Hormone replacement therapy (HRT) has been a source of debate and confusion, largely stemming from the results of the Women’s Health Initiative (WHI) trial, which was prematurely halted in 2002 and 2004. The trial reported increased risks of breast cancer, heart disease, stroke, and blood clots in women using oral conjugated equine estrogens (Premarin) combined with medroxyprogesterone acetate (MPA). However, these results are often misinterpreted to apply to all forms of HRT, which is not accurate. The WHI trial used Premarin (derived from pregnant mare urine) and a synthetic progestin, and its participants were typically older women who began HRT more than a decade after menopause. These factors do not reflect the benefits or risks of bioidentical hormone therapies, particularly when started earlier in the menopausal transition.
As a graduate student in physiology during the termination of the WHI, a time when misinformation and fear about HRT were rampant, I wrote my master’s thesis on the cardiovascular benefits of bioidentical transdermal HRT. At that time, the medical community faced a backlash against HRT due to the definitive conclusions drawn from the WHI trial, and voices advocating for more nuanced approaches to menopause care were largely silenced. Today, while there is renewed attention to menopause on social media and in recent publications, many women still struggle to find local providers with the expertise and willingness to offer the treatment they need. As women now live longer, often spending half their lives beyond their reproductive years, it is essential to counsel patients on their choices regarding hormone therapy and the risks associated with hormone deprivation, including impacts on bone, brain, skin, vaginal, and psychological health.
Transdermal estradiol and micronized progesterone provide significant advantages over the oral conjugated estrogens and synthetic progestins used in the WHI trial. Transdermal estradiol, delivered via patches or creams, bypasses the liver, reducing the risk of blood clots, stroke, and other cardiovascular issues associated with oral hormone use. It also mimics the body’s natural estrogen rhythms more effectively. Micronized progesterone, a bioidentical form of progesterone, is safer and better tolerated than synthetic progestins like MPA, avoiding many of the side effects that are common with synthetic hormone use. These therapies not only manage menopausal symptoms more effectively but also offer protective benefits for bone density and cardiovascular health, enabling women and their healthcare providers to make informed, safer decisions about HRT.
At Four Mile Creek Health, a direct primary care clinic, we dedicate the time needed to engage in these nuanced conversations, taking into account each patient’s family history, personal risk factors, and routine cancer screening. Hormone replacement therapy (HRT) is a critical aspect of improving quality of life for many women during menopause, and emerging evidence suggests it may also play a role in longevity and the prevention of Alzheimer’s disease, although larger trials are still ongoing. By providing individualized care and exploring the full spectrum of HRT benefits, we empower women to make informed choices that support both their current well-being and long-term health.
