Are you considering hormone replacement therapy to alleviate your symptoms? Although synthetic and natural bio-identical hormone replacement therapy both aim to help women and men find relief during the transitional years of menopause and andropause, the two methods are vastly different in terms of their safety and efficacy. Want to know why? Then let’s learn about the differences between the two and which one might be right for you.
Progesterone explained
Testosterone explained
Estrogen explained
It is one of the most common things we hear from new patients. You knew something was wrong. You went in, described the fatigue, the weight that will not move, the brain fog, the lost libido, the sleep that no longer restores you. Bloodwork was ordered. And the result came back normal.
You were told nothing needed treating. You left with your symptoms and no explanation.
Here is what most patients are never told: "normal" on a standard lab report does not mean healthy. It means average — average for people your age.
Standard laboratory reference ranges are built by measuring large populations and describing where most results fall. As a population ages, hormone production declines across the board. Those declining numbers get folded into the average, and the range shifts down with them. By the time you are in your fifties, the range you are being measured against reflects a population that is, on the whole, already experiencing the symptoms of hormone decline.
You can land comfortably inside that range and feel terrible. Not because you are imagining it, and not because the lab made an error — but because the yardstick was never designed to identify a healthy hormone level. It was designed to describe a typical one.
How We Read Your Labs Differently
Our approach comes out of age management medicine, a preventive discipline focused on treating the hormone deficits that develop with age rather than accepting them as inevitable.
Instead of comparing your results to the age-adjusted average, we compare them to the levels found in healthy adults between the ages of 20 and 40 — when hormone production is at its functional peak. That becomes the target we work toward, adjusted for you.
We also look at the measurement that matters most. Much of the hormone circulating in your bloodstream is bound to carrier proteins and biologically unavailable — present in the total, but not usable by your tissues. We evaluate free, unbound hormone levels, because that is the portion your body can actually put to work. Two people with identical total testosterone can have very different free levels, and very different symptoms.
Treating the Patient, Not Only the Number
Optimal ranges give us a target. They do not give us a protocol.
Your treatment plan is built from your lab work and your symptoms, your age, your activity level, your medical history, and your goals. We adjust based on how you respond and how you feel — not on a number in isolation. Two patients with nearly identical bloodwork can need meaningfully different plans, and follow-up testing tells us whether we are moving in the right direction.
A note on where this sits clinically. Targeting young-adult reference ranges rather than age-adjusted ranges is the defining principle of age management medicine, and it is not universally practiced. Conventional primary care generally treats age-adjusted ranges as the standard. We are transparent about that difference because we would rather you understand our reasoning and decide it fits than be surprised by it later.
Synthetic hormone replacement therapy (HRT) uses lab-made hormones that are not identical to the hormones produced by the human body. These hormones can have different chemical structures and biological effects compared to the body’s natural hormones. Synthetic HRT is commonly prescribed for menopause symptoms but may carry higher risks of side effects such as blood clots, stroke, and breast cancer.
One such example is synthetic estrogen-replacement drugs that increase the risk of several potentially fatal diseases, especially when combined with progestin. In 2002, a large-scale study called the Women’s Health Initiative (WHI) conducted hormone replacement therapy on women revealed that postmenopausal women who used a combination of synthetic estrogen and progestin had a higher risk of breast cancer, coronary artery disease, stroke and blood clots. In response to this alarming news, many doctors immediately recommended that patients stop synthetic HRT. Interestingly, statistics for the following year showed that breast cancer rates overall dropped about 7 percent and estrogen-sensitive breast cancers (which are more likely to occur when estrogen levels are high) among women ages 50 to 69 fell 12 percent.
Bio-identical hormones, on the other hand, are derived from natural sources and are designed to be identical in molecular structure to the hormones produced by the human body. This is why bio-identical hormone replacement therapy is more appealing to the masses when dealing with menopause or andropause. They are specifically designed to match your individual hormonal needs – unlike synthetic hormones, which use a one-size-fits-all approach to symptom relief, and hence may be better tolerated as compared to synthetic hormones. This perfect fit allows your body to completely utilize the hormone without the side effects that are common with non-bio-identical hormones.
There is an overwhelmingly large body of evidence that supports the claim that bio-identical hormone therapy is safer and more effective than synthetic hormone replacement. However, it’s important to remember that no drug, supplement or herb is 100 percent safe – there is always a chance that you may experience an adverse reaction. That’s why it’s critical for women and men to consult with a hormone specialist before beginning any hormone therapy for weight loss regimen to safeguard themselves from side effects.
To date, there have been no long-term studies of bio-identical hormones, but each short-term study shows positive results both in the relief of symptoms of hormonal imbalances like insomnia, cognitive problems, depression, anxiety, lower sex drive etc. and in the decreased risk of heart disease and breast cancer for women and erectile dysfunction in men. Meanwhile, both long-term and short-term studies show synthetic hormone replacement therapy to be less effective at treating symptoms and to increase the risk of breast cancer and cardiovascular disease.
For women, bio-identical progesterone and estrogen have repeatedly been shown to reduce and eliminate the breast-cell proliferation rates while synthetic versions of these hormones, especially progestin, have been shown to increase breast cancer risk significantly. In terms of cardiovascular disease, bio-identical progesterone maintains and enhances the heart protective effects of estrogen, decreasing the risk for heart attack and stroke. This occurs in part to the bio-identical progesterone augmenting HDL (the good cholesterol) effects. Synthetic progestin does just the opposite, reducing HDL and working against estrogen, causing increased risk of heart disease.
When it comes to administering bio-identical hormones, there are several delivery methods, including:
Hormone creams administered transdermally (i.e. applied to your skin) is one common alternative. However, since hormones are fat-soluble, they can build up in your fatty tissues when applied topically. This buildup in turn can disrupt other hormones. It is difficult to accurately determine the dose when using a cream.
Sublingual drops (absorbed through the mucous membranes of the mouth) can be a good option, as it enters your blood stream directly and will not build up in your tissues like the cream can. It’s also much easier to determine the dose you’re taking, as each drop is about one milligram.
Trans mucosal administration (in the form of a dissolvable gummy, cream or suppository absorbed through the mucous membranes of the mouth, vaginal or rectal tissues), is an ideal administration system, as applying hormones to your mucous epithelial membranes allows for more complete absorption.
Pellet implantation (testosterone and/or estradiol) delivered by subcutaneous implants (in the hip). Pellets deliver consistent, physiologic levels of hormones and avoid the fluctuations of hormone levels seen with other methods of delivery.
NOTE: other delivery options exist and are considered on an individual patient basis.
In order to balance your hormones, and get effective results for hormone replacement therapy you have to address your diet first. Treating hormone imbalances requires a whole-body approach; the best approaches are often preventive and involve diet, exercise and other lifestyle-based strategies.
For instance, both estrogen and progesterone are necessary in the female cycle, and their balance is key for optimal health. Many premenopausal women have an imbalance of these hormones. If you have insufficient levels of progesterone to counter excessive estrogen, this imbalance can be further exacerbated by chronic stress. Therefore, your answer might not necessarily lie in receiving hormone replacement therapy, but rather addressing your stress levels so that your body can normalize your hormone levels naturally.
A healthful diet, low in processed foods (which are high in health-harming sugars/fructose, grains, genetically engineered ingredients, trans fats, processed salt, and other chemical additives) and high in whole organic foods, along with regular exercise, can also go a long way to keeping your hormones balanced as you age.
It’s also important to realize that processed foods—all those refined carbohydrates, and processed and heated fats, serve to raise your estrogen to abnormal levels—as much as twice the normal, which are maintained for the better part of the adult lives of most American women. This is a MAJOR contributing cause of menopausal symptoms in the first place and can often require bio-identical hormone replacement therapy, especially for women. Processed foods also decrease a number of other hormones critical to your health and wellbeing.
Here’s a quick list of dietary recommendations to maintain healthy hormone levels:
The Paleolithic diet (unprocessed, nutrient-rich organic), which includes fermented and cultured foods, promotes healthy hormone levels, even as you age.
Avoid unsprouted grains, sugar or fructose as they decrease seven of the 12 most important hormones.
Alcohol decreases your human growth hormone (HGH), one of your most potent built-in anti-aging hormones. Having just one alcoholic drink per day can decrease your HGH by 75 percent.
Magnesium supplements improve your sex hormone levels, including your testosterone and HGH.
High-quality protein from meat and fish, as well as healthy fats such as egg yolk, lard, and butter, will improve progesterone and DHEA secretion, as will an otherwise healthy Paleolithic diet.
Progesterone can also be increased by several nutritional supplements, including vitamin A. As a general rule, fat-soluble vitamins will have a beneficial effect on sex hormones.
Progesterone prepares the uterus for implantation, makes it healthy for a successful pregnancy, and is essential for the growth and development of a baby. It acts to stabilize the tissue lining of the uterus so if it is absent, such as with an ovarian involution, irregular and heavy menstrual bleeding often occurs after a period without any menstrual bleeding. Thus, progesterone is used to prevent this irregularity of bleeding if it is given continuously.
If a one-time dose of progesterone is given (for example, such as with a shot or with 5-days of oral pills), then the falling progesterone levels will actually cause an estrogen-primed endometrium to slough and therefore start a menses.
Too much progesterone often causes tiredness and even sedation. Interestingly, this side effect can be beneficial in a woman who has epilepsy or even uterine irritability causing pre-term labor because progesterone in high doses can decreases seizure activity and uterine contractions. This can also benefit women who have difficulty sleeping.
Progesterone is very benign medication that most women tolerate well. Infrequently there are side-effects that may include the onset of your period. If this happens, and a period is delayed for a day or two, you may need to stop taking progesterone to bring on your period, then resume taking it 14 days after your period starts. Flushing may occur when taking progesterone because it raises your body temperature about one degree.
Progesterone is a natural hormone produced by the ovaries. Progestin refers to a group of synthetic hormones like Provera or medroxyprogesterone (MPA) acetate. Although they have similar actions, they are not identical to progesterone.
Synthetic progestins (also called progestogens or pro-gestational agents) are similar to bio-identical progesterones, and have been developed because they are longer-lasting, more potent, and patentable.
The synthetic progestins are similar to the progesterone your body produces, but the subtle chemical differences can significantly influence the hormone’s action and side-effects in the body. Synthetic progestins can cause side-effects of irritability, nauseas, depression and water retention in some women. Natural progesterone is molecularly identical to the hormone made in the body, and many women find it easier to tolerate.
In contrast to some synthetic progesterones, natural progesterones do not suppress good cholesterol (HDL), has no effect on blood pressure, and shows less tendency to cause increased male-hormone-like effects such as facial hair growth1.
Slow release oral capsules: 50-400 mg.
Combines low, even-release of medication with the convenience of dosing once or twice daily. The capsule produces consistent blood levels, which is critical for symptom management in PMS or menopause, and to avoid daytime drowsiness, erratic menstrual cycles or breakthrough bleeding.
Micronized oral capsules: 25-200mg.
This capsule is an immediate release form that is taken several times a day. Remember, progesterone is the hormone with a naturally calming effect. Oral forms of natural progesterone may cause drowsiness or dizziness if a women is taking a dosage that is too high for her individual needs. If drowsiness or dizziness occur, the dosage may need to be reduced. Taking natural progesterone with food also helps to avoid drowsiness.
Creams or gels. 20-100 mg.
Delivers continous, consistent absorption for symptom management. Progesterone cream is best absorbed when applied to the skin on the hands but can also be applied to the thin skin on the stomach, thighs, or inner arms, one to two times a day rotating to a variety of sites daily.
Sublingual troches. 50-200 mg.
These troches are taken one to four times daily. The progesterone is delivered through the submucosal membrane to the blood stream hence bypassing the liver.
Suppository. 25-400 mg.
Delivered vaginally or rectally in a wax base. They provide consistent, even absorption. Lower doses are most commonly used in treating ‘luteal phase defects’ and higher does are used for treating premenstrual syndrome.
Drops.
Oral drops can be used for quick onset of action and can be compounded in very small doses for sensitive people that need more adjustments.
Reference(s)
1. Natural Medicine 3(3):324-7 and Journal of the American College of Cardiology, Mach 1, 1997, pp.671-5
Testosterone is a hormone produced by our ovaries, and production begins to decrease around 40.
It is actually the central hormone in the aging process. Our other hormones, progesterone and estrogen – specifically the estrogen called estradiol – are also important. Loss of these hormones is also known as menopause. These hormones begin to decline in response to the drop in testosterone.
Testosterone loss is a slow process for women so it often sneaks up on us. This is a quality of life issue for women as well as a health risk. But why do we experience such signs of aging when we’ve only lived half our lives? The answer is in our longer lifespans. Historically, women did not live long enough to reach the age of it’s onset. To put it simply, women now outlive their testosterone production.
Testosterone is actually a women’s most abundant hormone. It is our primary sex hormone, three times as abundant as estradiol throughout our lives.
If you have your ovaries removed or you are in natural perimenopause or menopause, your testosterone levels drop by 1/3 or more. Besides the bone and sexual benefits, it is also acts on the brain, muscles, liver and blood vessels, as it enhances cognitive functions.
Although the change occurs more slowly in regard to testosterone release, it is common for women to produce fifty percent less testosterone after menopause than they did before peri-menopause began.
Although these changes occur in a similar fashion in every woman, the way that the body responds to that single chemical change can vary tremendously. Every woman’s internal physiology is unique, and many women begin to experience significant declines in physical health or sexual desire as a result of this hormonal change, although other women may not experience a significant change in sexual desire at this point in their lives.
Women that go through the process of hysterectomy or oophorectomy are at an even greater risk of experiencing issues as a result of low testosterone. Shutting down the ovaries separates the body from its primary source of endogenous testosterone, drastically reducing testosterone production to a rate far below a woman that has experienced menopause with her ovaries intact and otherwise functional.
Increased stress levels also have the ability to contribute to the early onset of the many symptoms related to peri-menopause as a woman approaches her early 40s. High levels of Cortisol, combined with low levels of testosterone, can directly lead to the development of the following symptoms:
Reduced Energy and Increased Fatigue
Brittle and Thinning Hair
Increased Risk of Osteoporosis
Atrophy of Muscle Tone
Increased Development of Adipose Fat
Reduced Libido
Increased Wrinkles and Decreased Skin Health (Cellulite)
Women over 40 often complain about dimples in our upper legs, buttocks, hips and thighs also known as cellulite. Cellulite is a function of a low-oxygen environment surrounding superficial fat. When testosterone decreases, muscles shrink and do not demand as much oxygen. The fat cells lying on top of those muscles became hypoxic, or “starved” for oxygen, and they succumb to scarring in areas of connective tissues in response. These scars pull the skin down and “dimple” the skin overlying our hypoxic fat.
Treatments for cellulite are aimed at oxygenating the fat, and the best oxygenator is replacing the testosterone so blood and oxygen are drawn to the working and growing muscles. This heals the cellulite from the inside out.” The Secret Female Hormone.
Why don’t men have it? Men have a much thicker epidermis–the very top layer of the skin. A thicker epidermis makes male skin MUCH more resilient to structural change and dimpling, which protects it from cellulite.
Originally, testosterone could only be delivered via injection but no longer. There are several delivery methods similar to the other hormones but pellet implantation has been used with great success in the U.S., Europe and Australia since 1938 and found to be superior to other methods of hormone delivery (Greenblatt 49, Mishnell 41, Stanczyk 88). It is not experimental. Pellets deliver consistent, physiologic levels of hormones and avoid the fluctuations of hormone levels seen with other methods of delivery (Greenblatt 49, Thoma 81, Stanczyk 88).
Hormones delivered by the subcutaneous implants bypass the liver, do not affect clotting factors and do not increase the risk of thrombosis (Notelovitz 87, Seed 00). Bioidentical testosterone delivered subcutaneously by pellets is cardiac protective, unlike oral, synthetic testosterone (Sands 97, Worboys 00)
Pellets are superior to oral and topical hormone therapy with respect to relief of menopausal symptoms (Staland 78, Cardoza 84). Estradiol and testosterone implants have consistently been shown to improve insomnia, sex drive, libido, hot flashes, palpitations, headaches, irritability, depression, aches, pains, and vaginal dryness.
Hormone replacement therapy with pellet implantation has an extremely low incidence of side effects (Cardoza 84, Barlow 86, Ganger 89, Pirwany 02) and high compliance rate (Gambrell 06). It has also been shown to be extremely effective in the treatment of migraine headaches.
Estrogen is probably the most widely known and discussed of all hormones. The term “estrogen” actually refers to any of a group of chemically similar hormones: estrone, estradiol (the most abundant in women of reproductive age) and estriol. Overall, estrogen is produced in the ovaries, adrenal glands and fat tissues. More specifically, the estradiol and estrone forms are produced primarily in the ovaries in premenopausal women, while estriol is produced by the placenta during pregnancy.
Bone
Estrogen produced by the ovaries helps prevent bone loss and works together with calcium, vitamin D and other hormones and minerals to build bones. Osteoporosis occurs when bones become too weak and brittle to support normal activities.
Your body constantly builds and remodels bone through a process called resorption and deposition. Up until around age 30, your body makes more new bone than it breaks down. But once estrogen levels start to decline, this process slows.
Thus, after menopause your body breaks down more bone than it rebuilds. In the years immediately after menopause, women may lose as much as 20 percent of their bone mass. Although the rate of bone loss eventually levels off after menopause, keeping bone structures strong and healthy to prevent osteoporosis becomes more of a challenge.
Vagina and Urinary Tract
When estrogen levels are low, as in menopause, the vagina can become drier and the vaginal walls thinner, making sex painful.
Additionally, the lining of the urethra, the tube that brings urine from the bladder to the outside of the body, thins. A small number of women may experience an increase in urinary tract infections (UTIs) that can be improved with the use of vaginal estrogen therapy.
Perimenopause: The Menopause Transition
Other physical and emotional changes are associated with fluctuating estrogen levels during the transition to menopause, called perimenopause. This phase typically lasts two to eight years. Estrogen levels may continue to fluctuate in the year after menopause. Symptoms include:
Hot flashes—a sudden sensation of heat in your face, neck and chest that may cause you to sweat profusely, increase your pulse rate and make you feel dizzy or nauseous. A hot flash typically lasts about three to six minutes, although the sensation can last longer and may disrupt sleep when it occurs at night.
Irregular menstrual cycles
Breast tenderness
Exacerbation of migraines
Mood swings