As a doc I know that when it comes to something as important as my transition, I sought out an expert, an endocrinologist that's been treating trans women for 30 years, and this is what he had to say on this very subject:
[The Annals of Internal Medicine on menopausal hormone therapy (HRT). Not a new study but a review of previous ones by data analysts from the U.S. Preventive Services Task Force (USPSTF), it painted a bleak picture of HRT whose benefits seemed limited to a diminished risk for osteoporotic fracture at the cost of increased risks for gall bladder disease, stroke, heart disease, potentially fatal lung clots and perhaps even breast cancer and dementia. This is not the first time this federal body has weighed in on the subject of HRT having made recommendations against it back in 2001 and 2004 after damaging reports by the "landmark" Women's Health Initiative Study (WHIMS) had been loudly and prematurely publicized, driving thousands of eligible women to needlessly abandon or avoid any forms of HRT.
The WHIMS examined the influence of one particular estrogenic product Premarin, containing some thirty different hormones, many of them equine and some of unknown nature, taken alone or in conjunction with a highly atypical synthetic progestin called Provera, which is about thirty times more potent than natural progesterone, in a one size fits all trial of hormones versus placebo. The patients involved in this study were poorly chosen having already spent more than a decade post-menopausal, so that the damage had already been done, and close to half of them switched from the hormones they were supposed to take without this being taken into account, during the course of the study. Other factors influencing their already compromised health such as obesity, alcohol consumption, and smoking were not accurately considered and the hormones being given were delivered by mouth so that they must first pass through the liver before reaching their target organs, a far from natural process.
Numerous follow up reports and recommendations have since been spawned from this ill-conceived, poorly executed study so irresponsibly publicized that, instead of oral Premarin and Provera solely being condemned, all forms of menopausal HRT, oral or otherwise, were dismissed out of hand. Now the USPSTF has entered the fray once again, using data largely derived from the WHIMS and related studies dealing with oral Premarin and Provera. The easiest way to make sense out of all this is by looking at the individual health outcomes that matter, whether for better or for worse.
Heart disease, the premier killer of women is far more lethal and frequent than breast cancer. Prior to menopause the natural ovarian hormones greatly reduce its risk but after menopause it skyrockets. When non-oral estradiol, the natural estrogen of women, is given to castrate female primates in adequate doses it greatly reduces heart disease compared with placebo, as it well should, given what we know scientifically about its mechanisms of action. Prempro studies failed to reproduce this result because equine estrogens cannot be converted into the crucial active byproduct of estradiol which naturally protects women from heart disease prior to menopause. Thankfully many modern physicians, particularly in Los Angeles today treat the menopause with non-oral estradiol and when its levels are adequately generated and stably maintained heart disease can be naturally prevented.
Another major concern of HRT is the risk for clots, to the legs, the lungs and the brain, leading to stroke or even sudden death. It is the liver first-pass that fuels this problem but whereas oral hormones augment these serious risks, the same is not true of nonoral estradiol, which can be delivered effectively using the modern Dot Matrix estradiol patch, a reliable, FDA approved platform, which, by the way is truly "bioidentical." In contrast, compounded forms of "Bioidentical Hormone Therapy" (BIHT) offer an unstable, erratic delivery platform for estrogen delivery which clearly disqualifies them from this preventive role. And the progesterone creams its purveyors have so popularized through clever marketing ploys tend to sequester under the skin, fueling depression and weight gain in a chemical manner while failing to be reliably delivered to the uterus for endometrial cancer prevention.
Gallbladder disease and elevations in triglycerides are also boosted only by oral forms of hormone therapy and are not a problem with nonoral estradiol. The concerns of this report about dementia are equally ill founded. The studies in question focused on loosely evaluated and defined cognitive dysfunction rather than actual, accurately identified dementia. Some degree of cognitive dysfunction is frequent in menopausal women relating to the use of antidepressant drugs, sedatives, alcohol use and even relating to depression in and of itself. The premise whereby hormone therapy might prevent or reduce dementia and depression is by increasing brain levels of estradiol. But oral equine estrogens paradoxically reduce brain estradiol levels rather than increasing them, by virtue of reducing hormonal access to the brain. In contrast, non-oral estradiol raises brain estradiol levels.
This leads us to the topic of breast cancer, the greatest fear of menopausal women. Now in the WHIM study even oral Premarin reduced rather than increased breast cancer when given without Provera. Provera seemed to be the only hormonal cause of an increased risk but this progestin is highly atypical whereas natural progesterone, particularly when given vaginally so as to minimize access to the breasts should not pose a threat. Finally the administration of estrogen and progesterone to women inadvertently reduces their levels of testosterone. Low-dose nonoral testosterone therapy can then be of great benefit by further reducing or reversing osteoporosis and physical aging, reversing depression and perhaps dementia and even reducing breast cancer risk to a further degree.
The results of HRT studies over the last ten or so years may be justifiably critical of oral equine estrogens used with one particular progestin but it does not follow that non-oral natural estradiol and progesterone need to be avoided, indeed they offer a potent, user-friendly natural form of preventive health care in women. And by this I do not mean "bioidentical Hormones". BIHT is a loose marketing buzzword used after the WHIMS scare, to exploit the vacuum it created. The estrogens it offers were never tested, measured or evaluated, and they appear to be a highly erratic platform for estrogen delivery, thus eliminating its benefits. Menopausal HRT can be a boon to the modern women, without putting her at breast cancer risk. In fact over the last 25 years while treating menopausal women with estradiol, progesterone and low-dose testosterone in a sophisticated and precise manner, I have not seen a single case (touch wood) of breast cancer complicating this treatment. To sum up, it's fine when bean counters count expertly, but they also need to know their beans.
