As a reproductive psychiatrist, much of my job is to help patients find a balance between the risks and benefits of treatment options for hormone related mood disorders. Reproductive events such as puberty, the menstrual cycle, pregnancy and the transition to menopause greatly increase the risk of depression and anxiety disorders. Patients may view hormone replacement therapy (HRT) as “natural” and as such, harmless. On the other hand, many physicians are reluctant to prescribe hormones due to the potential to cause harm, as certain hormones are implicated in the development of cancer and cardiovascular disease. The truth falls somewhere in the middle because we know that hormone therapy does carry some risks in terms of cancer, heart disease and stroke. Patients want to have their concerns adequately addressed while being allowed to participate in the decision-making regarding risks and benefits of treatment options.
A thorough risk assessment is necessary to prevent inappropriately prescribed hormones.
Perimenopausal and menopausal symptoms including hot flashes, vaginal dryness, sleep disturbances, depression and anxiety, are a significant health burden that can greatly decrease a woman’s quality of life. Perimenopausal and menopausal symptoms cause some women experience a dramatic decline in quality of life and they may seek out “bioidentical” compounded hormones to feel better. Compounded hormones are custom-made by a pharmacist based on a doctor’s order and are often advertised as being a safer, more effective and natural alternative to HRT. However, these claims remain unsupported by research and there is lack of FDA oversight which may create additional risks regarding safety. In addition, they are rarely covered by health insurance causing a potentially unnecessary financial burden.
Reducing potential harm is necessary as not all hormone replacement options carry the same risks.
While it is not recommended that hormones are prescribed as a preventative strategy for heart disease, diabetes, osteoporosis, or dementia, studies do show decreased rates of these conditions in women treated with transdermal estrogen (a gel, patch, or spray made with the estrogen hormone that is absorbed through the skin). A recent population-based cohort study of more than 900,000 women published in the journal Stroke found that transdermal estrogen therapy did not increase the risk of stroke (1). Oral estrogen was associated with an increase in the risk for ischemic stroke. In addition, 61% of women with menopausal depression will see remission of depressive symptoms following the application of transdermal estrogen (2).
Risk benefit assessment should always be completed along with appropriate screening to ensure that a patient’s preventative care services such as mammography, well woman exam, colonoscopy and bone density exam are up to date. In our practice, we use a decision-making tool to ensure compliance with evidence-based best prescribing practices. The research available helps to inform my go to hormone replacement option of transdermal patches, gels, and sprays (Through the Skin for the Win). While there are many options, in most cases, there is no need for patients to spend large amounts of money for compounded hormones.
For menopausal women who still have their uterus, the hormone progesterone is used along with estrogen for hormone therapy. If taken without progesterone, estrogen increases a woman’s risk for endometrial cancer. Women who have had a hysterectomy (uterus surgically removed) typically do not need progesterone. This is important because estrogen therapy alone has fewer long-term risks than HRT that uses a combination of estrogen and progesterone. Again, reinforcing the importance of a thorough risk/benefit patient assessment. Unfortunately, studies show that progesterone decreases the mood elevating benefits of estrogen. Finding the right dose to protect the uterus without eliminating benefits can be trial and error. Taking the time to track a patient’s symptom improvement or side effects can help guide adjustment decisions and ultimately result in high patient satisfaction and quality of life.
Our practice is dedicated to patient assessment and education as well as thoughtful and careful prescribing practices. For appropriate patients experiencing mood and menopausal symptoms, transdermal hormone replacement therapy can improve quality of life, relieve depression, decrease risk factors for some chronic illnesses and relieve symptoms that interfere with intimacy. We know patients want to feel better and working to relieve symptoms in a safe and responsible way is incredibly rewarding.
Are you interested in learning more about how you might benefit from HRT?
Balance Women’s Health specializes in women’s mood disorders and offers comprehensive evaluations to help you find the balance you seek. Call today at (405) 378-2727 to schedule an appointment with one of our health care providers.
1. Løkkegaard E, Hougaard Nielsen L, Keiding N. Risk of Stroke With Various Types of Menopausal Hormone Therapies: A national Cohort Study. Stroke. 2017;48:2266-2269.
2. Soares CN, Almeida OP, Joffe H, Cohen LS. Efficacy of Estradiol For the Treatment of Depressive Disorders in Perimenopausal Women: A Double-blind, Randomized, Placebo-controlled Trial. Arch Gen Psychiatry. 2001 Jun;58(6):529-34