A Safer Type of Hormone Therapy

If you’re going to take hormone therapy, it’s safer to take hormones that are identical to human hormones. In other words, hormones that are body-identical or bioidentical. The concept of bioidentical used to be controversial but is now conventional and mainstream.

In episode five of my podcast/YouTube video, I discuss hormone therapy including why the concept of bioidentical was controversial when it didn’t need to be; oral micronized progesterone for heavy periods, mood, sleep, and perimenopausal migraines; and some facts about body-identical estrogen.

Also available wherever you get your podcasts.

Transcript

Here’s a simple fact. If you’re going to take hormone therapy, it’s safer to take hormones that are identical to human hormones. In other words, hormones that are body-identical or bioidentical. The concept of bioidentical used to be controversial but is now conventional and mainstream.

Welcome back to the podcast. I’m your host Lara Briden, a naturopathic doctor and author of the books period repair manual and hormone repair manual.

It’s autumn here now in Christchurch, New Zealand where I live. The days are getting shorter, and so…I’ve just booked my annual flight home to Canada where I’m from. And if you follow me on Instagram, you can get ready for a few more photos of me hiking in the mountains.

Okay. So, this episode is about natural hormone therapy. Which can mean hormone therapy for perimenopause and menopause. It can also mean hormone therapy—particularly progesterone therapy—for PCOS, heavy periods, migraines, and other period problems.

A couple of things to get out of the way.

First, I’m talking about body-identical hormones, not contraceptive drugs. Which as I explained in episode one, are only hormone-like—not molecularly identical to actual hormones.

And second, I’m going to focus on estrogen and progesterone but of course, there are other body-identical steroid hormones like DHEA, cortisol, testosterone, pregnenolone, and more. And then there’s thyroid hormone and melatonin, which are conventionally body-identical. But if you want more information about any of that, please ask me in my forum.

For now, let’s look at body-identical estrogen and progesterone and why the term bioidentical has been controversial when it didn’t need to be. Because in case you’re wondering, body-identical and bioidentical mean exactly the same thing. That is, hormones—in this case, estrogen and progesterone—that are molecularly identical to estradiol, our main estrogen, and progesterone.

The modern consensus is that body-identical estradiol and progesterone are safer than the hormone-like drugs used in old-style hormone replacement therapy. That’s especially true for progesterone which, for example, probably reduces the risk of breast cancer while all types of progestins slightly increase the risk of breast cancer. And there are other differences between progesterone and progestins which I discuss on my blog.

The safety of body-identical progesterone has actually been evident in the research for a couple of decades. But like so many things in medicine, it took a while for that research to reach doctors’ offices. Rewind even six years and (depending on your country) you’d still find that the official medical consensus—at that time—was that there was no difference between progesterone and progestins in either effect or safety. While all along, there were some doctors—including me—who were convinced, ahead of the research, that progesterone was safer than progestins. And so found a way for our patients to access body-identical progesterone via compounding pharmacies.

That alternative approach to hormone therapy was referred to as “bioidentical hormone therapy” or “natural hormone therapy.” But of course, natural progesterone was natural only in that it was identical to human progesterone and therefore safer. “Natural” hormone therapy was always synthetic in that it was made in a lab from a plant sterol precursor as are all types of hormone therapy and contraceptive drugs—body-identical or not.

And that’s where the controversy began. Many experts did not think it was a good idea to use unregulated, compounded hormones in place of regulated, approved products. And in that, they had a point. Except that, back then, there was literally no other way to access body-identical progesterone. The experts also said—back then—that there was not yet definitive proof that body-identical hormones were safer, which was true. The evidence was not definitive but it did exist. And looking back, I feel the assertion by some experts that bioidentical was therefore a deception was in itself not true. Because although bioidentical as safer was not yet proven, it was entirely biologically plausible.

Hormones that are identical to human hormones are safer than hormone-like drugs. That was true back then, even before the definitive scientific proof. And it’s true now.

So, thank goodness the research did eventually catch up. And in 2016 (using Australia as an example), body-identical progesterone became available as the regulated product Prometrium, which is one of the brand names for “oral micronized progesterone,” which is now the preferred recommendation for the progesterone part of menopausal hormone therapy. Because it’s safer.

So, what does “oral micronized” progesterone mean? It just refers to a preparation of progesterone that is micronized or essentially emulsified to facilitate oral absorption. Without such preparation, progesterone cannot be absorbed orally, which is actually why progestins were invented in the first place.

In general, oral progesterone is preferable to topical progesterone, or progesterone cream. Certainly, that’s true if you’re using progesterone as the progesterone part of menopausal hormone therapy because you need enough progesterone to enter the body and protect the uterine lining from the estrogen part of your hormone therapy. Progesterone cream has been tested for that purpose and found to be not able to deliver enough progesterone to protect the uterine lining. So if you hear an expert say that progesterone cream has been studied and found to be ineffective, that’s what she is referring to.

Progesterone cream can, however, be helpful for other purposes such as taking the edge off perimenopausal mood symptoms or migraines. There’s not yet scientific evidence to support that effect, but that could be because there has not yet been a study to look at progesterone cream for that purpose.

All that said, for most things, oral progesterone is more effective than a cream, especially for heavy periods and especially for sleep problems. And that’s because oral progesterone has greater conversion to the sedating neurosteroid metabolite allopregnanolone. That makes oral progesterone more sedating or tranquillizing than topical progesterone or other ways of taking progesterone. In fact, I just received a comment on my blog from a reader who switched from Prometrium to progesterone troches or lozenges and is now “no longer experiencing the wonderful calm sleepy feeling” she had with Prometrium.

In my book Hormone Repair Manual, I talk a lot about using oral micronized progesterone for heavy bleeding, sleep, mood, migraines, breast pain, and night sweats. And provide what I hope are helpful sections about “how to speak with your doctor.” Because while progesterone cream is available over-the-counter in some countries, progesterone capsules always require a doctor’s prescription. As a tip, your doctor will be more likely to prescribe progesterone for heavy periods or bleeding problems than she will for mood, sleep, or migraines. So, it might be simplest to just focus on any bleeding symptom. Your doctor will also be more likely to prescribe progesterone plus estrogen. So you could take the strategy of accepting both prescriptions, and then (if you want) start with just the progesterone part. And one more tip: Always ask for progesterone by the brand name Prometrium or Utrogestan (depending on your country), and avoid the term “natural progesterone.”

Finally, oral micronized progesterone, or Prometrium, can be used for PCOS, which I discuss in a blog post and a scientific paper that I’ll link to in the show notes.

Now, for a little about body-identical estrogen. Which, of course, can be helpful for menopause and also for long-standing hypothalamic amenorrhea or relative energy deficiency in sport. We’ll look at each, starting with hypothalamic amenorrhea, which is, of course, primarily caused by undereating so the main treatment is to eat more to regain ovulation and therefore be able to make your own estrogen. However, if you’ve been without your period for years, your doctor may want to prescribe body-identical estrogen and progesterone, just as an interim measure to protect your bones. The pill used to be used for that purpose but now body-identical hormones are the evidence-based approach.

Next, estrogen therapy for menopause. Keeping in mind that many of the symptoms of perimenopause are actually from high estrogen, not low. But low estrogen does eventually come into it, of course. And some women can be helped by body-identical estradiol—at least for a while. Estrogen therapy can also reduce the risk of osteoporosis. We don’t have time to go into all the ins and outs of who needs estrogen and for how long. I cover that in Hormone Repair Manual, and of course, you should consult your doctor about your individual health situation.

For now, let’s look at five things about modern estrogen therapy: four uncontroversial things; and one slightly controversial.

First. Uncontroversially, most, but not all, modern estrogen therapy is body-identical estradiol. Which is good, and very different from the old-school Premarin estrogen medication.

Second. Uncontroversially, topical estradiol in the form of a patch or gel is generally safer than oral estrogen, especially for clotting risk.

Third. Uncontroversially, the combination of modern topical estradiol therapy plus oral micronized progesterone is pretty safe. Specifically, in terms of breast cancer risk, for example, modern estrogen therapy is safer than moderate alcohol intake.

Fourth. Uncontroversially, vaginal estrogen is also body-identical and can be very helpful for dryness and other symptoms of the genitourinary syndrome of menopause or GSM. And vaginal estrogen carries no breast cancer risk.

Finally, the one controversial point about estrogen. In general, if you’re going to take estrogen, I think it’s better to take it together with body-identical progesterone—even if you don’t have a uterus. The reason, which I explain in my book, is that progesterone is good for breasts and usually good for mood and can therefore shelter you from some of the possible side effects and risks of estrogen. Vaginal estrogen, however, can be taken on its own without progesterone.

Okay. The main takeaway is that body-identical hormone therapy just means hormones that are identical to human hormones. And that body-identical estrogen and progesterone prescriptions are fairly easy to access these days as the conventional products of Estradot, Prometrium, Utrogestan, and others. For a list of all the body-identical brands, see my blog post in the show notes. And you can also ask me in my forum at LaraBriden.com.

And if you’re a practitioner who treats women, consider coming along to my upcoming online workshop called Metabolic health and vitality for women over 40. Where (among other things) I’ll discuss why estrogen is a weight loss hormone. The link to the workshop is in the show notes.

I hope that’s been helpful and thanks so much for listening. Please share and leave a review. And I’ll see you next time when I’ll discuss how to diagnose and reverse insulin resistance.

25 thoughts on “A Safer Type of Hormone Therapy”

  1. It is a pleasure worth reading this article as it provides us information on practicing compassionate medicine.It is one of the best options to read from here in detail. I would go for this site even in future when needed. Great blog indeed, will visit again future to read more!!

    Reply
  2. Hi Lara,
    If a 54 year old woman, a few years into menopause is managing symptoms, should she do HRT or not? Which is better for her life and health span? HRT or no HRT? Reading seems to suggest starting HRT sooner rather than later is better if you ARE going to do it, but should a woman start it anyway to keep arteries supple? Thanks for your advice. Cheers, Ali

    Reply
    • At this stage, the general recommendation is estrogen therapy is really only for symptoms, early menopause, or a high risk of osteoporosis. It has not yet been determined if estrogen therapy can increase health span in healthy women. But in general, it’s considered safe to start within ten year of the final period.

      Reply
  3. Hi Lara, I’ve been prescribed Provera by my endocrinologist. I said I’d like to take Utrogestan instead. She’s wanting me to take the Utrogestan 25 days on and 3 days off. But I see you said to take it 2 weeks on, 2 weeks off?
    Can you clarify for me what way is best to take it?
    I have irregular bleeding (bleeding more than not), cystic jawline acne and hair loss.
    Thanks so much
    Olivia

    Reply
  4. Hello Lara,
    At age 45 I had multiple bilateral PE’s, 3 years after being on minastrin 24 Fe in 2016. I was traveling by plane and doing a lot of “sitting still” for a new job immediately before this happened.
    I was and am extremely healthy and physically fit.
    I recovered and take aspirin daily.
    Now at 52, July bloodwork hormone panel shows no progesterone, no estrogen and very low testosterone.
    I’m considering bio identical hormone therapy.
    Estriol/estradiol 80/20 cream, progesterone (prometrium capsule 200mg) and testosterone inj.
    I’ve read so many conflicting things about risk of blood clots having already had blood clots (but no predisposing blood factors for clotting).
    Do you give bio identical hormone therapy to women who’ve had clots?

    Reply
  5. thank you for post ,
    i have a question , i m currently on biodidentical testosterone cream , 15 mg , and since i m appling it , i gained 8 pounds , (i kept my weight for the last 25 years , and in 2 weeks i gained 8 pounds , with no other changes in my lifestyle , could testosterone be the reason?? what are your thoughts about testosterone replacement ??

    Reply
  6. Hi Lara,

    My integrative medicine doctor ran a few hormone tests because I have symptoms of a luteal phase defect. The hormone results came back that my progesterone was normal, but I was low normal on prognenolone (59 ng/dl) and slightly high on estradiol (128 pg/ml on day 17 of my cycle). The practioner suggested I supplement with pregnenolone and vitex, but I don’t know much about prognenolone and can’t find many studies. Any thoughts on supplementing with this hormone?

    Thanks so much.

    Reply
  7. I just took my first dose (100mg Prometrium) last night, and today feel like I have the flu – body aches, runny nose, feverish, headache. I haven’t had any covid exposures; with a little online search it looks like flu-like symptoms may be a side effect for some people. I’m hoping it will just take my body a bit to settle and adjust and this will go away, but wanted to ask if this can be a normal side effect? And also, I should take this for about 14 days each second half of cycle, yes?
    Thank you so much

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  8. Hi Lara, I’ve recently been prescribed 100mg bio-identical micronised progesterone/Utrogestan during luteal phase for PMDD. How does taking it orally or vaginally differ?

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  9. Hi! I’ve been on 200 mg of bioidentical progesterone daily during my luteal phase since last November. I am 37 and have PCOS and tested low progesterone. I am really happy with how the P4 has shortened and lightened my period and helped my skin, but I’m worried it has worsened my hair loss (which I had hoped it would help). Would this dose worsen hair loss? Is this temporary and will it stabilize or should I consider discontinuing the P4? I am also addressing insulin resistance (although I am quite thin so no weight to lose). Feel really confused about next steps and rather hysterical.

    Reply
  10. Hi Lara, this was a great podcast. I have a question about POF (premature ovarian failure) and the use of bio identical hormone therapy to offset risk of bone loss. I have a client in POF, she is 34 y/o. Considering her age, what are things that should be considered in her dosing and Rx duration of bio hormone therapy and are there other factors I should be looking at? Thanks for any tips, insights you can offer.

    Reply
    • In terms of dose, in general, someone in that situation would probably need at least 50 mcg of transdermal estradiol. Plus 100 or 200 mg progesterone. But of course, she should check with the prescribing doctor.

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  11. You stated, “And one more tip: Always ask for progesterone by the brand name Prometrium or Utrogestan (depending on your country), and avoid the term “natural progesterone.” ” Can you explain this a little further?

    Reply
    • Because doctors are more likely to prescribe Prometrium than “natural progesterone” — even though they’re the same thing.

      Reply
      • I have seen 3 specialists (consultants) here in the UK and they refuse to proscribe Utrogestan for cyclic progesterone therapy for PCOS. I simply got a, somewhat condescending, comment that it was ‘off licence’ and they only use it for HRT purposes for menopausal women. The only options offered were mirena, cerazette and noriethodrone. I wish I knew if it was just my health trust or a UK wide problem.

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      • Hi Lara, loved this episode- found it very helpful. My dr has recently prescribed me Visanne for heavy periods and endometriosis. Would taking prometrium be a better alternative to visanne? If so what dose of prometrium do you recommend?

        Reply
        • I discuss Prometrium for endometriosis in both my books Period Repair Manual and Hormone Repair Manual. The exact dose and whether you take it continuously or cyclically depends on your situation and endo severity. Also, see my video about endometriosis.

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      • Hi Laura, I found your podcast very interesting and came across your name through a Balance app I am on, The Louise Newson one. I’m pretty new to HRT and was prescribed oestrogel and micronised progesterone for the peri menopause. I’m 49, my hair was so much thicker before starting it, within a few weeks I found lots in my shower and actually think the 2 weeks of the micronised progesterone that it calmed down, I was told to take it for 3 months so my body would adjust, it seemed to get worse, a stinging scalp and hair becoming shorter also. I’ve come off it and my hair is still shedding, my doctor said it’s not a side effect, it has to be as my hair was double the thickness. I’m wondering if it’s worth trying a patch or tablet. So many women experience hair loss on HRT. I’ve read on a few groups. It’s very stressful and hard to get help and support. I’ve changed doctors so hoping I can get some help. Louise X

        Reply
        • There’s a time lag with hair loss, so to find the cause you always need to count back four months from the start of the hair loss.
          For example, had you recently come off the pill? Had you been having heavy periods? Is your thyroid ok? Were you prescribed testosterone at any time? or a progestin? Those are the common hair loss triggers. Also illness. So hair loss can occur three or four months after a fever.

          Both estrogen and oral micronised progesterone are good for hair.

          Reply
  12. Great podcast, as always, thank u for sharing ur wisdom!

    For menstrual migraines in Perimenopause I’m a bit confused on your take re: oral micronized progesterone (ie Prometrium) vs cream (ie Progonol)? I’m not sure if the migraines are a symptom of my PMDD or just Perimenopause in general, and if that would affect your thought process here? Appreciate any further insight you can offer. These migraines can steal 4-5 days from my life every month as progesterone comes off a small spike and crashes right b/f my period! 🙁

    Also, your thoughts on Magnesium are so insightful as well. I’ve just started taking Vital Nutrients Tri-Mag 250mg (60% Magnesium Oxide, 30% Citrate and 10% Glycinate) and Pure Encapsulations Magnesium Glycinate 120mg (1-2 capsules at onset of migraine). Is this in line w/ your beliefs about benefit of Mag Glycinate?

    Thanks!

    Reply
  13. I am taking Utrogestan and oestrogen gel since January. I have started having period like bleeding every three weeks since February, after no periods for several years as i am aged 59. I have previously had womb scan and checks with no problems found.

    Reply

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