HRT: A Tale Of Two Approaches

In yesterday’s newsletter, we asked you for your assessment of menopausal hormone replacement therapy (HRT).

• A little over a third said “It can be medically beneficial, but has some minor drawbacks”
• A little under a third said “It helps, but at the cost of increased cancer risk; not worth it”
• Almost as many said “It’s a wondrous cure-all that makes you happier, healthier, and smell nice too”
• Four said “It is a dangerous scam and a sham; “au naturel” is the way to go”

So what does the science say?

Which HRT?

One subscriber who voted for “It’s a wondrous cure-all that makes you healthier, happier, and smell nice too” wrote to add:

❝My answer is based on biodentical hormone replacement therapy. Your survey did not specify.❞

And that’s an important distinction! We did indeed mean bioidentical HRT, because, being completely honest here, this European writer had no idea that Premarin etc were still in such wide circulation in the US.

So to quickly clear up any confusion:

• Bioidentical hormones: these are (as the name suggests) identical on a molecular level to the kind produced by humans.
• Conjugated Equine Estrogens: such as Premarin, come from animals. Indeed, the name “Premarin” comes from “pregnant mare urine”, the substance used to make it.

There are also hormone analogs, such as medroxyprogesterone acetate, which is a progestin and not the same thing as progesterone. Hormone analogs such as the aforementioned MPA are again, a predominantly-American thing—though they did test it first in third-world countries, after testing it on animals and finding it gave them various kinds of cancer (breast, cervical, ovarian, uterine).

A quick jumping-off point if you’re interested in that:

Depot medroxyprogesterone acetate and the risk of breast and gynecologic cancer

this is about its use as a contraceptive (so, much lower doses needed), but it is the same thing sometimes given in the US as part of menopausal HRT. You will note that the date on that research is 1996; DMPA is not exactly cutting-edge and was first widely used in the 1950s.

Similarly, CEEs (like Premarin) have been used since the 1930s, while estradiol (bioidentical estrogen) has been in use since the 1970s.

In short: we recommend being wary of those older kinds and mostly won’t be talking about them here.

Bioidentical hormones are safer: True or False?

True! This is an open-and-shut case:

❝Physiological data and clinical outcomes demonstrate that bioidentical hormones are associated with lower risks, including the risk of breast cancer and cardiovascular disease, and are more efficacious than their synthetic and animal-derived counterparts.

Until evidence is found to the contrary, bioidentical hormones remain the preferred method of HRT. ❞

Further research since that review has further backed up its findings.

Source: Are Bioidentical Hormones Safer or More Efficacious than Other Commonly Used Versions in HRT?

So simply, if you’re going on HRT (estrogen and/or progesterone), you might want to check it’s the bioidentical kind.

HRT can increase the risk of breast cancer: True or False?

Contingently True, but for most people, there is no significant increase in risk.

First: again, we’re talking bioidentical hormones, and in this case, estradiol. Older animal-derived attempts had much higher risks with much lesser efficaciousness.

There have been so many studies on this (alas, none that have been publicised enough to undo the bad PR in the wake of old-fashioned HRT from before the 70s), but here’s a systematic review that highlights some very important things:

❝Estradiol-only therapy carries no risk for breast cancer, while the breast cancer risk varies according to the type of progestogen.

Estradiol therapy combined with medroxyprogesterone, norethisterone and levonorgestrel related to an increased risk of breast cancer, estradiol therapy combined with dydrogesterone and progesterone carries no risk❞

In fewer words:

• Estradiol by itself: no increased risk of breast cancer
• Estradiol with MDPA or other progestogens that aren’t really progesterone: increased risk of breast cancer
• Estradiol with actual progesterone: back to no increased risk of breast cancer

Source: Estradiol therapy and breast cancer risk in perimenopausal and postmenopausal women: a systematic review and meta-analysis

So again, you might want to make sure you are getting actual bioidentical hormones, and not something else!

However! If you are aware that you already have an increased risk of breast cancer (e.g. family history, you’ve had it before, you know you have certain genes for it, etc), then you should certainly discuss that with your doctor, because your personal circumstances may be different:

❝Tailored HRT may be used without strong evidence of a deleterious effect after ovarian cancer, endometrial cancer, most other gynecological cancers, bowel cancer, melanoma, a family history of breast cancer, benign breast disease, in carriers of BRACA mutations, after breast cancer if adjuvant therapy is not being used, past thromboembolism, varicose veins, fibroids and past endometriosis.

Relative contraindications are existing cardiovascular and cerebrovascular disease and breast cancer being treated with adjuvant therapies❞

Source: HRT in difficult circumstances: are there any absolute contraindications?

HRT makes you happier, healthier, and smell nice too: True or False?

Contingently True, assuming you do want its effects, which generally means the restoration of much of the youthful vitality you enjoyed pre-menopause.

The “and smell nice too” was partly rhetorical, but also partly literal: our scent is largely informed by our hormones, and higher estrogen results in a sweeter scent; lower estrogen results in a more bitter scent. Not generally considered an important health matter, but it’s a thing, so hey.

More often, people take menopausal HRT for more energy, stronger bones (reduced osteoporosis risk), healthier heart (reduced CVD risk), improved sexual health, better mood, healthier skin and hair, and general avoidance of menopause symptoms:

Read more: Skin, hair and beyond: the impact of menopause

We’d need another whole main feature to discuss all the benefits properly; today we’re just mythbusting.

HRT does have some drawbacks: True or False?

True, and/but how serious they are (beyond the aforementioned consideration in the case of an already-increased risk of breast cancer) is a matter of opinion.

For example, it is common to get a reprise of monthly cramps and/or mood swings, depending on how one is taking the HRT and other factors (e.g. your own personal physiology and genetic predispositions). For most people, these will even out over time.

It’s also even common to get a reprise of (much slighter than before) monthly bleeding, unless you have for example had a hysterectomy (no uterus = no bleeding). Again, this will usually settle down in a matter of months.

If you experience anything more alarming than that, then indeed check with your doctor.

HRT is a dangerous scam and sham: True or False?

False, simply. As described above, for most people they’re quite safe. Again, talking bioidentical hormones.

The other kind are in the most neutral sense a sham (i.e. they are literally sham hormones), though they’re not without their merits and for many people they may be better than nothing.

As for being a scam, biodentical hormones are widely prescribed in the many countries that have universal healthcare and/or a single-payer healthcare system, where there would be no profit motive (and considerable cost) in doing so.

They’re prescribed because they are effective and thus reduce healthcare spending in other areas (such as treating osteoporosis or CVD after the fact) and improve Health Related Quality of Life, and by extension, health-adjusted life-years, which is one of the top-used metrics for such systems.

See for example:

Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease

Our apologies, gentlemen

We wanted to also talk about testosterone therapy for the andropause, but we’ve run out of room today (because of covering the important distinction of bioidentical vs old-fashioned HRT)!

To make it up to you, we’ll do a full main feature on it (it’s an interesting topic) in the near future, so watch this space

Ladies, we’ll also at some point cover the pros and cons of different means of administration, e.g. pills, transdermal gel, injections, patches, pessaries, etc—which often have big differences.

That’ll be in a while though, because we try to vary our topics, so we can’t talk about menopausal HRT all the time, fascinating and important a topic it is.

Meanwhile… take care, all!

Sit Back, Relax, And…

In Tuesday’s newsletter, we asked you for your opinions of hypnotherapy, and got the above-depicted, below-described, set of responses:

• About 58% said “It is a good, evidenced-based practice that can help alleviate many conditions”
• Exactly 25% said “It is a scam and sham and/or wishful thinking at best, and should be avoided by all”
• About 13% said “It works only for those who are particularly suggestible—but it does work for them”
• One (1) person said “It is useful only for brain-centric conditions e.g. addictions, anxiety, phobias, etc”

So what does the science say?

Hypnotherapy is all in the patient’s head: True or False?

True! But guess which part of your body controls much of the rest of it.

So while hypnotherapy may be “all in the head”, its effects are not.

Since placebo effect, nocebo effect, and psychosomatic effect in general are well-documented, it’s quite safe to say at the very least that hypnotherapy thus “may be useful”.

Which prompts the question…

Hypnotherapy is just placebo: True or False?

False, probably. At the very least, if it’s placebo, it’s an unusually effective placebo.

And yes, even though testing against placebo is considered a good method of doing randomized controlled trials, some placebos are definitely better than others. If a placebo starts giving results much better than other placebos, is it still a placebo? Possibly a philosophical question whose answer may be rooted in semantics, but happily we do have a more useful answer…

Here’s an interesting paper which: a) begins its abstract with the strong, unequivocal statement “Hypnosis has proven clinical utility”, and b) goes on to examine the changes in neural activity during hypnosis:

Brain Activity and Functional Connectivity Associated with Hypnosis

It works only for the very suggestible: True or False?

False, broadly. As with any medical and/or therapeutic procedure, a patient’s expectations can affect the treatment outcome.

And, especially worthy of note, a patient’s level of engagement will vastly affect it treatment that has patient involvement. So for example, if a doctor prescribes a patient pills, which the patient does not think will work, so the patient takes them intermittently, because they’re slow to get the prescription refilled, etc, then surprise, the pills won’t get as good results (since they’re often not being taken).

How this plays out in hypnotherapy: because hypnotherapy is a guided process, part of its efficacy relies on the patient following instructions. If the hypnotherapist guides the patient’s mind, and internally the patient is just going “nope nope nope, what a lot of rubbish” then of course it will not work, just like if you ask for directions in the street and then ignore them, you won’t get to where you want to be.

For those who didn’t click on the above link by the way, you might want to go back and have a look at it, because it included groups of individuals with “high/low hypnotizability” per several ways of scoring such.

It works only for brain-centric things, e.g. addictions, anxieties, phobias, etc: True or False?

False—but it is better at those. Here for example is the UK’s Royal College of Psychiatrists’ information page, and if you go to “What conditions can hypnotherapy help to treat”, you’ll see two broad categories; the first is almost entirely brain-stuff; the second is more varied, and includes pain relief of various kinds, burn care, cancer treatment side effects, and even menopause symptoms. Finally, warts and other various skin conditions get their own (positive) mention, per “this is possible through the positive effects hypnosis has on the immune system”:

RCPsych | Hypnosis And Hypnotherapy

Wondering how much psychosomatic effect can do?

You might like this previous article; it’s not about hypnotherapy, but it is about the difference the mind can make on physical markers of aging:

Aging, Counterclockwise: When Age Is A Flexible Number

Take care!