What is Hormone Replacement Therapy?
As we age our hormone levels decline, and as a results we begin to feel more tired, get sick more frequently, we do not heal as fast and slowly chronic disease like hypertension, high cholesterol, depression and weight gain, to name a few, makes its debut. We start to age and sometimes it happens very rapidly.
Hormone replacement therapy (HRT) is a method of treatment based of replenishing the vital sex hormones like estrogen, testosterone, or progesterone with either plant based substances, or synthetic hormones that have an identical structure as the hormones naturally produced by the body.
This is very different than using synthetic hormones like Premarin – a mix of 17 different types of equine estrogens, a drug synthetically produced by Wyeth –Aerst from pregnant mares urine.
Many patients mistakenly believe that bio-identical hormones are only available as a customized compounded prescription, however there are many bio-identical FDA approved synthetically made hormones, in the form of patches, gels, vaginal creams or tablets, or pills.
When you come in for your appointment you should expect Dr. Cernaianu to gather a detailed personal and family history and perform a comprehensive physical exam, determining the need for bio-identical hormone use.
Are there any risks associated with the use of Hormone Replacement Therapy?
- Taking daily hormones for extended periods of time (10-20 years) might increase your risk of Cancer.
- Uterine cancer – taking estrogen and progesterone and following your physician’s recommendations does not increase the risk of uterine cancer, but it can increase risk of abnormal vaginal bleeding. Any vaginal bleeding after menopause could be a sign of uterine cancer, so it will need to be investigated with further testing, possibly a pelvic ultrasound or a biopsy of the lining of the uterus, sometimes even with a hysteroscopy (a procedure performed usually under anesthesia, when a camera is introduced into the uterus, and a curettage of the uterus is done or polyps are removed). These tests can be costly and painful. Estrogen therapy alone can increase the risk of uterine cancer. Not taking progesterone as recommended or prescribed by your doctor can increase risk of uterine cancer.
- Ovarian Cancer is not usually linked to Hormone Replacement. It is a rare cancer so it is harder to study, but there have been some reports of minimally increased risk. To put the risk into numbers, if 1,000 women who were 50 years old took HRT for 5 years, 1 extra ovarian cancer would be expected to develop.
- Breast Cancer Based on the WHI study, taking Estrogen-Progesterone therapy is linked to a higher risk of breast cancer. The longer HRT is used, the higher the risk. The risk returns to that of a woman who never used HRT (baseline risk) within 3 years of stopping the hormones. Breast cancers in women taking HRT are more likely to be found when they are bigger and have spread beyond the breast (http://www.cancer.org/cancer/cancercauses/othercarcinogens/medicaltreatments/menopausal-hormone-replacement-therapy-and-cancer-risk). To put the risk into numbers, if 10,000 women took HRT for 1 year, it would result in up to about 8 more cases of breast cancer per year than if they had not taken HRT. Taking HRT is also linked to increased breast density, which can make it harder to find breast cancer on a mammogram. Estrogen therapy alone does not increase the risk of breast cancer, and in certain women (those with no family history or those without a history of benign breast disease) it can actually lower the risk of breast cancer.
- HRT does not seem to have an effect on skin cancer, lung cancer or colorectal cancer (it might decrease colorectal cancer risk).
- Taking hormones daily may increase your risk of clotting and thromboembolic events (a piece of the clot formed in the deep venous system of the legs breaks away and travels to the lungs, which is life-threatening). In most studies that analyze the relationship between venous thromboembolism and HRT, the route of hormone administration has been primarily oral (estrogen pills). It has been proposed that orally administered estrogen may have a pro-thrombotic effect related to high concentrations of estrogen in the liver. Studies that compared oral and transdermal Estrogen have demonstrated that transdermal estrogen has little or no effect in increasing clotting risk and may actually have beneficial effects on pro-inflammatory markers, including C-reactive protein, and it may also have a suppressive effect on tissue plasminogen activator antigen and plasminogen activator inhibitor activity.
There is adequate evidence in the medical literature that natural progesterone is not associated with an increased risk of venous thromboembolism, but synthetic progestins (eg, Provera) do increase the risk of clotting.
The relative risk of clotting in women who take Estrogen seems to be even greater if the patient has preexisting risk factors such as obesity, immobilization, fracture, increased age and underlying coronary vascular disease. Women with prothrombotic mutations, such as Leiden factor V, G20210A prothrombin mutation, protein C and protein S deficiencies, and other congenital thrombophilic disorders have higher risk of venous thromboembolism.
Are there any side effects associated with Hormone Replacement therapy?
Estrogen replacement can cause the following side effects:
- vaginal bleeding
- breast engorgement
- breast tenderness
- water retention
- weight gain
- bloating or nausea
- darkening of the skin
- worsening of endometriosis
- growth of fibroids.
Progesterone replacement can cause some of the following side effects:
- digestive symptoms such as upset stomach, vomiting, constipation
- feeling sluggish
- mood swings and irritability
- excessive worrying
- weight gain
- breast tenderness
Testosterone therapy in women can have the following side effects:
- excessive hair growth on the face or other areas of the body
- hair loss on the scalp
- oily skin or acne
- hoarseness of deepening of the voice
- fluid retention
- increased size of the clitoris
Why should I take Hormones? Are there any benefits to using Hormone Replacement Therapy?
Each patient has a different reason for starting HRT. The purpose of the individualized comprehensive evaluation with Dr. Cernaianu is to determine if there are any benefits of taking HRT, whether there are risks, and if the benefits outweigh the possible risks.
Most common reasons why HRT should be considered would be:
Hot flashes and night sweats
Depression and Irritability
Poor memory and lack of focus
Weight gain or difficulty loosing weight
Loss of muscle mass
According to www.menopause.org :
“There is no single way to ensure the best possible quality of life around menopause and beyond. Each woman is unique and must weigh her discomfort from lack of hormones against her fear of treatment. Risk is defined as the possibility or chance of harm; it does not indicate that harm will occur.
Generally, HRT risks are lower in younger women than originally reported for all women (ages 50-70). It is now believed that women taking estrogen alone (such as women who have had their uterus removed by a hysterectomy) have a more favorable benefit-risk profile than those taking combined Estrogen/Progesterone . This is especially true for younger menopausal women (in their 50s or within 10 years of menopause) than for older women.
Medical professionals have modified their views about the role of hormones as more research has been conducted. Experts agree that there is much they still have to learn. Although recent studies such as the WHI have provided some clarity for large populations, they don’t necessarily address all of the issues an individual woman faces. Only she, with the counsel of her physician, can do that.
Many factors will be part of a woman’s decision to use a particular hormone product—her age, her risks, her preferences, available treatment options, and the cost of the product. Do her potential benefits outweigh her potential risks? Only after examining and understanding her own situation and after a thorough consultation with her physician can a woman make the best treatment choice.”
What types of Hormone Replacement Therapy are available?
- Estrogen is available by mouth as a pill, transdermal in the form of a gel, patch, pellet or a compounded cream, and vaginally as a cream, ring, or suppository.
- Progesterone is available by mouth as a pill, compounded capsule, and transdermal as a compounded cream.
- Testosterone is available transdermal in the form of a compounded cream, gel or pellet, and injectable for men.
All the above are bio-identical hormone products not be confused with synthetic hormones who differ in structure from our own hormones. The most commonly used synthetic non bio-identical hormones are:
Premarin (a mix of multiple different type of equine estrogens extracted from pregnant mares urine) Cenestin (a combination of 9 synthetic estrogens derived from plants) or
Enjuvia ( a mix of conjugated estrogens)
Medroxyprogesterone acetate – Provera
Methyl- testosterone in the patch Estra-test
Testosterone cypionate injected in the muscle
The concern about the use of bio-identical hormone therapy is really about custom-compounded recipes prepared by a pharmacist following a doctor’s order for a specific patient. These medications do not have FDA approval because individually mixed recipes have not been tested to prove that the active ingredients are absorbed appropriately, or provide predictable levels in blood and tissue. There is no scientific evidence that these natural compounded medications are safer or more effective than government-approved hormones, however they work well and many women feel significant improvement and relief from daily use of compounded hormones.
Please read the position of the Endocrine Society regarding the use of bio identical hormones, by clicking here: http://www.menopause.org/docs/default-document-library/bioidenticalht_endosoc7FEEC6FE637F.pdf?sfvrsn=2
There is no clear scientific evidence that salivary testing is superior over blood testing, plus it is very costly and not covered by insurance; at HERA Health Care we normally reserve salivary testing for adrenal hormones.
What is pellet therapy? What is sottopelle?
Sottopelle therapy consists in injecting pellets of bio identical estradiol and testosterone into the upper hip area, a simple procedure that is done under local anesthesia and takes 5 minutes.
The advantages of pellet therapy as opposed to other methods are:
- It is very convenient – no need for daily creams or pills or weekly patches – it is done every 3-4 months for women and every 6 months for men.
- It achieves steady state levels of hormones in the blood as opposed to other therapies (pills, creams and patches) that go through peak and trough levels, so pellet therapy is much more effective for resolution of fatigue, mood issues and does wonders for the libido as some patients’ testimonials indicate.
- It is the only method that is essentially bio available, since the body can regulate the rate of delivery from the pellet based on the heart rate (faster heart rate caused by exercise or stress will release more hormone, and slower heart rate when sleeping or meditating will release less hormones). All the other methods – pills, patches, creams – are not bio available since the body itself has no say in when it gets the hormones, and the method of delivery has to be used either daily, or 1-2 times a week in case patches are used.
The disadvantages of pellet therapy are:
- It is a procedure that carries certain risks, even though theses risks are minimal – for example: pain, bruising, swelling and soreness at the insertion site that lasts up to a few weeks, and risk of expulsion with excessive physical activity immediately after insertion.
- Once inserted the pellets cannot be removed, since they are located about 2 inches away from the small incision site, under the skin
- It is not covered by insurance and each insertion will cost $350 - $375 for women and $750-$775 for men. Insertions are done every 3-4 months – 3 times a year.
For more information about sottopelle therapy please go to: www.sottopelletherapy.com
The decision to use a certain type of hormone depends on patient preference, risks and benefits profile, goals, fears and misconceptions, and last but not least cost.
At HERA Health Care we believe in avoiding hormones that are different in structure than the one produced by the human body, so Dr. Cernaianu uses only bio-identical hormones.
The choice for a certain type of Hormone Replacement Therapy belongs only to the patient, and we encourage our patients to ponder the risks and benefits, and how a certain method can help or perhaps aggravate other medical issues, and we initiate therapy only after all the information regarding hormone use risks and benefits has been discussed, and all questions have been answered to the patients’ satisfaction.
Is Dr. Mirela Cernaianu trained and knowledgeable in bio identical hormone replacement therapy or HRT?
Dr. Cernaianu specializes in bio-identical hormone replacement therapy. She completed extensive training in the science of balancing hormones, including thyroid and adrenal support, by graduating from the Fellowship in Anti-Aging and Regenerative Medicine, and becoming a Sottopelle trained physician. Dr. Cernaianu is Board Certified in Obstetrics and Gynecology.
At HERA Health Care we perform thorough examinations, we order routine and specialized lab testing prior to creating personalized treatment plans, we encourage our patients to ask questions and we empower them to become educated before making any decision.
The information presented here is meant to be informative and educational only, and by no means replaces your doctor’s advice or recommendations.
Once I decide to use hormone replacement therapy how often do I need to come see the doctor?
Regular follow ups are required to determine whether the therapy works, whether there are any side effects and whether the benefits justify the risks or side effects, and how we can mitigate the side effects. Compliance with recommended follow up appointments ensures you are safe and healthy, as are being up to date with all necessary medical tests like pap smear, mammogram, osteoporosis screening, annual physicals, cholesterol check etc.
Is my health insurance going to pay for my hormone replacement therapy, office visits or medical tests?
Like most doctors’ offices we expect that your copay will be paid promptly at the time of your visit. For certain insurance plans like Cigna, Aetna, Blue Cross and Blue Shield we can check some of the patient’s benefits online at the time of the visit, but ultimately it is your responsibility to check and verify your benefits prior to the visit. We also have no information regarding your medication benefits at the pharmacy, but we do have a general idea of how much compounding hormone medications should cost. Please contact your insurance plan to help you determine what your cost will be for medications.
We also offer discount prices for medical testing through Quest Diagnostics or PDL for patients who do not have insurance, have a high deductible or a Kaiser plan. We do not know whether or not the blood tests required to follow up your hormone replacement therapy are going to be covered – please call your insurance plan for questions. We can provide the diagnostic codes that pertain to your symptoms and medical condition, but any questions regarding your bill for any lab test (except prepaid tests) will have to be directed to the lab you used - our office does not handle billing issues regarding your lab tests.