This post is for all you forty and fifty-somethings who are looking for some kind of clarity around hormone replacement therapy (HRT) or menopausal hormone therapy.
You want to know if HRT is safe and which type to choose. And you want to know if hormone treatment is actually going to help with the sleep disturbance and mood changes and crazy periods that you’re experiencing now (but really didn’t expect to see for a few more years).
Perimenopause or “second puberty” is the two to twelve years before menopause and can be the time of strongest symptoms.
Here’s what you need to know.
You’ll need progesterone before you need estrogen
The earliest symptoms of perimenopause (heavy periods, insomnia, and anxiety) are the result of losing progesterone, not estrogen. They typically occur while we’re still having periods but are making the natural progression to having more anovulatory cycles, rather than real periods.
👉 Tip: An anovulatory cycle is a cycle in which ovulation did not occur and progesterone was not made.
We lose progesterone during perimenopause but can have up to three times more estrogen than before.
High, fluctuating estrogen contributes to the symptoms of anxiety, migraines, and histamine or mast cell activation. (Symptoms that are sometimes referred to as “estrogen dominance” — a term I don’t like.)
Taking estrogen during perimenopause is not advisable. Progesterone is a better option.
Progesterone alone can relieve symptoms and lighten periods
Micronized progesterone or “body-identical” progesterone can relieve the mood and sleep symptoms of perimenopause including anxiety, insomnia, hot flushes, and reduced ability to cope with stress. Progesterone calms the brain and nervous system by converting to the neurosteroid allopregnanolone (ALLO) which acts on GABA receptors.
The advantage of taking progesterone on its own (without estrogen) is that it’s safer in terms of breast cancer risk and can be stopped anytime without triggering hot flushes. (Stopping estrogen suddenly can trigger hot flushes, so estrogen needs to be weaned down.)
Micronized progesterone capsules are prescription-only and are available as a compounded capsule or the brand names Prometrium, Utrogestan, or Teva generic capsules. They’re highly sedating so should be taken at bedtime.
Progesterone can also make periods lighter and is a good alternative to progestin drugs such as the pill and the hormonal IUD. Read For Healthcare Providers: Managing Menorrhagia Without Surgery.
The big difference between progesterone and progestins is that progesterone is usually good for mood, hair, bones, and heart, and may help to prevent breast cancer. Progestins, on the other hand, are usually bad for mood and can cause hair loss and increase the risk of breast cancer. Read The crucial difference between progesterone and progestins.
👉 Tip: Progesterone stimulates metabolic rate so can help to prevent menopausal weight gain.
For more information about the benefits of progesterone, read the Progesterone Therapy section of Prof Jerilynn Prior’s CeMCOR site. Prof Prior has also published several papers about the benefits of using progesterone-alone for the hot flushes of menopause and perimenopause.
You may eventually need estrogen
The later symptoms of perimenopause (hot flushes, vaginal dryness, weight gain, and depression) are the result of losing estrogen. They typically coincide with the final disappearance of periods.
At this stage, some estrogen can be helpful for symptom relief, but only in combination with progesterone!
My advice is to start with progesterone and if that doesn’t relieve all the symptoms, then look to a low-dose transdermal body-identical estradiol product such as Vagifem, Estradot, or Sandrena.
👉 Tip: You always need progesterone, even if you don’t have a uterus. Why? Because natural progesterone is good for mood and may help to protects breasts.
The safety of estrogen is still being debated. Dr Avrum Bluming made a strong case for the safety of estrogen in his book, Estrogen Matters. But then the 2019 Lancet study reignited concerns with its estimate that conventional combination HRT (estrogen plus progestin) is the cause of about 5% of breast cancers. Estrogen on its own was found to be quite a bit safer, which does suggest that a big part of the problem is the progestin. The study, unfortunately, did not provide any statistics about the safety of using micronized progesterone (Prometrium) on its own.
I think there is still a case for taking estrogen for symptom relief, but only in close consultation with your doctor. Here are a few more things to keep in mind:
- The new Lancet study states quite clearly that vaginal estrogen is safe.
- Many sources including the Australian Jean Hailes organization advise that transdermal body-identical estradiol (such as Estradot) is safer both in terms of heart disease and breast cancer risk. Transdermal estrogen bypasses the liver and so does not convert to harmful metabolites.
- Professor Eden from the Women’s Health & Research Institute of Australia says that micronized progesterone (Prometrium) is safer than a progestin.
- Estrogen is safest when commenced at the onset of menopause (when periods stop) rather than later in life.
Use the term “body-identical” when speaking with your doctor
There have been a few articles recently that are seemingly critical of “bioidentical hormones.” In actual fact, they’re critical of “compounded” or “individualized” hormone formulas, not the concept of bioidentical or body-identical.
Almost everyone now accepts that estradiol and progesterone are better and safer when they are “identical to the body’s own hormones.” Such hormones can be called bioidentical or body-identical because the two terms mean the same thing.
Bioidentical was the term for compounded hormones during all the decades when compounding was the only way to access estradiol and progesterone “identical to the body’s own hormones.”
Body-identical is now the preferred term for all the modern estradiol and progesterone formulations that are “identical to the body’s own hormones.” They include all the brands mentioned in this blog post.
Your doctor prefers the term body-identical because she prefers approved medications and not formulas made by a compounding chemist. She has concerns about the quality of compounded formulations and does not agree that hormone formulas can be “individualized” based on blood, saliva, or urine tests.
I agree with the last point. There is no way to “tailor” hormones based on any kind of testing.
Just to say again, I think the best and safest strategy is to start with progesterone on its own, and then, if that doesn’t relieve symptoms, consider adding low-dose transdermal estradiol such as Vagifem or Estradot 25.
Hopefully, that has clarified a few things. You may still be wondering if you need hormones at all or if you could get by with just lifestyle and supplements?
The short answer is yes. Lifestyle and supplements (especially magnesium) can be very helpful. Read Rescue prescription for perimenopause. Other helpful strategies include:
- reducing histamine foods
- quitting all alcohol
- exercising regularly.
If, after doing all that, you still have symptoms, I think it’s reasonable to take body-identical hormones, at least for a few years. They’re a better and safer treatment than the pill or antidepressants.
Ask me in the comments.