Hormone Replacement Therapy (HRT) has long been a topic of intense discussion and concern among women navigating the challenges of menopause. As women enter this natural phase of life, they often experience a range of symptoms, from hot flashes and mood swings to sleep disturbances and decreased sexual function. HRT has been a cornerstone in managing these symptoms, yet it's surrounded by fears and misconceptions. This article aims to demystify HRT, addressing common fears and distinguishing between what is backed by science and what remains in the realm of rumor.

Understanding HRT

HRT involves the administration of estrogen and progesterone to supplement the body's decreasing hormone levels during menopause. This can significantly alleviate menopausal symptoms and improve quality of life. Despite its benefits, HRT has been the subject of various fears and misconceptions.

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There is a significant amount of confusion and misinformation about the safety of hormone replacement therapy. This confusion involves mainly two question:

• Is Hormone Replacement Therapy safe?
• How long can women use Hormone Replacement Therapy?

Hormone replacement therapy involves replacement of estrogen, progesterone, and testosterone. These three hormones can be replaced individually, or in combination with one or two of the other hormones.

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Is Hormone Replacement Therapy safe?

The Journal of the American Medical Association (JAMA) stated in 2017 that after seven years of using hormones, there was NO associated risk of all-cause, cardiovascular, or cancer mortality during the cumulative follow up of 18 years. This statement means that after 18 years of hormone usage, there was NO associated increase risk of any cause for death. Probably the most reputable journal discussing and reviewing hormone replacement therapy is the Journal of the North American Menopause Society (NAMS). NAMS updated position statements from 2022 state that hormone therapy should be individualized, but there is a FAVORABLE benefit-risk ratio for treatment of hot flashes and for those with elevated risk for bone loss or fracture.

How long can women use hormones?

NAMS also states that on the question of continuation of hormone therapy after age 60, there does not need to be a discontinuation of hormone therapy.

Finally, NAMS also states that hormone therapy may be continued in women greater than 65 years for persistent hot flashes, prevention of osteoporosis, and quality of life issues, with proper evaluation and counseling. Estrogen, both vaginal and systemic (affecting the entire body) may be used for the prevention or treatment of the genitourinary syndrome of menopause at any age.

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Separating Fact from Fiction

It’s crucial to recognize that the landscape of HRT research is evolving. Early studies that fueled widespread fears did not always account for variables like age, health status, and the timing of therapy initiation. Modern research aims to provide clearer guidance, with evidence suggesting that HRT, when personalized and appropriately administered, offers more benefits than risks for many women.

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How we personalize HRT for each woman at Epiphany

Personalizing Hormone Replacement Therapy (HRT) is crucial to maximize its benefits while minimizing potential risks. This approach ensures that HRT is tailored to the unique needs, symptoms, health history, and lifestyle of each woman.

In order to understand how we personalize it for each women you have to understand all the options that are available and why we use specific products at Epiphany.

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Understanding the available options for HRT

1. Estrogen-only HRT

• Purpose: Primarily for women who have had a hysterectomy (removal of the uterus), as estrogen without progesterone can increase the risk of uterine cancer.
• Forms: Pills, skin patches, gels, and sprays. There are also vaginal rings, creams, and tablets specifically designed to treat vaginal and urinary symptoms.

2. Combined HRT

• Purpose: For women who still have their uterus, combining estrogen with progesterone or progestin (synthetic progesterone) to protect against endometrial cancer.
• Forms: Available as oral tablets, patches, gels, and sometimes vaginal creams. The combination can be sequential (estrogen daily with progesterone added for a portion of the cycle) or continuous (both hormones taken daily).

3. Bio-identical Hormones

• Description: These are hormones that are chemically identical to those the body produces. They can be commercially made or compounded in pharmacies based on a provider's prescription.
• Controversy and Consideration: While some advocate for bio-identical hormones claiming they are "natural" and safer, it's essential to note that FDA-approved bio-identical hormones are subject to rigorous testing for safety and efficacy, unlike compounded versions, which are not FDA-regulated.

4. Tibolone

• Description: A synthetic steroid that mimics the activity of estrogen, progesterone, and testosterone in the body. It is sometimes used as an alternative to traditional HRT, especially for women who are concerned about the side effects of other hormones.
• Use: Tibolone can help relieve menopausal symptoms and prevent osteoporosis but is not widely available in all countries and has its own set of potential risks and benefits.

5. Low-dose Vaginal Products

• Purpose: Specifically designed to treat vaginal and urinary symptoms of menopause such as dryness, itching, burning, and discomfort during intercourse.
• Forms: Available as creams, tablets, or rings, these products provide lower doses of estrogen directly to the vaginal area, minimizing systemic absorption and associated risks.

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Techniques to get HRT into the body

1. Oral Tablets

• Overview: One of the most common forms of HRT, oral tablets are taken daily.
• Benefits: Convenient and easy to use, with some evidence suggesting benefits for bone health beyond menopause symptom relief.
• Considerations: May have a higher risk of certain side effects, such as blood clots and stroke, especially in older women or those with certain health conditions.

2. Skin Patches

• Overview: Patches are applied to the skin and replaced every few days.
• Benefits: Provides a steady release of hormones into the bloodstream and may have a lower risk of certain side effects compared to oral tablets, such as blood clots.
• Considerations: Can cause skin irritation for some women.

3. Topical Gels and Creams

• Overview: Hormones are absorbed directly through the skin from the application of gels or creams.
• Benefits: Allows for the direct absorption of hormones into the bloodstream, potentially reducing the risk of some side effects associated with oral forms.
• Considerations: Dosage can be more difficult to precisely control; care must be taken to avoid transferring the hormone to others through skin contact.

4. Vaginal Estrogen

• Overview: Available as creams, tablets, or rings inserted into the vagina.
• Benefits: Specifically targets vaginal and urinary symptoms of menopause like dryness, discomfort during intercourse, and urinary urgency, with minimal systemic absorption.
• Considerations: Mainly effective for local symptoms and may need to be used in conjunction with other forms of HRT for broader menopause symptom relief.

5. Subcutaneous Pellets

• Overview: Pellets are implanted under the skin, usually in the hip area, and release hormones over several months.
• Benefits: Provides a consistent hormone level, reducing the need for daily or weekly dosing.
• Considerations: Requires a minor surgical procedure for insertion and may not be as easily adjusted once implanted.

6. Intramuscular Injections

• Overview: Hormones are injected into a muscle, usually every few weeks.
• Benefits: May offer a longer interval between doses compared to daily or weekly methods.
• Considerations: Can cause fluctuations in hormone levels, leading to a rollercoaster effect of symptoms for some women.

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How we provide HRT at Epiphany

We consider Biote® Bioidentical Hormone Pellet Therapy to be an effective and convenient method for applying HRT, particularly for those seeking an alternative to traditional synthetic hormone therapies. Bioidentical hormones are chemically identical to those the body naturally produces, which offers a more natural and harmonious integration with the body's hormone receptors. Pellet therapy involves the subcutaneous implantation of tiny, rice-sized pellets that release hormones steadily over several months. Here's why we choose pellets over other forms of HRT:

1. Consistent Hormone Levels

• Pellets provide a steady, consistent release of hormones over an extended period, typically 3-6 months, mimicking the body’s natural hormone secretion more closely than daily pills, patches, or creams. This steady state helps avoid the peaks and troughs in hormone levels that can be associated with other delivery methods.

2. Convenience and Compliance

• Once the pellets are implanted, there's no need for daily or even weekly dosing, which enhances compliance and convenience for the patient. This can be particularly appealing for individuals with busy lifestyles or those who have difficulty remembering to take daily medications.

3. Individualized Dosing

• Pellet therapy allows for a high degree of customization. The dose of hormone(s) can be tailored to the individual’s specific needs, based on extensive hormone level testing prior to the procedure. This personalized approach ensures that patients receive the optimal dose to address their symptoms effectively.

4. Reduced Risk of Transference

• Unlike creams or gels, which can accidentally transfer to family members or pets, pellet therapy eliminates the risk of transference once the pellets are inserted subcutaneously.

5. Potential for Fewer Side Effects

• The argument for potentially fewer side effects with pellet therapy centers on the use of bioidentical hormones and the method of delivery. Since the hormones are structurally identical to those produced by the body and delivered in a steady manner, proponents suggest this can lead to fewer side effects compared to traditional HRT.

6. Improved Symptom Relief

• Some patients report more significant relief from menopausal symptoms, including hot flashes, night sweats, mood swings, and sexual dysfunction, with pellet therapy compared to other forms of HRT. This may be due to the consistent serum hormone levels achieved with pellets.

7. Positive Effects on Bone, Brain, and Heart Health

• The continuous delivery of hormones may have positive effects on bone density, potentially reducing the risk of osteoporosis. There are also suggestions that BHRT pellets can positively impact cardiovascular health and cognitive function, although more research is needed in these areas.

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While pellet therapy provides these benefits, it's essential to recognize that the best method of HRT varies depending on individual patient factors, including health history, lifestyle, preference, and specific symptoms. Pellet therapy’s advantages in providing a steady, customized, and convenient hormone delivery method make it an attractive option for many, but like all medical treatments, it should be chosen based on a comprehensive evaluation and discussion between a patient and their healthcare provider.