HRT vs BHRT – the facts
There is no doubt that HRT was a fantastic invention which has revolutionised the lives of many women for nearly six decades. Up until recently it has been the only ‘medical’ option available to help alleviate menopausal symptoms. More recently its ‘natural’ alternative BHRT has risen in popularity. Hormone Replacement Therapy (HRT) vs Biodentical Hormone Replacement Therapy (BHRT)? Below we explore the facts about both treatments and we ask the question – does BHRT live up to all the hype?
What is Hormone Replacement Therapy (HRT)?
The purpose of HRT is to alleviate symptoms caused by the natural hormonal changes of menopause, the most prominent of which are typically hot flushes, mood changes, vaginal dryness and low libido. HRT consists of synthetic forms of hormones that bind to the same receptors and complete the same functions physiologically as the body’s natural hormone. These hormones can be tailored to symptom relief by varying doses.
Are concerns around its side effects founded?
In 2002, the results of the well documented and extensive women’s study, the WHI looked at the effects of using HRT. The study raised worldwide concern about the possible side effects such as increasing the likelihood of breast cancer and strokes which resulted in many women refusing treatment. Since then, further reanalysis has taken place and more recent evidence shows that the risks are small and outweigh the benefits of symptom relief as well as improved bone, urogenital and cardiovascular health.
Who should be treated with HRT?
If symptoms are extreme and unmanageable, it’s worth considering taking HRT in combination with good lifestyle management. Women who are within ten years of menopause or at an age younger than 60 years old are most likely to benefit from HRT. The exception to this general rule are women with a history of breast cancer, coronary heart disease, a previous blood clot or stroke, or active liver disease.
Why does the body need oestrogen?
During the normal menstrual cycle, oestrogen builds the lining of the uterus, the endometrium, in preparation for possible conception. But it also plays an important role in controlling how your body uses calcium, which strengthens your bones and raises good cholesterol in the blood.
What HRT options are available and how do you choose?
A doctor can prescribe HRT and in the UK, it’s available on the NHS. Once identified as a suitable candidate for hormone replacement therapy, choices regarding the type of oestrogen, route of administration, dosage and need for progesterone must be made. Oestrogens are available in myriad forms including a patch, pill, gel, lotion, topical sprays and intravaginal creams, tablets or rings. The type of oestrogen should be tailored to the women’s specific symptoms, for instance a woman experiencing isolated vaginal dryness and painful intercourse would benefit most from an intravaginal cream. On the other hand, vasomotor symptoms such as hot flushes have been shown to require a systemic therapy, such as a patch or pill.
As far as dosage, the most common approach is to start with the lowest dose possible, then titrate up until symptoms are alleviated. This approach is supported by studies indicating lower doses are associated with less clotting, inflammation and overall risk.
What other medications affect HRT?
There are a few that should be noted:
- Drinking alcohol while taking oral oestrogen has been shown to increase the amount of oestrogen in the blood by three times, so alcohol consumption should be limited!
- Women taking an anti-epileptic medication for seizures will have an increased clearance of oestrogen, therefore will require higher doses.
- Oral oestrogens decrease thyroid hormone, so women on thyroid replacement medications may need a higher dose.
- Women with severe kidney disease should be given lower doses of the oral preparation.
Should a progesterone be added?
Progesterone is the body’s natural antagonist to oestrogen, its job is to keep the oestrogen in check by preventing overgrowth of the uterine lining. If conception does not occur, progesterone’s next job is to shed the build-up of the lining of the endometrium, which manifests as menses. Therefore, all women with a uterus (i.e. have not undergone a hysterectomy) should have a form of progesterone added to their oestrogen replacement therapy to decrease irregular bleeding.
What are the side effects?
The most common side effects of HRT include soreness of the breasts, mood swings, bloating and vaginal bleeding. But just like the contraceptive pill, also an example of a synthetic oestrogens and progesterones, each brand will give you different side effects and you may have to try a few different ones before you get the one that suits you best.
How long should you take HRT?
The recommended duration for HRT is less than five years, as long-term risks beyond this point have not been well-studied. However, many women experience symptoms for up to ten years and opt for longer therapy. With that said, many women find no difficulty in discontinuing oestrogen. Studies have demonstrated that about 50% of women stop therapy within one year, with 75% stopping within two years. It’s important to know that abruptly stopping therapy can result in the return of symptoms. Despite this, studies have not conclusively shown a benefit provided by tapering off HRT. Other than the return of symptoms, the downside to stopping is decreased protection of osteoporosis. This is balanced by the decreased risk of breast cancer, resulting in a patient specific decision.
The ‘natural’ alternative Bioidentical Hormone Replacement Therapy
BHRT (also known as natural hormone therapy) refers to the use of customised multihormone treatment regimens with dose adjustments based on serial monitoring of a woman’s blood hormone levels. Bioidentical hormones are commonly extracted from soy and plants, then modified to have a molecular structure identical to hormones naturally produced in the human body. Initially deemed a more ‘natural’ approach to hormone replacement, BHRT enjoyed a popular media surge during the mid-2000s following a book by Suzanne Somers titled Ageless: The Naked Truth About Bioidentical Hormones.
Some studies demonstrated promising symptom relief, such as one demonstrating a 25% decrease in emotional lability and a 22% reduction in anxiety within six months. There was additionally a more modest, statistically insignificant reduction in night sweats and hot flushes, with decreases of 22% and 14% respectively. A comprehensive Cochrane review was performed in 2016, which included 23 randomised control trials and nearly 5800 women. The review concluded there was low to moderate evidence that BHRT in various forms and doses was more effective than placebo for treating moderate hot flushes in perimenopausal women. It also concluded there was low to moderate evidence that BHRT increased the rates of side effects including headache, vaginal bleeding, breast tenderness and rashes.
Other studies have shown the quality of these compounds to occasionally be below standards. One study demonstrated a high variability in the degree of absorption of common bioidentical hormones when compared to a traditional oestrogen patch. Studies similar to this have lead professional societies including the North American Menopause Society, American College of Obstetricians and Gynecologists, and the Endocrine Society, to officially advise against BHRT. The groups based this recommendation on several key facts:
- A complete lack of randomised control trials demonstrating compounded BHRT to be safe and effective for treating symptoms of menopause.
- The content, dose, quality and sterility of bioidentical hormone products are not subjected to regulation – leading to variability among potency and absorption.
- There is no requirement for inclusion of package inserts or warnings for these products.
- Despite these recommendations, bioidentical hormone use is on the rise, with the FDA (US Food and Drug Administration) estimating the use of custom-compounds on par with approved HRT. This treatment is not available from your GP and is not mass produced and available over the counter like other natural products. You will need to find a doctor qualified in natural or restorative medicine to prescribe tailored course of treatment.
Although both hormone therapies can significantly improve extreme menopausal symptoms, it’s important to consider all your options if your symptoms are less severe. This way you can make an informed decision about the right choices for you.