Types of HRT

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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.

Non-regulated products

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 better hormone doctors too!), 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. Apart from it being way more expensive, who knows how much progesterone was actually in his product? FDA-approved products got through testing and are regulated to make sure the amount of the drug it says we are getting is what we are actually getting.

Delivery methods

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.

Pellets

Pellets are very common for testosterone, likely because in the USA we are lacking an FDA-approved product, so pellets have filled that space.

I know patients who swear by their hormonal pellets, but pretty much every menopause expert I follow, including the ones that believe that testosterone can play an important role for some in HRT, strongly recommend against using pellets. Why? Because these can raise our doses of hormones too high and too fast, leading to side effects (especially when it comes to pellets for testosterone.) With estrogen, there is a wide variety of FDA-approved products to choose from. With testosterone, patients can use compounded creams or the male FDA-approved product.

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. For example, birth control might be a great option for you in perimenopause when your estrogen is going up and down erratically (causing you all kinds of symptoms) and also one of your goals is to prevent pregnancy.

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.