Is HRT Safe? 10 Questions Women Ask Most — Answered by a Functional MD

22:16So there does seem to be a protective benefit there. In terms of libido, some women find that we'll talk about testosterone in a minute, but just estrogen and progesterone alone improve sex drive libido. Libido is very complicated because it's not purely hormonal. It's also related to being sleep deprived, feeling overstretched if there's a lot going on, how you feel about your partner. I mean, those are important factors that also negatively impact libido. Even using a patch of estrogen, it may not be enough for some women to help with the vaginal dryness, thinning, and pain. So there can be an additional role for vaginal estrogen, which has also been shown to improve libido, or vaginal DHEA, which has been shown to improve libido above and beyond just improving the health of the tissues.

23:04Lastly, there can be a role for some women to use testosterone, low-dose testosterone, which can move the needle if those other things have not helped.

23:12Dr. Mark Hyman:The good thing though, but even if you had breast cancer, you can use vaginal estrogen safely. I think that's really important to point out because it doesn't tend to get systemically absorbed. And that's also been a shift in the last several years. Even women with estrogen positive breast cancer, if they're having an informed conversation with their oncologist, it seems to be pretty safe and it can really make a difference in symptoms. And the last thing is you touched on a little bit, but sleep has definitely helped by just reducing hot flashes with estrogen. but progesterone has a particularly unique effect around sedation, sleep.

23:42Dr. Mark Hyman:So maybe you can chat about that. And even you can use that even before you use any estrogens in the perimenopausal period effectively. So that's in a way of helping manage a lot of the symptoms of heavy bleeding, clotting, sleep issues, PMS, it all starts to accelerate in the late perimenopause. Progesterone has a calming sedating effect. And in the early perimenopause transition, where there's bigger oscillations in estrogen. For women who are prone to migraines, they can really flare. For women who have more histamine-related symptoms, those can also flare. And interestingly enough, giving progesterone by itself can kind of re-regulate those wider swings and help with those symptoms.

24:20So that might be an instance where we're focusing on high-dose progesterone initially in the menopause transition. All right.

24:26Dr. Mark Hyman:So people are sitting there wondering, okay, how do I know if I need it? How do I know if I start? What are the signs I should consider it? Is it testing? Is there my symptoms? Like what's the way to approach this? Again, this is a great opportunity to kind of check in with what's going on in your life. How do you feel? Are you starting to notice hot flashes, night sweats? Is your sleep changing? Are you having worsening premenstrual symptoms with mood swings? That would be a good time to start talking to your doctor about what's going on and whether hormones make sense then. Testing is tricky in perimenopause because it's going to change day to day and week to week and month to month.

25:01So you can do a snapshot in the moment. And it's not going to tell you the whole picture, but it can provide some clues. We treat the person, not the level in the perimenopause. I think it's also a great time to get a baseline. What's happening with your insulin? What is your A1C? What is your cholesterol? If you can get a baseline bone density, that would be fantastic. If you can't, you can start looking at these markers of bone turnover? Are you just looking like your bones are starting to turn over more rapidly, which is a predictor of future decline, current and future decline?

25:35Dr. Mark Hyman:I mean, don't you think women should ask for a kind of a mandatory DEXA scan for bone density and body comp in there at least by their mid-40s? It's just a non-starter almost. I know, but right now insurance, unless you're high risk, typically doesn't cover it until you're 60. They're not that expensive. I went to this place in Austin, I think it was 80 bucks for both. It was like super affordable it's much easier to get it and and i'm glad you brought up the bone density because your weight doesn't tell you the whole story women might if they especially if they haven't been physically active might actually have low muscle mass and identifying it early we can take steps to add in more resistance training make sure you're getting enough good quality protein supporting digestion absorption at a gut level um to help you with your body composition.

26:20Dr. Mark Hyman:And the good news about the dex scan, it can do both, the bone density and the body composition. Okay, well, Cindy, let's talk about testing, because I think people are confused to check blood tests, what about urine tests, what about saliva tests, like there's so many options. So how do you think about diagnostics when it comes to hormone therapy? Obviously, you're going to be looking at all the standard stuff like cortisol, thyroid, vitamin D, and so forth. But what about like hormones themselves? You know, Mark, I just have to say, it's interesting that You said the obvious stuff like thyroid and cortisol and vitamin D and insulin, but it's actually not obvious to everybody.

26:51Think about how many people come in and they're just looking at estrogen and progesterone. So I'm really glad you called that out. We look at the big hormone picture. I tend to use blood levels for quantity. I think they're probably the best if I'm looking to see where somebody is, also looking at the pituitary hormones, the FSH and LH. And then if we're monitoring somebody after we're starting treatment. I rely on the blood levels for quantity of the hormones. Saliva.

27:19Dr. Mark Hyman:To help manage prescriptions or - Yes, to help manage prescriptions to track somebody, especially if they're not responding, do we need to change the dose? The saliva tests, I don't use as much for estrogen and progesterone, but they're really great for looking at cortisol levels throughout the day. They correlate pretty well, and that gives us a snapshot of adrenal reserve, how stressful somebody might be, what things could be spiking their cortisol or not. And then for those estrogen metabolites and testosterone metabolites, the urine levels are what we look for. So it's a combination of things.

27:56Dr. Mark Hyman:So yeah, so you can use saliva for cortisol, you use blood for hormones, you also use urine for estrogen metabolism. So you kind of need a cocktail of things to really understand what's going on. And then it helps you understand where they're at, what to do. but the thing is as you're going through perimenopause, your hormones are all over the place. So any one level, any one time doesn't really give you the whole picture. So it's a combination of like your clinical expertise plus symptoms plus the lab testing all gives you sort of a framework. It's sort of like multiple ways of navigating and so it's important to sort of track that stuff and particularly if you're on hormones, you want to make sure you're not overshooting with estrogen, progesterone, testosterone.

28:34Dr. Mark Hyman:All right, so let's say somebody starts on it and they're like 50 and they get on it or do they stand until they die or like you take forever or you take it for a few years till your symptoms are over? Like, are there 80-year-olds having hot flashes who haven't gone, who haven't been on hormones? Probably not. So the question is like, what is the right amount of time? And there is no perfect answer there either, Mark, because I think if we just look back at how much the pendulum has shifted, there is still ongoing research. And every year we get new information that might shift the equation. So it's also about, okay, if you're thinking about hormones now, making the best decision you can with all the information you have, but checking in every year.

29:14Is it still the right option for me? How do I feel? What are my goals? What are my levels? What am I trying to achieve with hormones? And I would say there isn't a black and white answer to that. Some women might try it and they don't like how they feel. Progesterone, some women don't do well with progesterone. I mean, it just can be, most women do, but some women don't. So we might need to shift gears there. Or maybe they go in for a mammogram and they get a new diagnosis of breast cancer, and then we really need to shift gears there. There could be other health changes or priority changes. So I think it's an evolving conversation.

29:51It's about establishing benchmarks and then having a partner you trust that can continue the conversation every year.

29:58Dr. Mark Hyman:And also tracking things, right? You want to check your mammogram, your pap test, your bone density, your cardiovascular risk factors, your insulin, all the things that you want to be tracking. And that's what we do at the Ultra Wellness Center in Lenox. We do this for a long time. And we have the ability to really kind of dive in and help people navigate this. And it's one of the most satisfying parts of practice for me because you really can help people not suffer. And I don't think women should have to suffer. I think one of the other misinterpretations of this, if you start within five to 10 years, Physicians for a long time would say, okay, you've been on it 10 years.

30:30You have to stop your hormones. That's not true either. There are women who continue to stay on their hormones beyond the 10 years. If they're doing well, they're feeling well. It's working for them. I don't routinely take people off just because it's met a magic year mark based on some population data.

30:47Dr. Mark Hyman:Right, exactly. Just like how you make up those numbers, they just sort of make them up out of the air. Last question is really about who should not take hormones and hormone replacement therapy. Yeah, so we talked a lot about breast cancer. Even breast cancer is not all the same. Women who've had an estrogen-positive breast cancer or progesterone-receptor-positive breast cancer, it's still really considered relatively contraindicated unless you're using the vaginal estrogen. There's some newer evidence calling that into question, but that's really an informed discussion with your oncologist. Triple negative breast cancer, they're starting to look at maybe there might be a subset of women who could tolerate or have estrogen.

31:29But again, I think that is an informed conversation with your oncologist. So active breast cancer, I would say no. If you have unexplained vaginal bleeding, you don't know where it's coming from that could potentially be a sign of uterine cancer. you need to figure that out first. Active liver disease would not take hormone therapy. The research is also shifting. If you've had a personal history of blood clots or you have genetics for blood clotting, there's some emerging evidence that if you're using estrogen through the skin and you've got bothersome symptoms, that could be a possibility. But again, I would probably defer you to your hematologist for that.

32:06Those are the main contraindications.

32:08Dr. Mark Hyman:And liver disease, pelvic too, right? So breast cancer, clotting, liver disease, yeah, yeah. I would say you have to know yourself. If you're somebody who doesn't want to take them, who is going to every day you take it feel like, oh my gosh, is this not right? Am I going to cause breast cancer? It may not be the option. I'm not going to force anybody to take hormones who doesn't feel like it's right for them. I mean, that's important because people don't have to take them, they can do well with other ways of managing symptoms or these diseases or conditions that they're at risk for. But I think that the current thinking, and who knows this might change as more data comes in, is it's a more nuanced view than we had.

32:46Dr. Mark Hyman:And if people are confused or want to learn how to do this or need help and support, you know, our practice, the Ultramanol Center, we have five physicians, lots of physicians assistants, nutritionists, nurses, it really helps support people on this whole journey. So Sydney, thanks so much for joining us. You You have given us a lot to think about and a great explanation of how to just get to the nuts and bolts and the meat of the issue, so to speak. As you can see, everybody, hormone placement therapy isn't like just one size fits all for everybody. It's nuanced. It depends on your symptoms, your medical history, your goals, and the bigger picture of your health, you know, whether you have osteoporosis or heart disease or other things.

33:23Dr. Mark Hyman:And then, you know, hopefully what this conversation has done is cut through some of the confusion. For a long time, the conversations around hormone therapy has been really about fear and about misinterpreting the data and outdated information. And what we know now is way more nuanced than that, right? For the right person at the right time, hormone replacement therapy can be a powerful tool. And it's just that. It's a tool. It's not the only answer and not something to approach without guidance. So if you're navigating these questions for yourself, the most important step is to work with a practitioner, ideally a functional medicine practitioner, who can help you look at your full picture, not just your hormones in isolation.

33:57Dr. Mark Hyman:Because this isn't just about managing symptoms. It's about supporting your long-term health, your metabolism, your brain health, and how you want to feel as you get older. And that's really the goal. If you found this helpful, I encourage you to share it with someone who's navigating these same questions because the chances are they are. And if you want to dive deeper into this topic, look out for my upcoming episode with Dr. Sharon Malone, who's a board-certified OB-GYN and menopause specialist with decades of clinical and leadership experience in women's health. And here's a clip from that conversation.

34:24Dr. Mark Hyman:The thing that just maybe we should just unpack is this black box warning that came from the FDA because it's what got people really scared. And I remember because I was practicing really heavily with women that during that time when that study came out and it stopped the study. They literally stopped the study because they were concerned about the harmful effects. So that's a big deal. And overnight, I think 50 million women stopped hormones, which created a catastrophe in the country. How well I know. Yeah, right? And so we kind of had a backlash. Now we're kind of coming back to a more coherent way of thinking about it.

35:02Dr. Mark Hyman:And I'd like you to unpack how you think about prescribing hormones and which hormones and for whom and what the benefits are. Because the Women's Health Initiative did show that increased stroke and increased heart attack. And there were some... Did it, though? Did it? I mean, that's what they said, right? Okay, and I'm going to tell you it didn't really say that. Because the effect sizes were small or the... The effect sizes were small and they were as prescribed. Remember, the women entering the Women's Health Initiative, the average age was 63. Yeah. You could be anywhere from 50 to 79 years of age to be in that study.

35:44They didn't really even say, all right, these are women who've never had hormones before and now we're going to give some hormones and some not. The criteria for entering and being randomized, you just had to not have taken hormones for three months before entering the study. Do you see what I'm saying? So the population was really murky. They were too old. That's not how we're prescribing today. We prescribe what we do know is that the earlier you start treatment, the more long-term benefit you get.

36:15Dr. Mark Hyman:And is it riskier to start it when you're older? Well, yes, there are some. You get less benefit. And I don't think it takes any leap of faith to understand that the purpose of the Women's Health Initiative was to sort of figure out whether or not the hormones really were the secret sauce in reducing the cardiovascular disease. Because when the nurses study, 50 % decrease in heart disease in the women who took estrogen. Okay. Is it that or is it something else? and to have women come into the study at 79 years old, I think we can all agree that it doesn't matter what I give you. That horse is out of the barn by then.

37:02And by having too many women who already had established heart disease, how are you going to prevent something that you already have?

37:11Dr. Mark Hyman:Yes. It's like they didn't do angiograms on everybody and see what their hearts look like. Exactly. So when you stratify even the Women's Health Initiative, when you looked at the younger women who were in the minority, but the younger women did not have an increase in the risk of cardiovascular disease, all of the bad things, the only finding from the Women's Health Initiative that was statistically significant was there was an increase in the risk of blood clots. Yeah, blood clots. But there's a heart attack. It's a blood clot, right? No, but that's separate. This is listed as separate in part because it's DVTs or D-veil thromboses or pulmonary emboli, and that was reported separately.

37:52Dr. Mark Hyman:But estrogen does mechanistically cause an increase in clotting risk. We know that. Yes. Yes, it does. However, again, perspective matters. You need to know to say to someone that it's a 50 % increase or 100 % increase, well, what's the baseline? You know, and what we do know is that for women who start estrogen even oral earlier, when you're 40s or 50s, when you start, that increased risk of blood clotting that we don't have it, we don't see it. It happens when you're older. And so a lot of the findings from the Women's Health Initiative that were negative, even the cardiovascular disease was elevated, but only in the first year and not after that.

38:36Because, again, you're probably giving something to women who already have fairly advanced heart disease. What about the breast cancer risk? Ah, the breast cancer. Because that's what freaks women out. That is the number one reason why women avoid hormones. Oh, cardiovascular risk. I don't care about that. it's the breast cancer. That was the, that was really the nail in the coffin.

38:58Dr. Mark Hyman:Yeah. Cause it did show some increased risk, right? That's what they reported at least. Okay. Let me, let me tell you. I mean, that's what the, that's, that's what the, that's what the public said, understood. Oh, trust me. I've been in this, I've been in the weeds on this for so long. I'm just, I'm just framing it so people know. It's like, I'm not just saying. No, no, no, no, no. That was, that was what they held. That was the headline. That was the press conference. Oh, not only does this, you know, They held a press conference when they stopped the Women's Health Initiative to say, oh, not only does it not help your heart, it increases your risk of blood clots and heart disease and strokes.

39:32And it went on and on and on. Well, that's very scary. And I would challenge anyone to give me another example of when the NIH, the regulators at NIH held a press conference to announce a study. I mean, that's how big of a deal they thought that was. And I'll also mention that Bernadine Healy was not there at that time. So we're going to give her a pass on that. But here's the breast cancer story. And I will say this. The data is the data. You don't get to change the data because you don't like it. Okay? You can change your interpretation of the data, but it is what it is. But let's take it at face value.

40:10what did the Women's Health Initiative say about women who took estrogen, the Primarin, and the Provera? All right. They reported there was a 26 % increase in the risk of breast cancer in estrogen and progestin users versus non-users. 26%. That sounds terrible. Who wants that?

40:30Dr. Mark Hyman:That's relative risk. Right. But what did that mean in real terms? That means for women who did not take estrogen and progestin, the natural incidence is about 30 per 10 ,000 women per year will be diagnosed with breast cancer, living long enough to get it. In the estrogen and progestin user group, it went from 30 per 10 ,000 women per year to 38 per 10 ,000 per year, with no increase in the risk of dying from your breast cancer, even if you were diagnosed on hormone therapy. So let's make that sound a little better. All right. Eight per 10 ,000 additional cases of breast cancer. And that's 26%.

41:12That's 26%. Right. With no increased risk of dying from it. And then make it even better. Less than one in a thousand additional cases of breast cancer in the women who took estrogen and progestin. Now, that doesn't sound nearly as scary as 26%. Correct. But that was never really put into perspective.

41:34Dr. Mark Hyman:I think Mark Twain said there's lies, there's damn lies, there's statisticians. Exactly. And, you know, and there is, and when you put it that way, you say, oh, okay, well, eight in a thousand, but I'm no more likely to die from it, even if I'm taking hormone therapy. And even that statistic itself, and you and I know in a medical study, if you were going to report a finding, to call it a finding, it has to be statistically significant. It was not statistically significant. But that stuck like glue. It's still with us today because doctors and patients still believe that a family history of breast cancer is a reason not to take hormone therapy.

42:18So that's just a worst case scenario. Let's, you know, put it on, blame the old bad Primrin and Provera. Even that did not statistically increase your risk of breast cancer. And that is what has taken a long time for people to really understand those numbers. And because I remember the day that came out, it was 1992, and I had been prescribing for 10 years. Well, 2002, and I had been prescribing for 10 years before that. Yeah, me too. And patients were horrified. Oh, doctor, I can't believe you're trying to kill me with this stuff. And when I read the study, I said, wait a minute, it's not as bad as what they said.

42:59Yeah. And again, remember, applying that data, again, take it as it is, you can't apply that, the same data from 79-year-olds and 65-year-olds to 45-year-olds. They're not the same.

43:12Dr. Mark Hyman:What if brain fog, anxiety, and mood swings aren't simply all in your head? What if the health of your mind actually starts deeper in your body, in your gut, in your hormones, metabolism, and your immune system? Well, let me tell you, the connection is real and it affects how you think and you feel every single day. And that's why I created Brain Shaping Academy, a six-week program that shows you how healing your body can help you heal your mind. Brain Shaping Academy relies on the same targeted nutrition and lifestyle strategies that I've used for 30 years to help my patients improve their mental, emotional, and cognitive health.

43:46Dr. Mark Hyman:So if you want to feel calmer, clearer, and more in control and stay sharp and protect your brain as you age, check out Brain Shaping Academy at drhyman.com forward slash brain shaping. That's drhyman.com slash brain shaping. Thanks for joining me for office hours. I love diving into these topics with you. Remember, you are the CEO of your own health and every choice you make can move you closer to healing and vitality. I want to keep these episodes as relevant and useful as possible. So tell me, what do you want to explore next? What questions are you wrestling with? What breakthroughs are you chasing?

44:24Dr. Mark Hyman:Share your ideas in the comments on social media or through the link in the show notes. I'm listening. Until next time, keep taking charge, keep asking questions, and keep showing up for your health.

44:38Dr. Mark Hyman:If you love this podcast, please share it with someone else you think would also enjoy it. You can find me on all social media channels at Dr. Mark Hyman. Please reach out. I'd love to hear your comments and questions. Don't forget to rate, review, and subscribe to The Dr. Hyman Show wherever you get your podcasts. And don't forget to check out my YouTube channel at Dr. Mark Hyman for video versions of this podcast and more. Thank you so much again for tuning in. We'll see you next time on The Dr. Hyman Show. This podcast is separate from my clinical practice at the Ultra Wellness Center, my work at Cleveland Clinic, and Function Health, where I am Chief Medical Officer.

45:10Dr. Mark Hyman:This podcast represents my opinions and my guests' opinions. Neither myself nor the podcast endorses the views or statements of my guests. This podcast is for educational purposes only and is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided with the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, please seek out a qualified medical practitioner. And if you're looking for a functional medicine practitioner, visit my clinic, the Ultra Wellness Center at ultrawellnesscenter.com and request to become a patient.

45:42Dr. Mark Hyman:It's important to have someone in your corner who is a trained, licensed healthcare practitioner and can help you make changes, especially when it comes to your health. This podcast is free as part of my mission to bring practical ways of improving health to the public. So I'd like to express gratitude to sponsors that made today's podcast possible. Thanks so much again for listening.