What Is Hormone Replacement Therapy? Ten Questions You Need Answers To!

Image of a Question Mark? Ten Questions You Need Answers To About Hormone Replacement Therapy.

What Is Hormone Replacement Therapy? Ten Questions You Need Answers To!

What Is Hormone Replacement Therapy? Ten Questions You Need Answers To.

It’s my fifth birthday post-menopause, and I got a doozy of a gift—actually, three gifts.

My first gift is muscle loss despite my heavy strength training regime and uber-awesome nutrition protocol.

Second gift—Crepey, (not crappy) skin on my arms and legs

wait for it…

Third gift—Lipid results that are less than favorable despite my health coach lifestyle.

I’m usually not sassy about entering new seasons of womanhood. My first response to new phases of life is to learn, grow, and embrace the changes. I will do this, but for some reason, I feel like I need to get a little of my sassy out first!

Just keeping it real!

All sassiness aside, these new post-menopause symptoms prompted me to ask a question I’ve never asked myself. Do I want to consider learning more about hormone replacement therapy?

In RESTORE health coaching, I help women understand what’s going on in their complicated bodies and craft and implement simple, manageable lifestyle health practices to bring their hormones, metabolism, and health into a beautiful balance. Because I’m not a doctor, I turned to my dear friend Dr. Stefinai Tiveron to get my top 10 questions about HRT answered.

Since I have these questions, I thought you might have them too!

Keep in mind that my questions are intended to open up a dialog on HRT so that you have a framework for crafting your own questions for your doctor if you want to learn more.



The Ten Questions I Asked Dr. Stef About HRT

Ann: What Is HRT?

Dr. Stef:

HRT stands for hormone replacement therapy. HRT seeks to offset the estradiol loss because estradiol plays the dominant role in symptomatology and long-term health. HRT generally implies estrogen plus or minus other hormones (for example, progesterone and/or testosterone) depending on symptoms. We typically replace estradiol through HRT, though we can also replace estriol. There’s almost no case for replacing estrone.



Ann: What Are The Symptoms That HRT Could Possibly Improve?

Dr. Stef:

Most of the symptoms that females experience during perimenopause and menopause are attributed to the reduction in estrogen levels.
Typically, the first symptoms are vasomotor symptoms, usually in the form of hot flashes and night sweats. Depending on the person, this can be very significant, especially if sleep is affected. Those tend to pass in a few years. From that place, long-term complications come into play, such as vaginal atrophy (thinning and dryness), osteopenia/osteoporosis, and brain fog.

All females experience menopause and the menopausal transition differently. Some will experience very little in terms of symptoms and intensity. For others, this time is particularly debilitating.

In addition to hot flashes and night sweats, any of the following symptoms may impact your quality of life and, therefore, would factor into a decision about whether HRT is suitable for you.

  • Heart racing
  • Difficulty sleeping
  • Fatigue
  • Body aches
  • Headache
  • Migraine
  • Vaginal dryness
  • Vaginal and bladder infections (increased)
  • Low libido
  • Urinary incontinence (leaking of urine)
  • Skin and hair issues (hair thinning, skin dryness, acne, facial hair)
  • Psychological symptoms (mood swings, anxiety)
  • Cognitive changes (like recalling information slower than before)
  • Increased risk of disease. Low estrogen levels increase the risk of physical conditions, including osteoporosis and cardiovascular disease.

(Ann, again, this is an area I am particularly interested in due to my cardiovascular health history)



Ann: What hormones does HRT provide, and Is HRT only delivering estrogen?

Dr. Stef:

HRT generally implies estrogen plus or minus other hormones (for example, progesterone and/or testosterone) depending on symptoms.


Ann: What is estrogen?

Dr. Stef:

Estrogen is a hormone. There are three forms of estrogen in humans: E1 – estrone, E2 – estradiol, and E3 – estriol. Along with progesterone, FSH, and LH, estrogen is part of a symphony of hormones that regulate the menstrual cycle.

From the start of menstruation until menopause, menstrual hormones ebb and flow in a cyclical nature (outside of birth control use or pregnancy). Then, a hormonal shift occurs that kicks off the menopausal transition period—perimenopause.

During perimenopause, steadily declining levels of progesterone, unpredictable estrogen swings, and relatively higher androgen levels (i.e. DHEAs and Testosterone) contribute to irregular cycles and common vasomotor symptoms like hot flushes and night sweats.

Most of the symptoms that females experience during menopause are attributed to the reduction in estrogen levels.


Ann: Where can I read about the current science and learn the facts about the benefits and risks of HRT?

Dr. Stef:

The books mentioned below are a great starting point.

Hormone Repair Manual: Every Woman’s Guide to Healthy Hormones After 40 by Dr. Lara Briden.

Estrogen Matters by Avrum Bluminf, MD, and Carol Tavris, PhD


Ann: What’s the biggest myth about HRT?

Dr. Stef:

It’s important to note that the risks associated with HRT can vary depending on factors such as the type of hormones used, the route of administration, the duration of use, age/years since menopause, and current health status.

Hormone levels drop dramatically in menopause, which can worsen or exacerbate these symptoms – for some. Many times, the stability in hormone levels during menopause comes with a relief of symptoms.

“Women need to know that perimenopause ends in a kinder and calmer phase of life appropriately called menopause.” – Dr. Jerilynn Prior.

Period Repair Manual: Natural Treatment for Better Hormones and Better Periods by Dr. Laura Briden.

The biggest myth is likely that HRT is either bad or good. It’s either going to hurt you or save you. It’s either the standard of care or it’s not.

The truth is, it depends.

As with most things, there is nuance to this discussion. A study from the early 90s turned the entire medical community away from recommending HRT. The study had many flaws, yet it’s the source of many myths that prevail today, especially regarding breast cancer and cardiovascular disease risk. Currently, the research shows that the risk of heart disease goes down in females with estradiol.

The biggest flaws from the Women’s Health Initiative (WHI) study:

None of the participants were symptomatic.
Disproportionately unhealthy population.
Started ten years after menopause.
The form and format of estrogen (oral estrogen from horse urine) is no longer in use today.

As you can see, the failures of the study design and participant selection made it inappropriate for guiding clinical decisions in the real world. When using research to guide us, we must ensure that the study captures the appropriate population. There was a significant mismatch here.

Unfortunately, a flawed study with scary headlines regarding breast cancer risk (that were not accurately represented) is the reason that HRT is no longer a valuable discussion topic with our healthcare providers.


Ann: How do you understand what dosage is right for you?

Dr. Stef:

Dosing strategies: An art and a science. But more of an art.

Regarding “what dose is best for me,” the short answer is that dosing is based on symptoms. Some biomarkers (labs) can help guide us, but essentially, the dose is determined when symptoms are alleviated without creating more symptoms.

Symptoms matter most. Full stop.

It may take some time to determine the right HRT dose, so it is essential to work closely and collaboratively with your healthcare provider.

When it comes to dosing, here’s what matters:

Dosing strategy is based on symptoms. (includes dose and frequency of dosing)
Track your symptoms, including the severity of each one.
Find a doctor who is willing and able to work collaboratively with you.


Ann: What does HRT formulation mean?

Dr. Stef:

A formulation is your prescription of HRT. Typically, medications do not offer as much variability or customization as HRT. Formulation is a more accurate term to describe HRT.

There are currently 26 FDA-approved estrogen-only medications that come in different forms, patches, pills, injections, gels, vaginal creams, skin creams, sprays, vaginal inserts, and rings. Compounded versions of estrogen are typically made in creams or pellets or things of that nature.


Ann: What might help me determine which formulation is right for me?

Dr. Stef:

It comes down to a bunch of things:
What’s your preference?
What’s the availability?
What’s the cost (if relevant)?
Are there any other risks associated with it?

What to consider based on personal preferences, symptoms, goals, and risk factors:

FDA vs. compounded
Estrogen-only or combined
Form/route of administration
Compliance: what’s easier for you?
Risk vs Benefit discussion with your doctor.


Ann: What is a compounding pharmacy?

Dr. Stef:

When you want a compounded medication, you have to present a prescription for it, and then they will make it specifically for you. There are many reasons to opt for a compounding pharmacy, which is why they are valuable in their service – as long as they do things right.

Compounding offers many customization options, often in the form of bases for HRT therapy. You can work with a compounding pharmacist to “build” your formula. Ask for samples of bases for testing. This is a wonderful option for folks with sensitive skin.

However, it’s not without risk.

Most important is the sterility, potency, and accuracy of what’s in the drug. The lack of regulation is why these issues exist. The FDA maintains a list of compounding pharmacies that have ever been issued a warning letter or anything of that nature.

Depending on your comfort level, an FDA-approved formula might be a better choice.




Ann: Thanks for answering my questions. You’ve given me plenty to think about!

Dr. Stef:

Any decisions regarding HRT should be made on a case-by-case basis with a healthcare provider, considering your goals, medical history, symptoms, and preferences.

Ann Again:

If you want to learn more about how to thrive peri-post menopause by implementing a health strategy plan around nutrition, hydration, stress management, sleep & movement based on the current science that works for you schedule a RESTORE discovery health call with me today!


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