Understanding Menopause Hormone Therapy: HRT and BHRT

Decoding Female Reproductive Hormones:

Our bodies are wonderlands of hormonal activity, acting as the body’s chemical messengers. Estrogen and progesterone are the stars of your menstrual cycle and much more.

Estrogen does more than just make intimacy comfortable by keeping vaginal walls thick, elastic, and lubricated. It is important for your bones, muscles, organs, circulation, skin, hair, blood sugar, and cholesterol levels.

The ovaries produce two main estrogens: estrone (E1) and estradiol (E2). Other tissues, such as muscle, fat, adrenal glands, and the brain, also produce smaller amounts.

E2 is the main estrogen for pregnancy, needed for releasing eggs and getting the uterus ready for pregnancy.

Progesterone, produced when you ovulate, supports estrogen by preparing the uterus for pregnancy. It also aids in breast growth and regulates estrogen’s impact on the uterus lining (endometrium), which is shed during periods.

Low progesterone leads to too much growth of the uterus lining, causing irregular and heavy menstrual periods and possibly uterine cancer. Progesterone also influences sleep, mood, and blood pressure.

The Impact of Menopause:

As we get older, the body’s natural hormone production changes. After menopause, the ovaries stop producing E1, E2, and progesterone hormones.

This decline in estrogen and progesterone directly cause menopause symptoms like hot flashes, night sweats, vaginal pain, mood changes, sleep problems, cognitive changes, and risks to bone and cardiovascular health. That’s where menopause hormone therapy (MHT) comes in.

What’s in a Name? HRT vs MHT:

You may have heard of HRT or hormone therapy (HT). Well, there’s a new term on the block – menopause hormone therapy (MHT).

Why the change? It’s all about understanding menopause better. MHT accepts menopause as a natural stage and helps with its symptoms, unlike HRT which sees it as a problem.

Understanding MHT Options:

MHT is the gold standard¹ for menopause symptoms. It is safe for most individuals who are under 60 years old or within 10 years after their last period. Many studies² have proven its effectiveness.

More on the safety of MHT in another article to come.  At the same time, it is not a one-size-fits-all solution.

HRT vs. BHRT vs. Compounded BHRT:

It can be so confusing, but let’s try to simplify it.

HRT are pharmaceutical company-manufactured hormone therapies and some contraceptive pills that use urine of pregnant mares.  These hormone therapies are regulated by Health Canada for quality and safety. This type of hormone therapy does not mimic your own body’s production of hormones exactly but is close enough to be impactful in symptom management for women.

The term “bioidentical”, in BHRT can be misleading. For clarity, there is no bioidentical source that is “straight from nature”. All forms of hormone therapy are manipulated in a lab, to mimic the structure of hormones in our bodies. Bio-identical hormone therapies use phytoestrogens found in plants, such as soybeans and yams.  These phytoestrogens structurally mimic those naturally produced by the body.

BHRT includes both Health Canada approved pharmaceutical company-manufactured and compounded bioidentical hormone therapies from a compounding pharmacy.

Compounded BHRT is a custom-mixed formulation prepared by compounding pharmacists per a healthcare provider’s prescription. While these therapies offer customization of multiple hormones (estradiol, estrone, estriol, DHEA, testosterone, progesterone), they lack the extensive testing and regulatory oversight of commercially available pharmaceutical company-manufactured ones. Note, in Canada the government does place strict protocols and guidelines on compounding pharmacies.

You can easily tell whether the BHRT is pharmaceutical company-manufactured versus the compounded, by the package inserts or lack of them.  Pharmaceutical company manufactured BHRT contains extensive product information and may even include black-box warnings for any potential adverse effects from the medication.

Compounded BHRT offers an option for those allergic to ingredients found in pharmaceutical company-manufactured hormone therapies or for individuals requiring dosages not available in these products.

Systemic MHT vs Local MHT:

Understanding the different types of hormone therapy, including systemic MHT and local MHT, is important. Systemic MHT goes through blood and affects whole body. You can take it as oral tablets or apply it transdermally in creams, patches, or gels.

Local MHT focuses on treating vaginal dryness by directly targeting the vagina. You can apply or insert it in the vaginal area using creams, rings, or tablets.

Forms of Estrogen and Progesterone in MHT:

MHT includes various estrogen formulations, from synthetic conjugated equine estrogens (CEE) to the synthetic forms like ethinyl estradiol to plant-derived micronized 17β-estradiol ones. Estrogen can be administered orally, transdermally, or locally.

Women without a uterus can use systemic estrogen without needing progesterone supplements.

Progesterone is needed if you have a uterus because using estrogen alone for menopause symptoms can raise the risk of uterine cancer. It is important to note that if you do not have a uterus, this risk does not apply to you.

To reduce this risk, individuals take a progestogen (which is a general category that includes synthetic progestin and plant-derived micronized progesterone) with a systemic estrogen in MHT. If you are unable to take progestogen, there is an alternative called bazedoxifene³, which is a selective estrogen receptor modulator (SERM), not a hormone.

Progestins, a class of progestogen drugs that are manufactured by pharmaceutical companies, examples of these include medroxyprogesterone acetate and norethindrone acetate. The chemical structure of synthesized progestins is not the same as that of a plant-derived progestogen. This structural difference has a different impact on the way these progesterone-like molecules affect our bodies.

For instance, progestins are more effective at managing irregular bleeding. However, they do not provide the same benefits as plant-based progestogen in terms of sleep quality improvement. This distinction is critical when considering the overall impact of hormone-like treatments on health and well-being.

This highlights the significance of personalized hormone therapy during menopause.

Differences between HRT and BHRT for Menopause:

HRT means estrogen drugs regulated by Health Canada. They are synthetic hormones and not the same as systemic hormone therapy.

Health Canada regulates the pharmaceutical companies’ production of these estrogens for birth control and menopause symptom treatments.

What sets them apart is their variation in chemical structure compared to the estrogens naturally produced by your body. Small differences in their structure affect how your body breaks down, absorbs, and eventually eliminates them.

Bioidentical hormone replacement therapy (BHRT), takes a different approach, utilizing hormones derived from plants. These hormones are similar to the ones produced by the body. However, they are not identical to a person’s own hormones.

These hormones, often called “natural,” are changed in a lab at the pharmacy, making them no longer fully natural. Custom-compounded BHRT tailors it to an individual’s needs.

However, Health Canada⁴ does not regulate BHRT, as they do not go through the same approval process as regular drugs.

Making the Right Choice:

Selecting the most suitable MHT involves considering your health history, symptom profile, and preferences. Consulting with healthcare professionals experienced in menopause management is crucial to navigating this decision-making process effectively.

References:

1. NAMS Position Statement The 2022 hormone therapy position statement of The North American Menopause Society Menopause. The Journal of The North American Menopause Society 2022; 29, No. 7, pp. 767-794
2. Lee S R, Cho M K, Cho Y J, et al; The 2020 Menopausal Hormone Therapy Guidelines. Journal of Menopausal Medicine 2020; Aug 31 26(2): 69-98
3. Raina P, Patel P, Parmar M; Bazedoxifene. National Library of Medicine Stat Pearls 2024; February 28
4. Health Canada. Policy on Manufacturing and Compouding Drug Products in Canada (POL-0051) 2009; January 26