Bioidentical hormone replacement for women is underused because its positive effects are underestimated while its risks are exaggerated.
Let’s start with the benefits. The three most common causes of death and disability in women are heart disease, hip fractures and dementia.
Estrogen prevents heart disease with dramatic effects. The relative risk of heart disease for women who take estrogen is between 0.39 and 0.50 compared to women not taking estrogen. That means that women taking estrogen are much less likely to get heart disease. When a woman has elevated cholesterol the most likely prescription will be for a statin drug. This will most likely lower cholesterol, but to date, the literature reports minimal effect on mortality related to cardiovascular disease when taking statins. On the other hand, taking estradiol has been shown to lower LDL (bad) cholesterol while raising HDL (good) cholesterol and reduces risk of cardiovascular disease. If this were the only benefit of estradiol, it would certainly be worth considering.
Hip fractures result from osteoporosis. Bone loss starts at age 30 and dramatically accelerates at menopause. Many women who have osteoporosis are treated with bisphosphonates; the most common is alendronate (Fosamax). These drugs have side effects, which discourages many women from taking them. These drugs slow bone loss so have some benefit, but the bone loss progresses. On the other hand, estradiol actually promotes bone formation so bone density increases when taking estradiol. As opposed to preventing bone decay, estradiol promotes bone growth. Besides reducing the risk of hip fracture, estradiol actually strengthens teeth. Women who take estradiol have less tooth decay and tooth loss. While chewing food may seem like a minor benefit, it reinforces the idea that estrogen promotes bone growth.
Dementia keeps many from enjoying life, and as it progresses, it can lead to total dependency and even death. There are no effective treatments for dementia. There are medications that have been approved for Alzheimer’s disease. These have some benefits, again slowing down the progression but not reversing Alzheimer’s. However, very few treatments prevent Alzheimer’s. Estrogen prevents dementia. When women start estrogen early in menopause the risk for Alzheimer’s dementia decreases between 30 and 70 percent, varying among studies but consistently showing benefit. The protective benefit of estrogen for dementia when starting estrogen later is less dramatic but it still helps cognitive function.
While these conditions may seem remote to someone in her 40s and 50s, they are very common as women approach their 70s and 80s. Fortunately, bioidentical hormone replacement can help prevent all these conditions. In addition to these benefits, hormone replacement helps women feel good. Women who replace hormones have more energy, more vitality and better sexual health.
So based on these excellent benefits that both enhance life and extend life, why is there hesitation to prescribe hormone replacement and to start hormone replacement? The two biggest concerns are blood clots and cancer. The confusion I will describe is based on two synthetic drugs that were developed to simulate hormone replacement, Premarin and Provera.
With regard to blood clots, this risk was highlighted in the WHI study published in 2004. This study was the largest randomized, controlled study to date. Of 10,000 women over 65 who started hormone replacement, 30 had serious cardiac events related to blood clots. While that number seems very small (0.3%), that number is very significant to the 30 who experienced the severe side effect. Unfortunately, women who participated in the study were given Premarin and not estradiol. Premarin is estrogen derived from horses and is not what human women naturally produce. Because of this confusion, there is fear that taking estradiol is unsafe because it will cause clots. This fear has deprived many women of all of estradiol’s benefits. However, no study has demonstrated that administering estradiol causes clots to form or dislodge.
Another fear is that hormone replacement causes breast and uterine cancer. With regard to breast cancer the studies have shown that estrogen does not increase the risk, with some studies suggesting protection with the relative risk between 0.9 and 1 (in other words, one can reap the benefits of bioidentical replacement without fearing an increased cancer risk). The reason for the fear is due to Provera. This is a synthetic analog of progesterone, which unfortunately has devastating effects that are almost opposite to progesterone, its bioidentical counterpart. In the WHI study cited above, when taking Provera and Premarin, the breast cancer risk increased to 1.3. In contrast, progesterone has been shown to be protective against breast cancer and uterine cancer. Once again, confusion between a synthetic drug and a bioidentical hormone has created unnecessary fear and has deterred women from reaping the benefits of taking bioidentical hormones.
To summarize, hormone replacement is not a panacea and will not reverse aging. But if you are looking for a way to improve your energy and mood and lose weight while reducing the risk of heart disease, osteoporosis and dementia, bioidentical hormone replacement is an option you should consider. Understanding the literature and the distinction between synthetic and bioidentical hormones is key to understanding the risks and benefits. To learn more, you can check out my website, njhormones.com, or request a podcast that goes into more detail about hormone replacement.
By Warren Slaten, MD
Dr. Slaten is a wellness physician specializing in regenerative pain treatments and lifestyle counseling. He is certified in advanced bioidentical hormone replacement.