Since the Women’s Health Initiative study ending in 2002, there has been an increasing number of studies confirming that bio-identical hormones are safer than, and superior to, their synthetic counterparts. The important aspect of this is not so much the estrogen component, as ‘synthetic’ versions of this are not dissimilar to the body’s own 17beta estradiol, but in the progestin components, which are different in their molecular structure to bioidentical progesterone.
I have found that women respond better to the bioidentical form, with far fewer side effects. Many women have no difficulty in deciding against synthetic hormones, either because of their experience of the contraceptive pill, or because of side effects (very common in women with a degree of ‘estrogen dominance’ – a deficiency of progesterone in relation to levels of estrogen). Others have had no such problems, but are uneasy about the accumulating evidence.
However, for those women already on HRT for menopausal symptoms or bone density problems, there is often a dilemma. They may be uncertain of the effectiveness of the alternatives, and unsure of how to change from one to the other. Their GP may have limited knowledge of these, or even be actively against them. What to do?
Types of HRT
Because there are many different forms of synthetic HRT, it can be somewhat discouraging to women wanting to make the switch. Just to clarify, the main types of HRT are:
1. Continuous combined HRT; where either a patch or tablet containing both estrogen and a progestin such as Femoston Conti, Climest, Premique and Evorel Conti. This type is used straight through a repeated 28 day cycle.
2. Sequential combined HRT; where an estrogen patch or tablet is used to cover the 28 days of a cycle, and a progestin tablet added for the second half of it. A slight variation on this is with the former used only for the first 14 days, then a combined tablet or patch for the second 14 days. Examples of this type are Evorel Sequi, Prempack-C and Trisequens.
3. Estrogen alone HRT; as either patch or tablet continuously, or an implant, prescribed for women who have had a hysterectomy. Examples of this type are Elleste Solo, Estradot, Sandrena and Evorel. Many doctors now believe, however, that these women should be given the same protection as those with an intact uterus, as ‘unopposed’ estrogen also has an unwanted effect on sensitive breast and ovarian tissues.
How to come off your HRT
Whatever the form of HRT, the practical way to come off it is not so difficult as it might first appear. The important principle is to first add bio-identical progesterone, if the HRT is estrogen only, or to replace the synthetic progestin with progesterone if it is combined sequential. I find this can usually be done over one or two cycles of 28 days, rarely more than three, and it significantly reduces both the long-term cancer risk and that of cardiovascular events such as heart disease, stroke and blood clots. In addition it may well improve other factors such as energy levels, depression, anxiety, mood swings and sense of well-being.
Without going into detail for each form of HRT, it is possible to keep the estrogen part going continuously for each 28 day cycle, (eg by using estrogen tablets or patches ‘borrowed’ from supplies for following months), while introducing progesterone or replacing the synthetic progestin with it. In the case of the continuous combined forms, this would mean adding progesterone to the regime for one ‘cycle’ or month.
Some women are able to stop their HRT suddenly prior to going on to their new regime, but in the main these are women who have not previously had severe symptoms, or are using it for bone protection. Those who have had symptoms would be best advised to come off slowly, cutting tablets in half, then spacing them out, according to how they feel.
With patches you can then put a waterproof plaster between your skin and the patch to leave only a small part of the patch in direct contact with the skin so it is absorbing less hormone.
If necessary, it is possible to use the bioidentical progesterone together with the synthetic progestin for a month or so. The two forms act on the same cell receptors, so the natural form will not exert its full effect while this is done, but stores will build up in the body and help to prevent ‘rebound’ symptoms occurring when the progestin is stopped.
Once the situation is stable, attention can then be given to reducing or replacing the estrogen component. As natural bioidentical progesterone can be converted into estrogen in the body, this may be an added source, and women who have been deficient in progesterone may also not need always additional estrogen as the adrenals and fat cells continue to produce it as their ovarian function declines.
If needed, supplementation can be considered in the form of natural estrogen cream, or a bioidentical combination cream such as 20-1, containing both progesterone and estrogen. One could also consider phytoestrogens, supported by Vitamin E, omega fatty acids and a regime of bone support, which will have received a positive boost with the addition of progesterone itself.