What Your Gynecologist Won’t Tell You About BHRT and Sexuality at Midlife

Contributed by Dr. Michael Goodman

Red Hot Mamas Medical Expert

In today’s world of corporatized healthcare, where a premium is paid on seeing as many patients in the shortest amount of time as possible, and most medical care- especially peri-menopausal and menopausal care- is based on a “cookbook” approach (whether it be by traditional primary or gynecologic practitioners, or so-called, usually “franchised” “BHRT- bio identical hormone replacement therapy Practitioners,”) there is much confusion when it comes to hormonal therapy, menopause, and sexuality. Good, honest information and true personalization when it comes to therapy is rarely present from either your PCP or general Ob/Gyn.What is the honest information on hormonal therapy (“HT”) for menopause? Honest information on the pros and cons of hormones, the difference between hormones, the place of hormonal testing, and the safety of HT? What, exactly is “BHRT;” is it more or less safe than “conventional” HT, and how is it prescribed? What, really, is in all those over-the-counter or “alternative-practitioner”- recommended herbal and progesterone therapies. And what about your sex life as you pass through the menopause transition? Are you supposed to just “forget about it” as many PCPs and Ob/Gyns thoughtlessly proclaim as they try to get you in and out of their exam rooms in under 15 minutes..?! Read on for straightforward, knowledgeable, honest, and “encapsulated” information. 

Pros and Cons of HT during peri-menopause and menopause:

 

Hormonal therapy in the form of oral contraceptives (BC pills…) can help mightily with the irregular, frequently heavy and generally “weird” bleeding of peri-menopause, switching to lower-dose “BHRT” (see below) when peri-menopause is over, and true menopause begins. A well-trained menopause practitioner will know how to tell when this transition occurs. Therapy with low-dose transdermal (through the skin via patches, creams/gels, or implanted pellets) estrogen (estradiol) with or without progesterone may begin during peri-menopause, or may await the advent of menopause, when menses cease. Progesterone may be given to help with anxiety or sleep, as well as to “protect” the uterus (if present) from potential adverse effects of “unopposed” estrogen on the uterine lining.

 

Pros: Can control the frequently weird bleeding patterns of peri-menopause (BC pills work well here…), will eliminate the bothersome, often crazed symptoms of the transition (which can last an average of 7 ½ years…) including hot flashes/night sweats, memory problems, headaches, sleep disturbances, fatigue, disruption of sexual function, mood disruption, etc… If started near to menopause ( the sooner the better, but certainly within 7-8 years; much sooner- within 3 years of last period- is best), HT/BHRT will significantly diminish the risk of cardiovascular death, protect your bones, significantly lower risk of dementia and colon cancer and improve post-menopausal sexual health. Estrogen helps maintain a healthy collagen layer under the skin, and helps with the metabolic problems associated with menopause (weight issues, memory, overall strength and “quality of life…”)

 

Cons: You have both to pay for it, and take it on a regular basis! Women on postmenopausal hormones are more likely to have occasional periods after menopause. Often, you need to work with a knowledgeable practitioner to “get it right…” If started late (> 7/8 years after final manses), there are more adverse, and fewer beneficial effects for HT. If taken for > 10/15 years, there is a small (<1%) increase in the risk of dying from breast cancer (along with the ~ 30% diminished risk of cardiovascular death, and very significant diminishment in hip fracture, vertebral fracture, Alzheimer’s. colon cancer, etc.)

The place for hormonal testing

There is truly very limited need to “test your hormone levels…” especially during the menopausal transition, as well as afterwards. This is a marketing ploy of unscrupulous and undereducated cookbook practitioners: “OH! Let’s test your hormone levels to get you balanced…” It does not work that way. First, hormone levels shift, day-by-day. Second, there truly are no “norms” to balance-different women thrive on significantly varying hormone levels. And, third, just when do you draw the blood: an hour, 4 hours, 24 hours- when?? after last hormone dose? The results will be all different. And the confusion is only compounded by saliva testing, which unfortunately has a built-in inaccuracy that can approach 25%. You will find that the chief individuals utilizing saliva testing are persons- chiropractors, so-called “alternative practitioners,” naturopaths, etc.- who legally cannot order & interpret blood testing. So they say saliva is “better,” because they are limited in their scope.

Much “hormonal testing” offered by alternative practitioners is little more than a marketing ploy.   Yes, properly done testosterone testing can help. And, occasionally estradiol levels can help with a therapeutic decision (rarely…) Progesterone testing is always a waste of time & money. Oh- and did I tell you: usually the person ordering the saliva test makes $10-20 off of each test! Got the idea..?!

Hormonal “balancing” is done best by an educated, experienced menopausal practitioner. You will never go wrong if you choose an NAMS-Certified Menopausal Practitioner (found on www.menopause.org), as these individuals must study, and pass a rigorous full-day exam to become certified!

So, what-exactly- is BHRT? Is it true that it is safer than “conventional” HT?

(Honest answer here-not necessarily what you’ll hear from the cookbook franchise “hormone mills” staffed by non-menopause specialist general docs who basically spout company rhetoric…). BHRT = “bioidentical hormone replacement therapy”. “Bioidenticals” are synthesized hormones, synthesized from plant sterols such as soy and wild Mexican yam in the laboratory to molecularly mimic that which is produced in the human body (estradiol, progesterone, testosterone…) To my knowledge, all of the estradiol for the world is produced by one of 2 factories in Germany (Mallenckrodt Chemicals or Organon Pharmaceuticals) and sold either to pharmaceutical companies who prepare them in various patches, gels/creams or tablets, or to wholesalers who sell to compounding pharmacies who blend it into various creams, gels, and pellets. What you get from the compounder is exactly the same product that you get from your regular pharmacy from a “drug company.” The difference it that one is FDA-regulated, so you know the exact amount you’re getting and its safety profile, and the other is “approximated,” as there is no research or regulation on the compounded product in regards to the amount to give, or safety profile. Personally, I feel that compounding is quite reasonable and safe, but the reality is that the classic BHRT compounded product as prescribed by many undereducated practitioners is definitely less safe than the FDA-approved product, as many “BHRT practitioners” routinely give higher than safe dosages that have never been tested, making the risk of breast cancer theoretically higher with many compounded estrogen preparations than the tested FDA-regulated product.

 

What is in all those “alternative herbal products” with names that “sound” like hormone therapy..?

 

If you buy it over the counter, or from your chiropractor or alternative practitioner, or from an online site or magazine, even if the name sounds “hormonal,” the product contains no hormones. Just clever marketing, relying heavily on placebo efficacy (which actually can be quite effective if no harm is done…). Clever marketers have devised names for these products to make you think that what you are getting is a hormonal product, or a substitute for a hormone. One thing guaranteed: if it was not prescribed by a MD, DO, or qualified NP or PA, there are no hormones in it. It is illegal to sell any estrogen or testosterone product, or any product with more than a very small amount of progesterone in it without a prescription. “If all you have is a hammer, everything looks like a nail…” That is why practitioners that legally cannot write prescriptions and prescribe often tout these frequently useless products. Better to stick with an integrative licensed MD or DO or “midlevel” practitioner who has the choice of different technologies and products rather than someone (frequently a self-named “Alternative Practitioner”) who has a good spiel but factually is prohibited from providing any true medical or hormonal care.

What about my sex life during peri-menopause, menopause, and beyond?!

This is an area of shame for so many medical practitioners! I can’t tell you the huge number of my patients who come to me after seeing their family practitioner or general gynecologist with concerns over dwindling sex drive and overall sexual function and are dismissed with the thoughtless comments, “…well, it goes along with age…” or “that’s what happens when you get older…” WELL! Maybe that’s the sad fact of their own life, or very likely they are in a hurry and it’s easier to just put you off, but the fact is: sex can [continue] to be great into later decades!

 

Good sex ongoing into the 4th, 5th, 6th, 7th decades of life flows from a combination of good general health (stress reduction, proper diet, an ongoing no-nonsense exercise program), good hormonal health (vaginal micro-dose estrogen or substitute; ongoing low-dose transdermal systemic estrogen and possibly testosterone administration), good communication with your partner, the willingness of both of you to re-evaluate and “update” your sexual relationship, and of course your partner’s erectile ability… If the quantity and quality of your sexually intimate relationship with your “significant other” needs strengthening, do not hesitate to counsel with a sexual medicine practitioner- an MD or therapist both knowledgeable and interested in women’s sexual needs and issues…

 

–Michael P Goodman, MD, FCOG, NCMP, IF, CCD, AACS

Caring For Women Wellness Center

Davis, CA, USA