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Hormone Replacement Therapy – Part 2

This is part 2 of 2. On this page you’ll find:

  • How to find a doctor
  • Types of HRT
  • How to test your hormones
  • Symptoms of perimenopause

In part 1, we discussed:

  • What is HRT?
  • Infomation on HRT using estrogen, progesterone, and testosterone (the forgotten hormone!)
  • Discussion on the safety of HRT
  • HRT for people with endometriosis

Your doctor should have knowledge and experience in hormones and HRT

The North American Menopause Society (NAMS) has a “find a provider” section. You can search by zip code, and it lists doctors who have passed a competency examination developed by NAMS and have been awarded the credential of Certified Menopause Practitioner. It lists gynecologists, endocrinologists, physician assistants, naturopaths, and other types of healthcare professionals. Of course, that doesn’t mean every doctor in their database can treat you for your specific case, so you still need to look into them as you would for any doctor, but it can be a good starting place. If a doctor doesn’t have the NAMS certification, it also doesn’t mean they aren’t qualified to help you. You may also want to be careful with private hormone clinics because some use unregulated hormones.

Ask your doctor questions to see their expertise and treatment approach. Some examples might be:

  • Does HRT generally help with symptoms like mine?
  • What are the risks vs the benefits?
  • How long will I be on it?
  • Do you use bioidentical or synthetic hormones?
  • Will you test my hormones? If yes, how will you test them?
  • How do you prescribe them? Will it be oral, a patch, a cream, etc?

Types of HRT

There are many ways a person can take HRT, such as oral, transdermal (patch), percutaneous (cream, gel), intramuscular, sublingual, vaginal (gels, cream, tablet, ring, and pessary), nasal, pellets, etc. The absorption and bio availability of the hormone can change depending on the delivery route. With each type of hormone delivery, there are pros and cons that you should discuss with your qualified medical professional.

Most of the menopause specialists I follow say to use FDA approved products because they are regulated, and to avoid custom-compounded hormones or pellets if FDA approved options are available. An example of when a custom-compounded hormone is helpful is when a person has an allergy to an ingredient in an FDA approved product. Another example is for testosterone: unfortunately, there are no FDA approved testosterone products for females. Some providers will prescribe the male FDA approved product and tell the patient to use a smaller dose. Others will prescribe custom-compounded testosterone instead.

In terms of pellets: I know people who swear by their hormonal pellets, and they work with providers who know how to properly monitor their testosterone levels while on them. It’s not to say that all pellets are bad, but rather there are many providers out there who don’t know how to properly dose pellets, leading to their patients having extremely high testosterone levels and therefore a lot of side effects! Like with anything medical, we should do research about the hormones we are looking to take and discuss the safety and efficacy with a doctor who is experienced in HRT.

Unfortunately, when I first started taking progesterone, it was a product made by a functional medicine doctor and sold in his online store. This was a huge red flag about him which I wasn’t aware of at the time. Eventually, I learned that better options were available, and got my primary care physician to prescribe me regulated, FDA approved oral micronized progesterone, which was covered by my insurance, for a fraction of the price.

Bioidentical hormones

The term bioidentical has been used in different ways. When people say bioidentical, they are typically referring to hormones that are as close to what ovaries make as possible, such as oral micronized progesterone. This is different from the non-bioidentical progestins in birth control, which have names like levonorgestrel or drospirenone.

However, bioidentical hormones is actually a term invented by marketers, and has no scientific meaning, so some people exploit the term bioidentical to use for marketing their custom hormones, like the functional medicine doctor I saw did – when in reality, there were much better, FDA approved, regulated hormone options available to me.

You can find a list of FDA-approved hormone products here: NAMs menonote on bioidentical hormone therapy.

Birth control isn’t HRT

If we are considering HRT, it’s important that the doctor we work with is knowledgeable on hormones. Some doctors think that taking hormonal birth control “balances hormones”, but birth controls do not do this. The hormones in birth control are synthetic, and they usually maintain hormones at a steady hormone level. If you have ever looked at a chart of your hormones online, you will see that actual natural hormones in a cycling person have a rhythm. For example, in a person with a 28-day cycle, estrogen rises around day 7 until ovulation. After ovulation, progesterone rises, and estrogen starts rising again around day 17. Both peak around day 21 and then fall to a low level when menstruation starts. With birth control, these peaks don’t happen.

Birth control is really helpful for so many of us in this community, be it in preventing pregnancy or managing symptoms of painful periods, heavy periods, endometriosis, adenomyosis, fibroids, and other problems related to periods and cycles. But birth control isn’t hormone replacement therapy, so if you are looking for HRT, and the doctor you are with immediately suggests you take birth control for HRT (without any discussion about estrogen therapy), this is often an indication that they aren’t well versed in hormones. 

Having said this, that isn’t to say that hormonal birth control isn’t right for you in your individual situation – this depends on your symptoms, your treatment goals, your side effects, and other factors. You can discuss the pros and cons of different options with your doctor. At the same time, remember that many gynecologists are not well versed in HRT, so it’s important for you to go in with background knowledge too so you can know when to get a second opinion if needed.

Hormone Testing

There are different types of hormone testing. The most common and reliable are blood tests, which are often covered by insurance. “Salivary and urine hormone testing to determine dosing are unreliable and not recommended.”(Source: NAMS position statement)

“It is not necessary to check blood, urine, or saliva hormone levels to find the right [HRT] dose. During reproductive life, estrogen levels vary throughout the menstrual cycle and during each day, so there is no perfect hormone level for any [person].” (Source: NAMs menonote on bioidentical hormone therapy.)

Usually HRT treatments are based on your symptoms, because treatment is prescribed to improve perimenopause or menopause symptoms, and not to aim for a certain level on blood tests. However, some doctors may do an initial blood test to see your levels. If after a few months on HRT it doesn’t seem like you are responding to it, they may check your levels again to gauge if you are absorbing the hormones you are taking and if you need to change the dose or delivery method. However, many doctors treat solely on symptoms and do not do any blood tests. 

The DUTCH test has gained popularity among naturopaths and functional medicine doctors. Not only is it not covered by most insurance and can cost $400 or more depending on the practitioner, but the criticisms on the DUTCH test are that it’s unnecessary and even that the info is clinically meaningless for guiding HRT. Most of the same info can be gathered from blood tests with an endocrinologist or gynecologist for a fraction of the price, and as mentioned above, most HRT treatments are based on your symptoms, not on your hormone levels. If you’re working with a doctor who wants you to get the DUTCH test, definitely read unbiased reviews on it before dropping a ton of money on the test and don’t be afraid to ask your doctor to explore using the blood testing options with you. If they won’t or can’t, this could be an indication that they are not fit to treat your hormones or that you may need to work with a different doctor for your HRT.

Here’s a helpful, independent review of the DUTCH test from Abby Langer, RD.

Is there a test for perimenopause?

There is no lab test that can tell you, but depending on your age and symptoms, you can likely distinguish if you are in perimenopause.

Here’s a list of common perimenopause symptoms (in no particular order):

  • irregular periods
  • hot flashes
  • sleep problems like insomnia, waking during the night
  • mood changes, low mood, depression
  • anxiety
  • decreased libido
  • dry eyes
  • migraine headaches
  • aches and pains, increased fibromyalgia-like pains
  • vaginal dryness
  • increased urinary problems, UTI-like symptoms
  • dizziness
  • tinnitus
  • burning mouth
  • gum problems
  • changing cholesterol levels
  • forgetfulness
  • onset of histamine intolerance or increased allergies
  • racing heart
  • and so much more

I feel like the perimenopause and menopause symptoms we hear most about are hot flashes and mood changes, but there are so many more ways that we can be affected. Some people don’t have any hot flashes but have a bunch of other seemingly random symptoms like racing heart, burning mouth and dizziness. This is why it’s important to familiarize ourselves with perimenopause and menopause symptoms because we can go on a wild goose chase trying to figure out what is going on with our downturn in health. This happened to me unfortunately, I was sent to allergists, dermatologists, cardiologists and other doctors, and no one figured out that I was in perimenopause. Unfortunately, we haven’t been taught body literacy around menopause and neither have most doctors.

For more info

  • North American Menopause Society (NAMS). They have position statements on hormonal and nonhormonal therapy, “menonotes” or short info sheets on important topics, and Find a Provider section. You can search by zip code, and it lists doctors who have passed a competency examination developed by NAMS and have been awarded the credential of Certified Menopause Practitioner.

  • Newson Health – Louise Newson, MD, is a GP and Menopause Specialist and holds an Advanced Menopause Specialist certificate with Faculty of Sexual and Reproductive Healthcare. There is loads of educational material on her website and podcast. I especially appreciate that she has information on testosterone as most menopause specialists don’t understand the importance of it in people assigned female at birth. Some of my favorite episodes on testosterone on her podcast were 116, 118, and 119.

  • You Are Not Broken – Kelly Casperson, MD is a NAMS-certified urologist who has an amazing podcast on hormones, sex, and other topics. Browse her podcast! Some of my favorite episodes were on vaginal estrogen, an overview of HRT (episode 225 and 205), and testosterone.

  • Millenium Wellness Center – helpful info on hormones, especially on pellets. Pellets have a bad reputation and many clinics that insert pellets don’t monitor well the testosterone levels resulting in extremely high levels for some people. If you are thinking about using pellets, it’s important to work with a provider who is willing to work with you to get your levels right.

  • Hot and Bothered: What No One Tells You About Menopause and How to Feel Like Yourself Againbook by Jancee Dunn. I’ve read several books on menopause but none of them made the cut to this list. However I enjoyed this humorous and informative book on menopause. She shares personal experiences in a lighthearted way, while weaving in info from her interviews with menopause experts. One part I didn’t like was that the only mention of testosterone HRT painted it negatively, even though it’s an important hormone for people assigned female at birth as well.

  • Lara Briden – The Period Revolutionary – I wasn’t sure if I should link Lara Briden on her because I find some of her info problematic, so I’ve linked her last because I did find her general information helpful to understand the menstrual cycle, perimenopause, and menopause, and how to support our bodies during this time. However, as for her information on endometriosis, I have seen misinformation there, so take any of that info with a grain of salt. Having said that though, some of her recommendations may be helpful for some people to manage endometriosis symptoms, but not to suppress the disease, shrink, or remove it. While she links to some studies on how X supplement etc can “reduce lesions” and other claims, these studies have design flaws. Remember – no matter the diet, lifestyle, herbs, supplements, etc, endometriosis still remains and can even progress leading to fused organs, bowel blockages, silent kidney death, etc, even if a person becomes asymptomatic.