A 2007 article from the journal Climacteric starts off with a bang in a review of hormone therapy (HRT) for menopause, “The risks attributed to hormone therapy have been overestimated and the data has been wrongly extrapolated to the whole class of therapies.” These are fighting words and reflect the strong opinions one has when they take the time to look into the issue of HRT. This week we look at what is probably one of the most influential changes in hormone prescribing: medication delivery. There is a big difference in risk between taking HRT as a pill and utilizing patches and creams. This is absolutely significant, particularly when it pertains to estrogens.
What happens to hormones taken as oral pills?
When hormones are made in the body, they enter directly into the bloodstream and make their way to tissues where they are utilized and processed. When we take hormones as oral pills, something different happens. They enter the blood leaving the stomach and intestines and go straight to the liver first. This results in a unique ratio of processed hormone forms that is not identical to the ratios seen when we make the hormones ourselves. It is this initial processing by the liver which many feel accounts for a significant amount of the risk seen in the WHI. The mechanisms for this risk are continuously being investigated and revised in search of safer medication options. However, the bottom line is, oral dosing of HRT, particularly estrogen, has become less favorable in both the conventional and alternative medical communities. This has resulted in a plethora of safer, easy to use, and well tolerated options for many women.
What are the options, if not pills?
Both estrogen and progestogens (the name of the class of hormones which contains progesterone) have different options for delivery.
Estrogens:
- Transdermal. This means via the skin. Transdermal methods include: patches, creams, sprays, and gels. Many of the conventional transdermal options are low-dose bioidentical estradiol. Some bioidentical brand names include (not a complete list): Vivelle-Dot®, Climara®, Menostar®, Estrace®, Divigel®, Evamist®.
- Nasal spray
- Vaginal: these come as rings, tablets, gels, and creams. Many of the conventional vaginal options are also low-dose bioidentical estradiol, although CEE is still used. Some bioidentical brand names include (again, not complete): Vagifem®, Estrace®, Estring®.
Progestogens:
Progestogens vary greatly. Bioidentical progesterone exists in several forms (including oral), but other conventional options fall on a wide spectrum in their relationship to this hormone. Some of the newer versions of this class are more true to the key characteristics of the natural progesterone. It is safe to say that progestogens are getting much better, but there are still some practitioners using the medroxyprogesterone acetate (MPA) from the original WHI. There are some instances where this makes sense (it is also unbelievably cheap), but for the most part, much safer and well-tolerated options are now available.
- Transdermal: gels and creams primarily. Almost all of these must be compounded. There is some controversy that transdermal progestogens are not as effective at balancing estrogens in the uterus.
- Vaginal: creams, gels, suppositories. Some conventional options here are bioidentical progesterone. One bioidentical brand here is Prometrium®
- Uterine: the Mirena® system is the main example here. While this progestin is not bioidentical, it has very little, if any, effect on the rest of the body.
There is growing significance in how HRT is given to women seeking help with menopausal symptoms. It appears that bypassing the liver processing by placing hormones on the skin, mucous membranes or near the uterus, decreases the risks associated with these medications. Luckily, there are compounded and conventional options widely available to women that offer low-dose, bioidentical relief for their symptoms.
Next week we talk about how dosing of hormones has changed since the WHI.
