2015-1 Hormone Replacement Options for Men and Women

If your levels of hormones are low you may be considering some hormone replacement options and want to know the pros and cons of each.
There are several options available and the two most important hormone replacement options are the route of administration and the form or type of hormone used, which I will explain below.

Hormone Replacement Options by Route of Administration

The way you take a hormone can affect the absorption and blood levels, and can have different side effects. The most common forms are outlined below.

Oral – Some hormones can be given orally or by mouth, which is convenient and easy. However some cannot be given this way because they are broken down by stomach acid. Those that are absorbed go to the liver first before getting to the bloodstream and tissues. The liver metabolizes or changes the hormone leaving less active ingredient, so doses have to be higher. This is called first pass effect. There can be side effects to oral administration and some oral hormones can inflame the liver and increase the risk of gallbladder stones.

Estrogen given orally can inflame the liver, increase the risk of gallstones and form clotting factors. The clotting factors cause platelets to stick to plaque in the arteries which eventually break off, increasing the risk of heart attack and stroke. Blood clots can form anywhere and break off. This is known as VTE or venous thromboembolism. The liver also increases the level of a protein called Sex Hormone Binding Globulin (SHBG) that binds hormones like estrogen and testosterone and makes them less available to the tissues. Only free, unbound hormone can have an effect. Better hormone replacement options for estrogen would be applying it to the skin to minimize these side effects and allow more hormones to be available to the tissues at a lower dose. You may come to the conclusion when reading the studies quoted below that this is a better hormone replacement option.

Injections are hormone replacement options that are best used for hormones that cannot be administered orally or through the skin such as insulin, human growth hormone (HGH), and human chorionic gonadotropin (HCG).

Testosterone is often given by injection and was at one time the only route of administration. The advantage is less frequent administration such as weekly to monthly injections. However, this can result in mood swings from high levels at the time of injection and depression and irritability as the injection wears off. The more frequent the injection, the less dramatic the mood swings. Frequent injections are inconvenient. Better hormone replacement options are to give testosterone through the skin in cream or gel form to keep levels stable and to avoid some of the side effect such as increased red blood cell count, acne and enlarged breasts.

Topical application is a hormone replacement option that has become more popular due to the ease of applying them and the ability to control the dose. The major drawback is transmitting the hormone to others, which can be overcome by covering the area that you apply hormone to and not rubbing up against anyone for at least an hour or two after applying them. Estrogen, progesterone, DHEA, cortisone and testosterone can be given topically.

Progesterone can be given topically, however a beneficial side effect of oral administration is a calming effect since the liver metabolizes progesterone to allopregnanolone, which acts on the GABA receptors in the brain to calm the nervous system. Therefore giving progesterone orally is a better hormone replacement option for women who have a lot of anxiety.

Hormone Replacement Options by Form for Women

There is and always will be a debate regarding the safety and efficacy of bioidentical hormones and synthetic hormones, especially for women who are concerned about the risk of heart disease and breast cancer. The same is true for men. Male hormone replacement options will also be reviewed.

There are many large scale studies on synthetic hormones and some on bioidentical hormones. The Women’s Health Initiative (WHI) is an old study that used high dose, oral, synthetic hormones on women whose average age was 63 and 10 years post menopause. The hormones used in that study were the most common hormone replacement options at that time. The findings were that the risk of stokes and heart attack was higher in women who took those oral hormones. Because of that, it scared many a doctor from prescribing hormones and many patients from taking them. Here are the conclusions of some other hormone replacement options cited in the studies:

Studying the effects on different routes of administration and forms such as synthetic versus bioidentical hormones and topical versus oral, led to different conclusions. Studies indicate that topical estrogen and oral natural, bioidentical progesterone may be better hormone replacement options.

Kenneth Holtorf, MD reviewed the literature and published The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? The conclusion: “Physiological data and clinical outcomes demonstrate that bioidentical hormones are associated with lower risks, including the risk of breast cancer and cardiovascular disease, and are more efficacious than their synthetic and animal-derived counterparts. Until evidence is found to the contrary, bioidentical hormones remain the preferred method of HRT. Further randomized controlled trials are needed to delineate these differences more clearly.” In other words, the author after comparing and studying the literature found that bioidential hormones were safer hormone replacement options.

Another published study stated bioidentical hormones with estrogen given topically and progesterone given orally are more beneficial hormone replacement options. HRT optimization, using transdermal estradiol plus micronized progesterone, a safer HRT. Giving estrogen topically decreases the risk of clots, embolism, and stroke and gallbladder disease. Bioidentical progesterone had positive effects on decreasing blood pressure, clots and embolism and even breast cancer.

There are more and more studies that are newer than the old Women’s Health Initiative study that scared many women from taking hormones. This study: What's new in hormone replacement therapy: focus on transdermal estradiol and micronized progesterone, also came to the conclusion that: ”The use of transdermal estradiol (topical bioidentical estrogen) and micronized progesterone (natural bioidentical progesterone) could reduce or possibly even negate the excess risk of VTE (venous thrombotic embolism which are clots that break off and clog arteries causing heart attack and strokes), stroke, cholecystitis (inflammation of the gallbladder), and possibly even breast cancer associated with oral HRT (hormone replacement therapy) use.” The authors clearly determine these to be better hormone replacement options.

Another quote from the above mentioned study is: “Guidelines from the North American Menopause Society, the Endocrine Society, the International Menopause Society, and specific guidelines from the European Menopause and Andropause Society for the management of menopausal women with a personal or family history of VTE all contain positive statements regarding both transdermal (topical or through the skin) estradiol and micronized progesterone.” Even the menopause societies had good things to say about using topical estrogen and bioidentical progesterone as good hormone replacement options.

The list of studies goes on and on. The review article “Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review, “came up with different conclusions from the Women’s Health Initiative. They challenged the premise of that study and looked at reviewed other studies and their conclusion was that the risk of clots and liver and gallbladder disease with topical estrogen was negligible and natural progesterone has a favorable effect on the blood vessels and brain and may even confer less or no risk of breast cancer.

This study: “Postmenopausal hormone replacement therapy and cardiovascular disease: the value of transdermal estradiol and micronized progesterone,” found that this combination protected the heart and decreased the risk of new onset diabetes. It was recommended as a better hormone replacement option.

This review “Hormone replacement therapy in women with breast cancer. Do the risks outweigh the benefits,” concluded that when it comes to breast cancer, in healthy postmenopausal women, the benefits associated with estrogen replacement therapy/hormone replacement therapy, outweigh the risks

Even thought the press focuses on the negative, sensational studies that are still using the same study population from the Women’s Health Initiative, there are more and better hormone replacement options and studies that evaluated their safety. By reading some of the other studies, that used more updated treatment regimens, you can formulate your own opinion.

Hormone Replacement Options for Men

Women were encouraged to stop taking hormones after the WHI study and now men are encouraged to do the same because of this study, “Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels.” This study showed an increased risk of heart attacks and strokes in elderly veterans who already had coronary artery disease and other medical conditions that put them at risk. Does this sound familiar? It is so similar to the WHI in design and doesn’t differentiate between the types or levels of testosterone. There were serious flaws in this study. It was observational and these types of studies don’t prove cause and effect. Testosterone levels after treatment were not optimal. In fact the levels were in the 300’s and below 300 is considered low. Another observational study, “Testosterone treatment and mortality in men with low testosterone levels,” showed that men with higher levels had almost half the mortality of those with lower levels of testosterone. There are many other articles that showed a benefits and again topical, and bioidentical testosterone were noted to be better hormone replacement options.

Low testosterone is associated with increased mortality from all causes and increased mortality from cardiovascular disease and cancer It is related to diseases such as diabetes, accelerated artery stiffness, abnormal lipids, metabolic syndrome, increased belly fat and inflammation. The following articles showed an association with low testosterone and mortality, as well as its influence on a variety of disorders. There was a decrease in mortality and an increase in survival when testosterone levels were high and the opposite when levels were low. Many studies showed that those who chose testosterone as a hormone replacement option had improved survival.

Testosterone was used in patients with heart failure and improved exercise capacity without any adverse effects as demonstrated in this study: “Testosterone supplementation in heart failure: a meta-analysis.”

Diabetics who accepted hormone replacement options with testosterone had increased survival as indicated in the following study. “Testosterone deficiency is associated with increased risk of mortality and testosterone replacement improves survival in men with type 2 diabetes.” Most men were given bioidentical testosterone gel. Men with testosterone less than the normal range had an increased risk of death due to heart disease. Whereas the men treated with testosterone had increased survival that was practically double that of the untreated group!

When using testosterone as a hormone replacement option, it is important to monitor the levels. In the study where participants showed an increased risk of heart disease, their testosterone levels were in the low normal range, too low to have the desired effect. Whereas in the above mentioned study, participants that had increased survival, had testosterone levels in the mid to upper normal range.

As far as cancer is concerned, this article and others, concluded that there is a lack of association between testosterone therapy and prostate cancer. Does testosterone therapy increase the risk of prostate cancer?

There are many more studies that showed improvement in survival. You should consider the levels, type or form and the study population. One negative study using testosterone as a hormone replacement option does not negate all of the positive studies. Educate yourself before coming to any conclusion.

Hormone Replacement Options by Form for Men

The study “Testosterone replacement therapy in male hypogonadism” stated that natural testosterone should be used, not modified molecules.

The study “New modalities of transdermal testosterone replacement” stated that the topical route of administration is effective and has a good safety profile with no harmful effects on lipids and prostate. It improves bone and lean body mass, decreases fat and improves mood and sexual function. Topical testosterone products are more beneficial hormone replacement options because acne, increased red blood cell count, and enlarged breasts are less common with this topical than with the injections of synthetic.

The article “Androgen replacement therapy: present and future,” advocates the use of natural (bioidentical) testosterone since it provides the full spectrum of testosterone activities. Topical forms were considered to be good hormone replacement options and a new long acting injection as well. However, the new injections have not been around long enough to evaluate long term effects and are not bioidentical.

Since there is a lot of contradiction in the literature and the media tends to focus on sensational news that makes good headlines, when considering hormone replacement options, it is important to have a discussion with a functional medicine doctor familiar with many forms of hormone replacement therapy as well as how they are metabolized by your body. Everyone metabolizes them differently. A good physician will take into account your individual risk factors, symptoms, levels and other factors and help you determine what, if any, hormone replacement options would be most appropriate for you. Educate yourself and don’t allow headlines or individual doctor’s opinions to sway you. Make your own decision. There is no need to suffer. If you have symptoms, consider hormone replacement options.

Author's Bio: 

Lorraine Maita, MD is a recognized and award winning physician and author transforming people's lives through preventive and anti aging medicine. She is a Diplomate of the American Academy of Anti Aging and Regenerative Medicine and Board Certified in Internal Medicine and has over 18 years experience in Preventive Health and Wellness, Internal, Occupational and Travel Medicine and Executive Health.

Dr. Maita served as Vice President and Chief Medical Officer at Prudential Financial, Medical Director on The Pfizer Health Leadership Team and Medical Director of North America for Johnson & Johnson Global Health Service and was an attending physician at St.Luke's/Roosevelt Hospital, Emergency Department and Executive Health Examine rs in New York City. She is a consultant for companies wanting to develop or enhance their employee and occupational health and wellness programs and has a private practice in Short Hills, NJ.

She is author of "Vibrance for Life: How to Live Younger and Healthier".