When is it too Late to Start HRT?
Recently we received a great question/comment from a listener of our podcast (The Progress Your Health Podcast). I’ll call her ‘Jenny’ (because I never reveal any personal information for the sake of privacy). Jenny was wondering if she is too far into menopause to be able to take bio-identical hormone replacement therapy.
She has been post-menopausal for the last ten years, using an estradiol vaginal insert for her GSU/vaginal atrophy. Her pharmacist thought that changing her prescription and implementing bio-identical hormone replacement could help with her bones, cholesterol, and heart protection. This is an excellent question, as many other women have these same thoughts.
Below is the question from our podcast listener:
I am a healthy and uber fit 60 yr woman who has been menopausal for ten years. My chief complaint is GSM. I have been on 10mcg Vagifem for this entire time, 3-6/week. Well-controlled. My cholesterol is 7! LDL 3.5 / HDL 3.28
I saw a pharmacist who is a BHRT specialist, and she recommends:
.25mg BiEst, 100mg progesterone and +- testosterone depending on levels. She thinks this will balance my hormones better, possibly improve my lipid profile, and protect my heart and bones. Am I too late in the game for BHRT? Do you agree with her suggestions?
What is GSM?
GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. GSM and vaginal atrophy can be used interchangeably. Vaginal atrophy occurs when the estrogen levels drop causing changes in the vaginal tissues. Estrogen really primes the vaginal cells and will maturate them from parabasal cells into mature vaginal cells. When the estrogen drops in menopause, the tissues can become dry, with less lubrication and the tissues can become more fragile. This is where you will find pain or even bleeding (from the tissues tearing) with intercourse.
I like the term GSM, genitourinary syndrome of menopause because when the estrogen drops it can cause so much more than just dry, fragile vaginal tissues. It can cause the flora of the vaginal vault to change. This increases the risk of vaginal infections such as yeast/candida and bacterial vaginosis. It can also cause more increased risk for urinary tract infections. As well as urinary stress incontinence. The urethra (the tube that connects the bladder to the outside world, aka the toilet), can become more lax when the estrogen levels drop in menopause.
This can cause urinary leakage with coughing, jumping, laughing, exercising, sneezing, doing crunches, jogging, walking, you get the drift. GSU/vaginal atrophy can be so mild that women do not even notice any changes. And other women can have such severe symptoms that they cannot even go for a walk without the tissues chaffing and causing pain.
Jenny had been using an estradiol vaginal insert (vagifem) to help with her GSM/vaginal atrophy symptoms and was getting excellent results. Ideally when using an estrogen vaginal application, the estrogen is not supposed to enter the bloodstream and just provide local symptoms relief. In my personal experiences with patients, I have found increased estradiol levels, when only using an estradiol insert.
So while in theory, the estradiol is only supposed to stay localized to the vaginal vault, it could be matriculating into the bloodstream. This is why I usually only use estriol vaginally for GSM. Estriol will not enter the bloodstream and will stay localized to the vaginal tissues. Estriol will also not have an effect on the uterus and cause thickened endometrial lining as you would see in estradiol.
Jenny’s pharmacist recommended adding in bio-identical hormone replacement (BHRT). This is where the questions we get sometimes don’t have enough information. Did Jenny’s pharmacist want to replace her estradiol vaginal insert? Or did she want to add the biest/progesterone/testosterone in addition to the vaginal application of estradiol?
These are two very different scenarios. The biest/progesterone/testosterone BHRT would be a systemic dosing, meaning the goal is to get it into the bloodstream. Biest (which is a combination of estriol and estradiol) would most likely be a transdermal cream/application. As well as the testosterone would be transdermal. Oral dosing of estrogen and testosterone is not well tolerated and puts a burden on the liver and has minimal absorption.
Progesterone can be dosed as a transdermal cream or oral. If a woman has a uterus and is taking any estradiol systemically, she should be taking the progesterone orally. Estradiol can thicken the uterine lining when taken without progesterone. Oral progesterone protects the uterine lining better than the cream form. My point being here, taking the biest/progesterone/testosterone systemically may not be enough to help Jenny’s GSM/vaginal atrophy. The vaginal tissues respond much better to a localized application for GSM.
I have many women taking their progesterone orally and their biest and testosterone transdermally in addition to a local application of estriol to the vaginal tissues. This is where you get the best of both worlds, a solution to the GSM symptoms plus the benefits of system BHRT. Those benefits range from better sleep, improved libido, ceasing hot flashes and night sweats, improved mood and hair/skin to name a few. So I do not think Jenny should replace her vaginal application with the BHRT. But should consider switching to estriol for the GSM.
Is Jenny too old to start BHRT?
The dose that Jenny’s pharmacist recommended was a very low dose of biest. The progesterone at 100mg is a very common dose. I am thinking her pharmacist wanted to start low on the biest and work their way up. It has been ten years since Jenny’s own body was producing hormones. When introducing the hormones after such a length of time can cause side effects. While the .25mg biest is very small, it is a wise choice to start low and slowly increase as needed.
It is much easier to start small and work up, then to overshoot the mark. Like I mentioned, 100mg of progesterone is a common dose. I do not go under 100mg of progesterone if a woman has a uterus to help prevent the lining from thickening when taking estrogen.
So to answer the question, Jenny is not too late to the table for BHRT. But I do think the longer a woman has not had hormones in their body, start small.
Cholesterol and the Hormone Connection:
Jenny mentions her cholesterol is high. Every country has different units for labs and lab values. A total cholesterol level for Jenny should be less than 5 (The U.S. has different units less than 200). Her total cholesterol is high at 7, which she is perplexed by because she is very healthy and a good exerciser.
There could be some familial genetic component at play here. I have lots of female patients who have higher cholesterol than you would expect given their lifestyle and dietary habits. But sometimes that darn genetics can have an influence. Also, the total cholesterol is misleading. What is more important is the breakdown of the cholesterol. Cholesterol is broken down into LDL (low density lipoprotein), VLDL (very low density lipoprotein), Triglycerides and HDL (high density lipoprotein).
The LDL and VLDL are considered the “bad cholesterol”. And the HDL is the beneficial cholesterol, the higher the better. Jenny’s HDLs are good, so having a high HDL can make the total look falsely elevated. I have some female patients whose HDLs are close to 100 (U.S. values), which is astonishing. But it will make their overall total cholesterol look high.
Also like I mentioned, the triglycerides are important to consider here. There is an equation you can do to see if you have insulin resistance. Insulin resistance is a marker for diabetes. You take your triglyceride and divided them by the HDL number. And if it is less than 1.5 you do not have insulin resistance. There are other factors to look at such as blood sugars and fasting insulin levels.
But it is a neat quick equation anyone can do if they have their cholesterol values. For example if someone had a triglyceride level of 130 and their HDL level was 50. 130 divided by 50 equals 2.6. That is looking like a risky factor for insulin resistance should be investigated. But lets say someone’s triglycerides are 100 and HDL is 75. 100 divided by 75 equals 1.333. That looks pretty good.
It is true that hormones, especially estrogen can help keep cholesterol levels down. This is why once a woman hits menopause you will see the cholesterol start to rise. So, yes, Jenny’s pharmacist is right that the hormones could in theory help her cholesterol levels. But as I mentioned above the biest dose is quite small at .25mg that you might not see much of a decrease in the total cholesterol for Jenny.
Other factors that are more important than cholesterol:
There are other factors that are more important that your LDL and total cholesterol. It might be of benefit to run some other testing for Jenny. Really to give her a piece of mind. She is very fit and obviously takes great care of herself, but seems to have more than likely familiar high cholesterol.
Running a LPa (lipoprotein A), Apo-b(Apolipoprotein B), NMR lipoprofile would give us a better insight into if Jenny’s higher cholesterol were really a risk factor for a cardiovascular event.
LPa (lipoprotein A): This is a test that you really only need to do once. It is more of a genetic marker that high cholesterol is going to cause a cardiovascular risk. If it is high then you have a risk factor for cardiovascular disease.
Apo-b (Apolipoprotein b): This helps differentiate if a high LDL level is dangerous. If the Apo-b is high then it is necessary to aggressively work on reducing the LDL cholesterol NMR (nuclear magnetic resonance): this is a lipid subfractionation test. This really breaks down the cholesterol profile to tell you if your cholesterol levels could be a risk.
Jenny mentioned that the BHRT could help her bones. This is true, hormones are very helpful for bone density. That is why when women enter menopause they should get a baseline screening for bone density called a DEXA scan. Because you will see bone density decrease over time with post-menopausal women when the hormone levels are non-existent.
But like I mentioned before the biest dose is pretty small that it might not have an impact on Jenny’s bones. Now one of the best ways to preserve and build bone density is weight bearing exercise. Anything that allows your body weight on the ground. This would be walking, hiking, lifting weights, running. Runners always have good bone density (maybe not great joints long term:/). I would say, the fact that Jenny says she is uber fit must mean she exercises. That right there is helping her bones much more than a low dose hormone protocol.
Hormones: Take or Not to Take?
With the speed of innovation in social media and the internet, there is so much information on hormone replacement, healthy hormone strategies, menopause bellies, supplements, powders, gummies… There is almost too much information out there, making it hard to weed through to see what is beneficial and what is just not. Coming from a doctor that has worked with thousands of women with hormones since 2004, I will tell you, BHRT can have an amazing impact on your life and quality of life.
But it needs to be tailored to you. Because you are not one size fits all. Your hormone goals, lifestyle, genetics, even your personal environment, will have an impact on what your BHRT doses or the type of BHRT would be best for you. I have had women change their jobs, end marriages, get married/partnered, move, become empty nesters, and it changes what BHRT doses and types of hormones they are taking. We are always changing, growing, becoming stronger versions of ourselves. That means our supplements, BHRT and lifestyle change with our growing selves.
If you have any questions, that means many, many other women have the same concerns too. Feel free to reach out and send us a message on, Ask The Dr.
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Episode 052 – What Biest Ratio is Best for Menopause?
This is such helpful information. I have often wondered who 80:20 is good for and who 50:50 is good for.
One thing I'm still confused by is the estrogen weight gain component. You said that estrogen (as well as menopause in general) could be the cause of her weight gain. I can relate. I was very thin my whole life, now 53 and about 30 lbs overweight. But you also said she might benefit from getting her estrogen balanced, and she was not using enough.
If too low a dose made her gain weight, won't an increased dose cause more weight gain? I have heard other podcasts and read articles that in menopause, we gain weight because our estrogen falls. Estrogen seems to be blamed for weight gain, whether it's high or low. Can you help clarify? There's something I'm not understanding. Thank you! Tracy
Often estrogen has been the scapegoat for weight gain. I'm sure you have heard too much causes weight gain. Too little can pack on the pounds. It can be pretty confusing. So which is it? Is too much estrogen causing my pants to become uncomfortably tight? Or is it too little estrogen that has given me the gut I never had?
Well, it’s not that simple. Estrogen levels do have a hand in weight gain and weight loss. But it is not the only variable. It really is the combination of the balance of estrogen with other hormones in your body. To name a few main players, progesterone, insulin, and cortisol, as well as enzymes, lipoprotein lipase (LPL), and hormone-sensitive lipase (HSL). Okay, I know that sounds vague and doesn't answer the question. Let's back up a bit and look at what women are saying about estrogen.
As soon as menopause hits, women complain that they are instantly 15-30 lbs heavier. Not because of diet or lifestyle. It's like menopause adds an unwanted 15-30 lbs overnight. Then some women are on hormone replacement therapy, taking estrogen, and are horrified because the HRT caused them to gain 10 lbs in a month. So what is it? Did the lack of estrogen in menopause cause that 20 lb weight gain? Or did that hormone replacement estrogen create rolls that were never there? Well, actually, both are true. Before you throw out your jeans in favor of high-waisted yoga pants, let’s learn about the other players in weight gain.
Progesterone will buffer estrogen. Estrogen does like to grow things'. That is why in puberty, you grow breasts and hips. Progesterone helps to balance some of the growth' that estrogen can cause. That is why in perimenopause, when the progesterone drops and the estrogen is running the show, the weight gain begins. That is also why when a woman starts estrogen therapy for menopause but not enough progesterone, there is weight gain.
‘Doc, I really don't feel like myself. I think it's my hormones. Could it be my hormones? Can you test my hormones?'
How many times have I heard new clients tell me this story? They go to see their GP, Gyno, or Internist, asking to have their hormones tested. Only to be told that there is no testing for hormones. Or that it's not necessary to test hormones. Only to leave feeling dismissed, with no answers to why they do not feel well.
While I understand that your GP, Gynocologist, and Primary Care Physician are not the jack of all trades,’ there are many tests for hormones. There are blood tests, urinary testing, and even saliva testing. The more difficult part of hormone testing is the interpretation. The basic lab values assigned by the labs are very vast, and without experience and training, it can be quite difficult to determine if there is a hormone imbalance.
If you are feeling like you have a hormone imbalance or having symptoms concerning your hormones, below is a list of common hormones to be tested and why. Because blood lab testing is so popular, I am going to stick to blood testing. Later we will have more labs and interpretations for urine and saliva.
To start, blood testing is just a look at one moment in time with respect to your hormone levels. In a menstruating woman, her hormone levels are changing every day. But in a menopausal woman where the ovarian function has ceased, her hormone levels are going to be pretty level day to day. So in a female that is still having her period, I like to try and aim for getting the blood drawn around day 12 and/or day 21. In a 28-day cycle, the estrogen will surge around day 12, and the progesterone will surge on day 21. This can give us better insight into her levels of progesterone and estrogen. In a menopausal woman that has not had a period or has sporadic periods with common menopausal symptoms, I will have her draw her blood any time of the month.
FSH and LH:
FSH stands for follicle-stimulating hormone, and LH stands for luteinizing hormone. These are not actually hormones. They are stimulating hormones.' Meaning both the FSH and LH are released from the pituitary gland (in your brain) in response to estrogen and progesterone production. The FSH and LH work in what is called a negative feedback loop.’ Meaning if the levels of estrogen and progesterone are high, then the FSH and LH are low. In turn, if the estrogen and progesterone levels are low, then the FSH and LH are high. It is like when you want your husband to take out the garbage. If he doesn't, you might raise your voice until he does. It is the same with all stimulating hormones. If the ovarian production of hormones is low, as in menopause or perimenopause, the FSH and LH levels will look high.
Estradiol and Progesterone:
Always test estradiol to get specific results for estrogen levels. Estradiol is much more specific for estrogen levels than simple total estrogens. Ideally, in a menstruating woman having the blood test around day 21 will give you insight if that woman is ovulating. It will so give you insight if there is progesteron