BHRT SHOULD BE STANDARD OF CARE

The reason I believe that bioidentical hormone replacement for women should be standard of care is because estrogen helps prevent heart disease, improves bone density and reduces the risk of dementia.  Heart disease, osteoporosis and dementia are the three most common causes of death among elderly women and estrogen helps prevent all three.

Those with high cholesterol are at risk for heart disease.  However, reducing the cholesterol with a statin drug does not reduce the risk of heart disease or a cardiac event except for a mild reduction in risk for those at very high risk for heart disease.  On the other hand, those women who replace bioidentical estrogen (estradiol) have a 50-60% reduction in heart disease and cardiac events.  Women who take estradiol feel more energy and vitality while losing weight.  It seems to me that a treatment that helps one feel great while reducing risk of heart disease should be standard of care.

Osteoporosis has a very high prevalence among menopausal women.  During menopause, there is a precipitous decline in bone density for many women.  Osteoporosis is painless unless a fracture results.  Unfortunately, a hip fracture has a high mortality rate for women (18% in first year) and can be very disabling for the survivor, leading to nursing home placement.  The most common treatment for osteoporosis is alendronate (Fosamax).  This does not help grow bone.  Rather, it slows the decline of bone.  In contrast, estradiol actually helps grow bone.  That is, those who take estradiol actually see their bone density increase.  Thus, taking estradiol is one of the most effective ways to significantly reduce the risk of hip fracture.  With bioidentical hormone replacement, women have improved mood and sleep better.  It seems to me that a treatment that helps improve mood while reducing the risk of hip fracture should be standard of care.

Dementia deprives many from enjoying life and as it progresses, 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%, 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.  Women who utilize bioidentical hormone replacement have improved sexual health with increased libido.  It seems to me that a treatment that improves sexual health while reducing the risk of dementia should be standard of care.

I believe that the reason that the medical community does not embrace bioidentical hormone replacement as the standard of care is because there is confusion between bioidentical hormones and synthetic pharmaceuticals.  To maximize benefit from hormones, progesterone is added.  This is a bioidentical hormone that protects the uterus from increased proliferation and enhances mood.  However, Provera, which is a synthetic pharmaceutical version of progesterone, is commonly used and has terrible side effects.  Unfortunately, many physicians confuse Provera with progesterone.  Let’s compare the two.  Provera increases the risk of breast cancer while progesterone inhibits epithelial cell proliferation, thus reducing the risk of cancer.  Provera counteracts the beneficial cardiac effects of estradiol while progesterone acts synergistically with estradiol to optimize cardiac benefit.  Provera causes irritability and depressed mood while progesterone enhances mood.  Despite these stark differences, many physicians and even many review studies, conflate Provera and progesterone.  This confusion harms women by depriving them of accurate information that would help them clearly see the benefits of bioidentical hormones. 

Another source of confusion is mistaking Premarin and estradiol.  Premarin, which is the pharmaceutical version of estrogen, is derived from horses, while bioidentical estradiol, which has the same beneficial effects of estrogen that was produced during the fertile years.  Premarin provides some of the benefits of estrogen including improved bone density but comes at a cost – there is a dislodging of clots so those who have plaque build-up in their arteries are predisposed to a blood clot or even stroke.  However, estradiol, which is a bioidentical estrogen, has not been shown to dislodge clots so does not have this same risk.  Interestingly, both Premarin and estradiol have not been shown to increase the risk of breast cancer.  Despite this, many physicians and the general population believe that estrogen causes breast cancer.  We would be much healthier and age much better if this was clarified.

Most review studies that look at hormone replacement give equal weight to studies that use bioidentical hormones and synthetic pharmaceutical versions of these hormones.  The result is that the benefits of hormone replacement are understated while potential harmful effects of hormone replacement are exaggerated.  Thus, to understand the literature and the benefits of bioidentical hormones, physicians need to sort through the studies to distinguish between bioidentical hormones and synthetic hormones.  If such a distinction were made, I am confident that bioidentical hormones would be the standard of care.  This is because bioidentical hormones have been shown to dramatically reduce the risk of heart disease, have been shown to increase bone density and to reduce the risk of dementia.  At the same time that one is improving their heart health, bone health and brain health with bioidentical hormones, one will feel great and lose weight.  That is why I believe that bioidentical hormones should be standard of care.

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