monitor your doses, and make adjustments as needed.

A common formula will be estradiol (E2) as a cream (or capsule) and progesterone as a capsule. The progesterone is often used as a capsule instead of a cream because more research exists demonstrating that oral progesterone will effectively prevent growth of the uterine lining. There is also a vaginal gel from pharmaceutical companies that can be used with estrogen. 

For decades with hormone replacement therapy, a combination of estrogens has been used. It is referred to as “biest” and includes estradiol and estriol. Recent research indicates that estradiol is more effective for helping with most menopausal symptoms and health benefits, and so use of estriol is becoming less common in an HRT formula. 

For vaginal use and GSM, estriol from a compounding pharmacy is effective and can be used as a cream or suppository once or twice per week. Pharmaceutical companies also make estradiol products for vaginal use. 

When you’re over 65 years old, it is preferred to use estrogen cream (to prevent blood clot risk) with progesterone orally. When testosterone is added, it would be used in cream a form. 

Whenever you’re using hormone replacement therapy, it’s important to monitor the dose. Especially when you are beginning to find the dose that works best for you, you may need to do testing and modify your dose a few times until you find your best dose. Your dose may also change as your body changes and based on stress exposure. I recommend checking in with the practitioner who is helping you with your HRT doses at least once per year. 

One of the biggest issues I see is when practitioners prescribe the same dose of hormones to all women and don’t follow up with testing to be sure you’re on the right dose for you 

It is possible to test estrogen, progesterone, and testosterone levels in blood, urine, or saliva testing. They each have their own potential advantages and disadvantages, so it is important that your practitioner knows which tests to order to help monitor your dosing. When taking HRT, salivary testing for estrogen and progesterone can provide the most accurate information. For testosterone, levels can be measured in the blood. 

I also recommend checking on estrogen metabolites in urine to understand how well your liver is detoxifying estrogen and if support is needed. We want to ensure your liver can metabolize estrogen well in order to prevent potential negative effects from estrogen.

Monitoring and Next Steps

I hope this information helps you to understand the important decision about whether to take hormone replacement therapy. The next step is finding a practitioner who can help you. 

I’ve been helping women with HRT for over 25 years. My goal is always to carefully understand your body and medical history, and your goals for your health, and then to talk through all of the options together. We can then determine a starting place for you to try natural (bioidentical) hormones so you can get a sense of how it feels in your body. We monitor with testing and adjust as needed until you find the best solution for you. 

If you’d like to learn more about how I can help with hormone replacement therapy, please feel free to reach out to my office. You may email us at office@doctordoni.com or call (855) 316-2114. We can discuss how best for you to access HRT from a compounding pharmacy. I am licensed in several states and am able to help patients from most locations. For HRT, you don’t necessarily need to have a practitioner in your local area. 

If you would like to learn more about how you can navigate through menopause you can check out my Mastering Menopause masterclass here. Or you can sign up for the Thriving Through Menopause Program here.

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I’m very passionate about helping women to know that there are safe and effective ways to access hormone replacement therapy and to have a practitioner who will support you with testing and dosing adjustments as needed. 

It concerns me that in years past, women were not provided adequate support with menopausal symptoms and disease prevention. The research reviewed in this episode is now opening the possibilities for more women to access hormone replacement therapy and benefit from it.

Remember, investing in your health is not selfish – it’s necessary. Just as we’re told on airplanes to put on our own oxygen mask before helping others, we must prioritize our own health to be able to care for those who depend on us. 

The time has come for women to take charge of their health and well-being, understanding that preventive care now leads to better outcomes in the future.

It is also important to know that it is possible to recover from stress and trauma and truly heal, because you’re not likely to hear that from your standard doctor’s office. Keep in mind, they are not educated about diet, exercise, supplements, or stress recovery. And many are not yet educated about bioidentical hormone replacement therapy. 

I am living proof that it is possible to heal holistically and naturally. It’s possible to balance your hormones or to use hormone replacement safely and effectively, as well as to clear HPV and get a normal pap result, and to eliminate the effects of stress, trauma, anxiety and depression. I help patients with to do this in my practice every day – by phone and zoom, anywhere in the world. You can set up a one-on-one appointment here.

Once I meet with you one on one, we will create a strategic plan based on your health needs during menopause, including sessions with the health coach on my team to help guide you to implement my proprietary C.A.R.E. and Stress Mastery programs. 

Thank you for joining me today in this episode of How Humans Heal. Make sure to follow and subscribe so you don’t miss the next one! You can access it on YouTube, Apple Podcasts, or wherever you prefer. You can also watch at doctordoni.com.

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