The absence of estrogen in the body affects women differently. Some women have no symptoms. Most women have one or more of several symptoms:

• Hot flashes
• Night sweats
• Vaginal dryness
• Mood swings
• Depression
• Decreased libido
• Skin dryness
• Arthritis-like symptoms
• Mental dysfunction, “brain fog”

The average age of menopause is 51-52. The average length of hot flashes is 4 years.

A woman is considered in “menopause” when she has gone one year without a period. Perimenopause is defined as the events preceding menopause. This time is characterized by irregular cycles. The ovaries become dysfunctional as the number of eggs diminishes.

Perimenopause is a time of irregular bleeding. Some women do not have a period for several months. When the period does not come some women experience menopausal symptoms briefly until the period resumes.  Other women may have prolonged episodes of bleeding as hormones fluctuate.

Not knowing what the ovaries will do from one week to the next can create distress, especially if mood swings develop and emotions are out of control.

Hormone replacement therapy can mean single or multiple hormones being replaced to relieve menopausal symptoms and include:

• Estrogen
• Progesterone
• Testosterone

HRT can be given orally, transdermal or by subcutaneous pellet. They can be commercial FDA-approved products or compounded formulations. 

Estradiol is the most prescribed estrogen. It is available through insurance as a pill, patch, gel, or cream. We individualize decision making with each patient. Estrogen can be compounded into a cream, troche, or pellet. Some practitioners will claim a troche is “bio-identical”. However, if it goes in your mouth, it is not bio-identical, it is oral.

Progesterone is most commonly prescribed as an oral capsule. It tends to have a sedating quality that many women feel helps them sleep better. Synthetic progestins(Provera, norethindrone) are less costly but tend to have more side effects.

Testosterone is metabolized into estradiol by the ovary. There are currently no commercially available products. The FDA did not approve a testosterone patch for women’s libido a few years ago due to concerns about cardiovascular disease and other safety issues.

The term” bio-identical” refers to non-oral(transdermal or subcutaneous) absorption of the hormone. A patch, gel, cream or pellet would qualify as bio-identical. FDA approved patches, creams and gels are covered by insurance.

Compounded creams and pellets are not approved by the FDA or covered by insurance. Pellets and compounded creams may contain estradiol, testosterone, progesterone or a combination of two or all three.

Some compounders will claim they provide “natural hormones”. That is untrue. They use the same manufactured hormones as companies that make commercial HRT.

Some compounded products contain estrone and/or estriol. They are weak estrogen metabolites that do not have any unique function and are unnecessary. 

Pellet prescribers have been accused of purposely inserting high doses of testosterone in the pellets. The result is levels that act like “anabolic steroids”. The resultant increased energy can be addictive. Many women cannot stop even when they develop facial hair, deepening voice, and other male-like side effects.

The American College of Obstetricians and Gynecologists have expressed concern about these unethical practices.

Modern medical science led to production of estrogen for human consumption and had an enormous impact on quality of life for many women. However, not all women have severe enough symptoms to require HRT. Breast cancer survivors are told to avoid HRT. Alternatives to HRT include:

SSRI antidepressants – Many studies have shown some reduction in hot flashes, but not as effective as estrogen. One, “Brisdelle” is FDA approved.

NK3 antagonists – This class of medicine works directly in the brain to halt hot flashes and is highly effective. The only current FDA approved product is “Veozah”. It was not assessed for other symptoms such as depression and mood swings.

Herbal remedies – Examples include Black cohosh, Dong quai, St. John’s wort, Maca, Valerian root, Ginseng, Evening of primrose oil Red clover and Licorice. According the Menopause Clinic, London “most of the complementary medicines on the market have never been subjected to the rigorous scrutiny for safety and effectiveness that are required for conventional medicines.”

Phyto-estrogens – these are soy products that are controversial, with mixed results in placebo-controlled studies.

Acupuncture – may help with hot flashes.

Yoga – and other exercise programs have been recommended to reduce hot flashes.

Other FDA approved medications used ”off label” – medications on the market for other reasons that have been shown to help hot flashes include gabapentin, clonidine, belladonna, mirtazapine.

Many experts express concern about ingesting unknown compounds long term. It is impossible to be sure an herbal compound worked, or that the menopausal symptoms would have gone away on their own. None of these alternatives are as effective at relieving menopausal symptoms as HRT.

According to a 2022 publication in The Cancer Journal, if “Initiated in women <60 years of age and/or at or near menopause, HRT significantly reduces all-cause mortality and cardiovascular disease (CVD) whereas other primary CVD prevention therapies such as lipid-lowering fail to do so. Magnitude and type of HRT-associated risks, including breast cancer, stroke and venous thromboembolism are rare (<10 events/10,000 women), not unique to HRT and comparable with other medications”.

Breast cancer: Many studies have found HRT increases the risk of breast cancer. Estrogen alone appears to have a lower risk than estrogen/progesterone(E/P) HRT. 

Cardiovascular disease: Oral estrogen may cause a higher risk of cardiovascular problems than transdermal estrogen. 
replacement Therapy

• Hot flashes go away
• Sleep tends to improve
• Vaginal dryness is not a problem 
• Mood swings go away
• Depression improves
• Libido improves
• Skin feels less dry
• Arthritis-like symptoms improve
• Brain fog improves
• Live longer

Breakthrough bleeding is a common side effect of HRT in a woman who has a uterus. Bleeding on HRT can be a challenge. 

Progesterone is necessary when the uterus is present. As some women notice oral contraceptives cause mood Swings and depression. So can E/P HRT in some women.

Migraine is sometimes a problem for women on HRT.

There are numerous protocols we can use to address these problems.