No HRT for me!

 Katherine went through menopause when she was 55 years old. She was about 57 years old when she came to my office to check in on her overall health and to fine tune her supplement regime. She was healthy and, other than some bladder leakage issues (for which I referred her to a pelvic floor specialist,) she didn’t express much concern about menopause. Unlike many women in this age group, her libido and sex drive were pretty good and she didn’t complain of vaginal dryness. Although she had hot flashes 5-6 times per day, she found relief using a fan, which also calmed her night sweats.

The most important thing to note is that Katherine did not want to do hormone replacement therapy (HRT). She had very strong opinions against it even though she had no family history of estrogenic cancers or other health conditions that can be reasons to avoid HRT.

Initial Tests

After her first visit I ordered a full panel of tests. As expected, her hormones were low but everything else looked good. Her autoimmune panel was negative, vitamin B12 and glucose were good and vitamin D levels were in a decent range – 50 – as well.  As I expected, her estradiol and progesterone were non-existent and her FSH and LH were super high – all indicative of someone in menopause! Katherine remained steadfast in her view that menopause “isn’t that bothersome.”

We agreed to address her symptoms with non-hormonal support, so I prescribed vaginal vitamin E suppositories to keep her vaginal tissues well lubricated. It doesn’t plump the tissues like estrogen will but does provide noticeable support.  A “loading dose” was given every day for two weeks followed by one every other day on-going.

I also recommended a supplement by Metagenics, Estrovera, which is shown to be helpful for hot flashes. It’s also used for sleep and mood issues and anxiety. I added one additional herbal blend, Menopausal Health, by Herb Farm, that includes several general hormone balancers and, importantly for Katherine, Motherwort, which has an estrogenic effect that can be calming for anxiousness and racing heart rates, a symptom she noted.

Follow-up

For a couple of follow-up visits, Katherine continued to note that she was handling her menopausal symptoms well, so we didn’t book any further. I finally saw her again when she was 61 and things had changed significantly. Although I had written a big, bold note in her chart a few years earlier not to talk about HRT, she was now ready to discuss options in detail! All of her symptoms had worsened, partly due to laxity on her supplement regimen but mostly, I think, due to the stress of a recent divorce. Her thyroid level (TSH) was up to 4.2, which increased her fatigue and other symptoms.

At this visit I put her on two caps/day of Thyroid Synergy™ by Designs for Health. She agreed to continue her B vitamins and, because her latest vaginal exam had showed a small amount of vaginal atrophy. I started her on a 1 mg. estriol vaginal suppository. I also referred her for acupuncture. Her general energy “state” is kind of revv’d up which can kind of be a nightmare during menopause. I wanted to get her parasympathetic system engaged and see if we could bring a little more calm. Acupuncture has some promising research for menopause symptom relief. I ordered another round of comprehensive labs.

Follow-up one month later

Katherine’s labs showed low preglenone and low DHEA which are both precursors for all hormones, especially estrogen and progesterone. I put her on 10mg of DHEA and 100 mg pregnenelone – both orally. She also felt like the vaginal suppository wasn’t helping so I upped the dose to 2mg. with a loading dose: once/night for a week, decreasing it to twice/week after that.

Because she still had some hot flashes and was noticing her libido “sucks” we opted for starting HRT to give her more support. To keep any additional costs down I prescribed the Vivelle dot/patch .025mg twice/week which is available through many health insurance plans. It’s basically estradiol and still bio-identical. To note: We describe bio-identical as preparations that contain hormones that are identical to the ones you make in your body. They are not equine-sourced hormones like Premarin which caused a lot of concern, and issues, decades ago. Commercial, non-compounded, bio-identical hormone solutions are available, cost-effective and safe. Katherine also took 100mg progesterone capsules at night for sleep and stayed on this regimen for a couple of months before we increased her Vivelle dosage to .0375 twice/week.

For those still concerned about HRT, I recommend that you have a visit with a knowledgeable primary care doctor, OB/GYN or functionals/integrative practitioner deeply trained in modern approaches to hormone replacement and menopause. They can be hard to find but educating yourself and getting recommendations from your friends/inner circle can uncover the gems. These open conversations are very important! Some of the questions I always ask my patients who are considering HRT include:

- Do you have vaginal bleeding?

- Have you had breast cancer or a history of breast cancer in your family?

- Do you have Deep Vein Thrombosis (DVT) or any clotting disorder? 

-Do you have kidney disease?

-Do you have cardiovascular disease?

-Do you smoke?

-Do you have unresolved uterine fibroids?

What’s it cost?

Office visit: Initial office visit was $550 for a 90-minute visit; first follow-up visit (1 hour) was $200.

 Labs: All labs ordered were in-network and covered by her health insurance.

Prescriptions: All of her hormone prescriptions were covered. Thyroid Synergy ™ $45/month; Estrovera $35/month; Acupuncture costs range per session from $70-100.

Lifestyle: The first line of defense for menopause symptoms is to work on the basics of your lifestyle: sleep, exercise, nutrition and stress reduction. The great thing is that most of these things are free. Commit to getting as much restful sleep as you can. Walk or run daily, on your lunch break, in between meetings, during phone calls with family. Try a free, guided mediation on YouTube or Spotify. Even just 5-10 minutes of quiet, deep breathing at the beginning or end of your day. Put headphones on to drown out any noise. Nutrition can be more complex but make every attempt to ignore the fads and complicated diets. Filtered water. Eliminate packaged snacks and take as much sugar out of your diet as possible. Simplify and don’t let the fads of nutrition give you more stress.