The correct HRT
The most obvious fact is that we should avoid any oral therapy whether it is the logical oestradiol, which is the hormone produced by women naturally, or the ridiculous collection of preparations containing horse-oestrogens such as Premarin Premique Prempro etc. Oestradiol should be given transdermally as this route avoids the first pass liver stimulation of clotting factors with oral oestrogens which lead to the probable increase in deep vein thrombosis, heart attacks and stroke with oral oestrogens whether it is the oral contraceptive pill or HRT.
Testosterone, is often thought of as male hormone but the ovaries in young women produce very large amounts of this, naturally and it is very useful for problems of mood, energy and libido. 93% of my HRT patients also have testosterone as well as transdermal oestradiol with excellent results.
Women with a uterus need endometrial protection with progesterone either tablets or a Mirena coil but continuous progestogens should be avoided because if there is a risk of breast cancer with HRT as it is probably due to continuous synthetic progestogens and NOT oestrogens. All studies looking at oestrogen alone reveal a decreased or a no change incidence of breast cancer.
The types of transdermal oestradiol are:
- Gels - Oestrogel My first choice or Sandrena sachets (for hand luggage)
For Testosterone there are gels Testim or Testogel both only licensed for men but are used in women using a smaller dose. There was a patch licensed for women called Intrinsa but the manufactures discontinued it on commercial grounds. It wasn’t selling enough because the manufacturers recommended too low a dose. One of the lessons of HRT is that one has to use a dose that works. This will be assessed by the history of response rather than repeated blood tests.
Another brilliant means of delivering oestrogen and testosterone is by a hormone implant which is convenient, painless and lasts about 6 months. It is ideal for women post-hysterectomy but is rarely available on the NHS and it is more expensive than gels or patches.
Bio identical Hormones
The therapy outlined above is all "bioidentical" and has been used by many of us in Europe for 20 years. No, it is not a clever American invention as they are still stuck with oral oestrogens particularly the ghastly Premarin. The hormones I use can all be obtained on the NHS if your GP is willing although he/she will probably decline to prescribe testosterone as it is not licensed for women now that the patches have been withdrawn.
This treatment should not be confused with the many purveyors of bioidentical hormones on the internet who use oestradiol and testosterone (so far so good) orally (not so good) with oestrone and estriol (2 weak and unnecessary oestrogens), DHEA which only works when converted to testosterone and daily progesterone either orally or by cream which is not even absorbed. These oral tablets or lozenges are manufactured by compounding pharmacies which are unregulated for safety and efficiency. There is a move in the UK and USA to have them banned as a health hazard. Indeed, last year the Advertising Standard Authority has ruled that the claims made in promoting bio-identical hormone treatment is misleading, with no evidence to the claims that such treatment is more effective or safer to the HRT I describe above. Another warning - if any of these practitioners invite you to measure your salivary hormones in order to have a bespoke made to measure HRT you should head for the hills and take your wallet with you!