Ask Dr. Roach: Patient can only obtain a certain HRT with a nontraditional doc

DEAR DR. ROACH >> I am 62 years old and postmenopausal. I am reading more about bioidentical hormones giving added protection to the heart and brain, in addition to helping with hair loss and weight gain. However, it seems that the only way one can obtain these hormones is through nontraditional, functional medicine doctors. I haven’t asked my insurance yet if I can get these, but I’m pretty certain that they will not prescribe these to me. (I will ask on my next visit.)

Can you offer any advice on the efficacy of these hormone replacement therapy (HRT) treatments? It seems past opinions about how HRT could lead to increased cases of breast cancer have changed.

— P.M.

Dear Reader >> You are quite right that our understanding of the relationship between HRT and breast cancer, as well as heart disease, continues to evolve. HRT is approved to treat symptoms of menopause, such as hot flashes.

With increasing frequency, physicians prescribe bioidentical hormones rather than conjugated equine estrogens and medroxyprogesterone, which were tested in large trials. They showed an increased risk of coronary artery disease when given to women over 60 or women who are 10 years past menopause. They also showed an increased risk of breast cancer when they were used in combination.

Researchers believe that human bioidentical hormones confer a lower risk of breast cancer compared to conjugated estrogens. As long as they are given right after menopause, biodientical hormones have a low risk of heart disease. I do not start estrogen for women who are more than 10 years past menopause, due to the increased risk of heart attack. I also do not prescribe any oral estrogen in a woman with a history of breast cancer, and I consult with a woman’s oncologist before using any estrogen, even topical.

You are right that there are some doctors who use custom-compounded hormones, and the dosing may be based on blood levels. I don’t advise custom compounding, as the safety and efficacy is not well-established; the potency is variable; and they are not subject to regulatory oversight. For this reason, when I prescribe HRT, I prescribe the FDA-approved bioidentical hormones that are extensively tested.

Although I frequently prescribe HRT for women with symptoms of menopause, I do not prescribe these regimens for the purpose of preventing heart or brain disease, as we know they have risks (including a small risk of blood clots). Also, the benefit in protection is unproven. Observational trials suggest that there may be a benefit in prevention of heart disease and breast cancer with the newer regimens, but I am very conservative and await strong interventional studies before prescribing treatments to prevent disease.

My colleagues in gynecology tend to have more experience in prescribing HRT. After the release of the large trials, many internists simply stopped prescribing these medications, which is a shame because they remain highly effective treatment for menopausal symptoms. When used properly, they are very safe for most women. However, I have had many readers tell me that they have been unable to find a physician who will prescribe these medicines for their symptoms, even if they are willing to take the risks.


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