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When NOT To Take HRT

"Wait, so what are you saying, is HRT a good idea or not?" I was talking with a patient to whom I had recommended hormone replacement, but mentioned I had some concerns about "everyone" taking HRT. In fact, I do qualify my general advice, and suggest that hormones are not always the right choice. I speak so consistently about the safety of hormone replacement in menopause, that I am afraid it might be missed that my endorsement always comes with a qualifying phrase, so here it comes: in my opinion, and I believe according to the research...

Hormones are safe if and only if  they are well prescribed and carefully monitored.

Beyond safe, hormones are beneficial in menopause. Our levels of the hormones estradiol and progesterone decline markedly when women enter menopause.  With essentially no estradiol or progesterone, we lose the protective effect of female hormones on our brain health, digestive function, bone health, and even, yes—breast health.

Estrogen does lower breast cancer risk, mostly. To review a little estrogen history, the large Women’s Health International (WHI) study was halted prematurely because it found an increased risk of breast cancer. That news was hailed far and wide and ever since then doctors and patients have repeated the meme that hormones cause breast cancer. The next step in the history is that the WHI data has been continually re-evaluated and milked for all that it’s worth. What became clear pretty quickly is that the estrogen itself actually lowered breast cancer risk. That, however, never made the headlines. Over an average of about 7 years of follow-up, study participants taking estrogen had fewer breast cancer tumors than those in the placebo group

HRT can be estrogen alone in women who have had a hysterectomy, but the estrogen must be modulated by a form of progesterone to prevent endometrial cancer in a woman with an intact uterus. Unfortunately, in the WHI they used a synthetic progestin, not progesterone, and that is what caused the increased breast cancer risk. Today, bio-identical HRT would include a biology-identical progesterone, which does not increase the risk of breast cancer. (A little off-topic today, but in general I would add progesterone for even those women who no longer have a uterus, for some of its other benefits.)

That said, the relationship between hormones and breast cancer is complex and only fully examined in a length article, perhaps best done here in this excellent and exhaustive article by Janet Gray, Ph.D. on the website of the Breast Cancer Fund. Complicated story on breast health, but remember that hormones exert a beneficial effect on many organ systems, as listed above. Still…

Maybe don’t take hormones if…

Each woman should know something of her own risks for health problems in general, but particularly those that have been associated with high levels of either estrogen or progesterone. Possible increased risk associated with hormones would include elevated risk for breast cancer, stroke, or blood clotting. Each of these can be understood, evaluated, and managed in cooperation with a knowledgeable physician. Today let’s just talk about breast cancer, as that is the one that usually scares high risk women away from taking menopausal HRT.

Higher than usual risks for breast cancer include family history, smoking, carrying extra weight (especially around the middle), a less than vigorous exercise schedule, and high exposure to other estrogen-like compounds (chemicals or makeup are common sources.) Drinking alcohol increases your risk, unless you know how your liver handles alcohol and estrogen! If you are at high risk, the hormones are still good for you but must be monitored in two ways.

First, your estrogen should be prescribed topically (cream or patch) and replaced into some lower end of the physiological range on a blood test. You don’t want the hormones of a teenager, but rather the lower levels of a mid-cycle adult woman; in my practice I like to see levels of 50-120 pg/mL . Higher levels increase your risk for endometrial cancer or estrogen dominance, and are unnecessary to yield a benefit.

Secondly, and most importantly: your prescriber should understand how to test and manage your estrogen metabolism. Estrogen takes a detoxification pathway through the liver that is crowded with all the different chemicals to which we are exposed in modern life, including many xenoestrogens: chemical compounds designed for a completely different purpose but which behave as estrogen in the body. The detox path has two steps, Phase 1 and Phase 2. Phase 1 removes the estrogen from the blood, creating an intermediate compound “marked” in either the 2-, the 4-, or the 16-position on the estrogen molecule. When prominent, the 2-estrogen compound is associated with a reduced risk of breast cancer, so it’s the better form. You get more of the 2-form with lucky genetics (hard to change!), eating lots of cruciferous vegetables, or taking appropriate supplements. My favorite is Indole Forte by Pro Thera which is a combination of the useful estrogen metabolizing indole compounds from cruciferous vegetables. (Taking just 1 a day, I was able to correct my genetically weak Phase 1 estrogen metabolism.)

Phase 1 metabolism isn’t enough; Phase 2 of liver detoxification works by “methylation” or attachment of a methyl (CH3) group that enables the body to eliminate the estrogen fully, in urine or stool. Your capacity to methylate is essential for any and all detoxification, not just estrogen, but since we’re talking about adding extra estrogen to the mix in your body, it becomes particularly important. Your genetics and your nutrition determine how well you are “methylating” your estrogen compounds.

There is now one simple test, very affordable even if not covered by insurance, to test both Phase 1 and Phase 2 detoxification of estrogen (and by proxy, any other estrogenic compounds your liver is dealing with. In fact, methylation is a crucial step in all processes of detoxification, so the test yields a wealth of relevant information.) Created by Mark Newman, an experienced laboratory scientist who saw a growing need, the DUTCH test enables you to easily collect 4-5 dried urine samples over a 24-hour period and test estrogen metabolism alone or estrogen in combination with assays of adrenal hormones, melatonin, and testosterone related hormones.

Again, correcting methylation defects can be as simple as adjusting your diet (more organ meats and leafy greens) or taking the right methyl-donating supplement for you. Methyl groups can be obtained for Phase 2 detoxification from methylated versions of B vitamins, glycine (great for sleep and joint health), or the compound SAMe (also great for joints and used for depression.)

No one wants to take a lifetime of unnecessary supplements so this is where knowledgeable testing can give a woman the guidance she needs to take hormones safely. (You can get the DUTCH test for yourself through their website, but it’s more helpful if your doctor carries the DUTCH test—less expensive and your doctor can help with the interpretation.)

So, yes or no on the HRT?

So ultimately, my recommendation is that, in general, taking hormones is a good idea. Specifically, for any one individual though, it makes a world of difference how they are prescribed, monitored, adjusted and supplemented. I personally would not be comfortable taking or advising a woman to take bio-identical HRT unless she is working with a practitioner who knows how to evaluate and adjust for hormone detoxification, not just the hormones themselves. And then, of course it's up to the woman to do her part, to get the tests and take any action that might be needed.




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