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Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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September 05 2018

The Pros & Cons of Hormone Replacement Therapy for Primal Women

By Mark Sisson
89 Comments

A Primal woman’s first reaction to the prospect of taking synthetic hormone replacements for menopause? Probably a healthy dose of skepticism. We in the ancestral health community, after all, tend to view pharmaceuticals as a last resort—interventions that are overprescribed by vested interests, create their own set of side effects, and may even do more harm than good. To suggest that we “need” this or that prescription raises our hackles.

Besides, it’s not like menopause is a product of modernity or an aberration our ancestors never experienced; it’s a physiological stage that evolution has protected and selected in humans. It’s perfectly natural. Rather than the debilitating, miserable experience many women report having, menopause should be easier. Graceful, even. But it often isn’t.

And nature unfortunately doesn’t care about that. Menopause is nature’s way of preventing undue discomfort and reducing genetic damage to the group. Your average 50-year-old woman has a lot to offer the tribe in terms of wisdom, child care, and general know-how, but natural selection has also determined that it’s better for everyone if middle-aged women don’t easily get pregnant. Menopause achieves this by down-regulating the hormones and weakening the tissues necessary for conception. The problem is that these same hormones and tissues also figure prominently in a woman’s enjoyment of life and overall health.

What can happen when Mother Nature decides to step in?

  • Anxiety
  • Irritability
  • Loss of libido, vaginal atrophy
  • Night sweats
  • Hot flashes
  • Weight gain
  • Forgetfulness

Longer-term, menopause increases the risk of serious diseases like osteoporosis, heart disease, and breast cancer.

Those aren’t mere inconveniences. They can mar the beauty of what should be an enjoyable part of a woman’s life, interfering with her relationships, her productivity, her cognitive function, her sleep, and her basic ability to enjoy living.

Mother Grok didn’t take pharmaceutical hormone replacements, you might counter. She didn’t hit up the shaman for a compound blend of hormones, so why should you?

First of all, maybe she did. Pre-scientific peoples have been known to develop folk cures that seem primitive but end up getting scientific validation. Think of the medieval garlic-based concoction that we just found out can eliminate medication-resistant staph infections. Or the indigenous Amazonian tribes who somehow figured out if you brewed a certain vine with a certain leaf and drank the finished product you’d visit the spirit world, all without knowing the vine contained DMT and the leaf contained an MAO-inhibitor that made the DMT orally active. Or, to bring it back to menopause, the yam, which cultures have used for hundreds of years for menopause treatment without actually knowing it contains an estrogen mimetic with clinical efficacy.

Second of all, the basic Primal stance on pharmaceutical interventions is that they are useful and suitable when correcting a deficiency, a genetic proclivity, or an evolutionary mismatch—particularly when dietary and lifestyle interventions aren’t cutting it. If they can help us treat a condition that seriously impedes our life or pursuit of health, we should avail ourselves of the fruits of modern science. Hormone replacement therapy may very well qualify.

Philosophical qualms aside—does hormone replacement therapy (HRT) work? What factors play into its effectiveness—and safety?

First, Is It Safe?

This might just be the most contentious topic in medicine.

For decades, HRT was the standard treatment for postmenopausal women. Not only was it given to treat the symptoms of menopause, it was billed as an antidote to many of the chronic diseases that increased in frequency after menopause like breast cancer, osteoporosis, and heart disease. Most of this was based on observational data and small pilot studies. That changed with the Women’s Health Initiative (WHI), a massive series of randomized controlled trials involving tens of thousands of postmenopausal women. Finally, the establishment would get the solid backing they needed to continue prescribing HRT to millions of women for prevention of chronic disease.

Except it didn’t turn out so well. Midway through, they stopped the trial because they weren’t getting the desired results.

There were two different HRT study groups. In one study, women without uteruses either got placebo or estrogen alone. In the other, women with uteruses got a combo of estrogen and progestin (a progesterone analogue) or placebo. The estrogen was Premarin, a conjugated estrogen. The progestin was Prempro, or medroxyprogesterone acetate.

The E/P combo increased the risk of heart disease, breast cancer, pulmonary embolism, and stroke, and reduced the risk of colorectal cancer and fractures (but not enough to offset the increased risks).

The estrogen alone had no effect on heart disease (contrary to their hypotheses), but it did appear to increase the risk of stroke while decreasing the risk of breast cancer and fractures.

Following the publication and wide dissemination of the WHI results, HRT use plummeted among women. Breast cancer cases subsequently dropped by 15-20,000 per year. Hormone replacement therapy developed a bad rap that it has yet to shake.

Is it deserved? Yes and no.

While the WHI results highlight some very real risks associated with HRT, they don’t tell the whole story. There are other variables to consider when deciding on HRT.

How Early You Start Taking HRT Matters

Most of the women in the WHI study began HRT when they were very post-menopause: older, in their 60s and upward. They got worse results.

A much smaller proportion of the women in the study were under 60 when they started HRT. They had better results. In fact, among those women who initiated HRT before age 60, total mortality actually dropped by 30%.

Another analysis of the Women’s Health Initiative data found that women who started taking HRT during early pre-menopause were less likely to see the negative effects, like increased breast cancer and heart disease.

Another study found that older post-menopausal women taking estrogen took hits to their working memory that remained after therapy cessation, while younger post-menopausal women had no such reaction.

Women who took oral estradiol 6 years after menopause saw their subclinical atherosclerosis slow down. Those who took it later (10 years after) did not.

A recent large Cochrane meta-analysis found that while in general postmenopausal women taking HRT had a moderately increased risk of heart disease, breast cancer, and other diseases, a subgroup of healthy, 50-59 year old (so, younger) HRT users only had a slightly increased risk of venous thromboembolism.

The longer you wait to initiate HRT after menopause, the more adverse effects occur. Start earlier, if you do start

How You Administer the HRT Matters

Oral hormones have different metabolic fates than transdermal hormones. When you swallow a hormone, it goes to the liver for processing. This creates various metabolites with different bioactivity. One example is oral estrogen. When you take estrogen orally, you raise CRP, a marker of inflammation. Transdermal estrogen has no effect on CRP.

Oral HRT has been shown across multiple studies to increase the risk of venous thromboembolism, while transdermal HRT does not. This is because oral HRT increases thrombin generation and clotting, while transdermal HRT does not.

In the Women’s Health Initiative that found negative effects, the HRT given to the subjects was oral. Perhaps this was the issue.

For local vaginal symptoms, local application is probably ideal, while oral application is suboptimal. In one study, vaginal estriol was far more bioactive than oral estriol, despite the latter resulting in higher serum levels of the hormone.

However, topical isn’t always best. In one study, sublingual users of bioidentical hormones saw relief from night sweats, irritability, hot flashes, anxiety, emotional lability, sleep, libido, fatigue, and memory loss, while topical users only saw relief from night sweats, emotional lability, and irritability.

The Type Of Hormone You Take Matters

Another factor the WHI failed to address was the composition of the medication itself. They used synthetic hormones—conjugated estradiol and medroxyprogesterone acetate. Could bioidentical hormones, exact replicas of endogenous hormones which exploded in popularity following the WHI, have a different effect?

The amount of research into conventional HRT dwarfs bioidentical hormone therapy (BHT) research, but what we have looks pretty compelling.

Breast cancer is a major concern for HRT users. Most breast cancers respond to estrogen, just over half respond to progesterone, and traditional HRT seems to increase their risk. Yet, at least in healthy postmenopausal women, a combination percutaneous estradiol gel (inserted into the skin) and oral micronized progesterone—both bioidentical to their endogenous counterparts—had no effect on epithelial proliferation of the breast tissue, while reducing activity of a protein that protects cancer from cell death. The conventional HRT had the opposite effect, increasing epithelial proliferation and breast volume (a risk factor for breast cancer). This wasn’t about cancer, but it’s suggestive.

In another study, postmenopausal women on BHT (which included estriol, estradiol, progesterone, testosterone, and DHEA) saw improvements across all measured cardiovascular, inflammatory, immune, and glucoregulatory biomarkers despite being exposed to high levels of life stress.

Then again, in a recent study, bioidentical hormones performed poorly compared to the pharmaceuticals equine estrogen and medroxyprogesterone acetate. The pharmaceutical hormones resulted in a lower risk of breast cancer, although the bioidentical hormones still reduced the risk compared to placebo.

Which Hormones You Take Matters

The vast majority of postmenopausal women take estrogen, progesterone, or some combination of the two. But there’s another hormone that, despite plummeting during menopause, gets ignored—testosterone.

Although testosterone is the “male hormone,” it also plays a vital role in female physiology, especially sexual function. Menopause reduces testosterone by about half, and studies indicate that topical testosterone replacement therapy can improve sexual function and desire (combined with estrogen) as well as musculoskeletal health and cognitive performance in postmenopausal women. More importantly, topical testosterone improves sexual function without causing any of the adverse effects commonly associated with testosterone usage in women, like hair loss, voice deepening, body hair growth, facial hair growth, breast pain or tenderness, or headaches.

Adding low-dose testosterone to a low-dose estrogen regimen may even be better at reducing somatic symptoms of menopause (sleep disturbances, hot flashes, and other physical symptoms) than a higher dose of estrogen alone.

Your Expectations Matter

Our big mistake was treating HRT as a panacea for the chronic conditions of aging. It’s not that smart hormone replacement can’t or won’t reduce the risk of certain diseases, like osteoporosis or heart disease. It’s that we’re still figuring it out.

A better, safer move is to focus on what we know HRT can treat: the symptoms of menopause.

Want to reduce hot flashes and get more sleep? HRT works.

Want to reduce anxiety? HRT works.

Want to improve cognitive function and your sense of smell? HRT works.

The use of bioidentical hormones may be safer or more effective against the bigger stuff. It remains to be seen. Until then, treat symptoms, not chronic disease—but keep in mind your overall risks and discern whether treating the symptoms is worth any additional risk for that bigger stuff.

Your Personal Context Matters

Women with a history of estrogen-responsive breast cancer (80% of breast cancers) should exhibit caution and check with their oncologist before taking any kind of HRT.

ApoE4 carriers should seriously look into taking HRT. In one recent study, postmenopausal ApoE4 carriers exhibited rapid cellular aging—except if they were taking HRT.

Whatever You Decide…

Don’t feel guilty if you decide to take some form of it. I myself take a small dose of testosterone to get my levels up to where they should be. My wife, Carrie, has taken bioidentical hormones in the past (a modest compound blend of estrogen, progesterone, and testosterone) to deal with the symptoms of menopause, including persistent brain fog that didn’t respond to any other herbal or alternative measure in her case. There’s no shame. This is restoration of what’s healthy and supportive of a good life. 

Heck, I know women who are both aware of the potential long term risks—heart disease, breast cancer, and the like—and enthusiastic about the shorter-term, more immediate quality-of-life benefits they currently enjoy. They prefer the definite benefits over the small and uncertain absolute risk increases. Some have even said that feeling better day-to-day gives them the energy to continue living a healthy life in other ways.

I also know women who do the opposite, who either are lucky enough to not experience any profound symptoms in their transition or who prefer to use other methods and interventions to deal with their symptoms in order to avoid any increased long-term complications. (I’ll delve more into this in the future if there’s interest.) Regardless, it’s all a choice.

Hopefully after today you feel better equipped to make an informed one.

What about you, folks? I know I have thousands of readers who are facing this very question—or who have already faced it. What did you choose? How did you handle the HRT question?

Thanks for reading. Take care!

References:

Wu WH, Liu LY, Chung CJ, Jou HJ, Wang TA. Estrogenic effect of yam ingestion in healthy postmenopausal women. J Am Coll Nutr. 2005;24(4):235-43.

Murkes D, Lalitkumar PG, Leifland K, Lundström E, Söderqvist G. Percutaneous estradiol/oral micronized progesterone has less-adverse effects and different gene regulations than oral conjugated equine estrogens/medroxyprogesterone acetate in the breasts of healthy women in vivo. Gynecol Endocrinol. 2012;28 Suppl 2:12-5.

Ruiz AD, Daniels KR. The effectiveness of sublingual and topical compounded bioidentical hormone replacement therapy in postmenopausal women: an observational cohort study. Int J Pharm Compd. 2014;18(1):70-7.

Stephenson K, Neuenschwander PF, Kurdowska AK. The effects of compounded bioidentical transdermal hormone therapy on hemostatic, inflammatory, immune factors; cardiovascular biomarkers; quality-of-life measures; and health outcomes in perimenopausal and postmenopausal women. Int J Pharm Compd. 2013;17(1):74-85.

Zeng Z, Jiang X, Li X, Wells A, Luo Y, Neapolitan R. Conjugated equine estrogen and medroxyprogesterone acetate are associated with decreased risk of breast cancer relative to bioidentical hormone therapy and controls. PLoS ONE. 2018;13(5):e0197064.

Schiff I, Tulchinsky D, Ryan KJ, Kadner S, Levitz M. Plasma estriol and its conjugates following oral and vaginal administration of estriol to postmenopausal women: correlations with gonadotropin levels. Am J Obstet Gynecol. 1980;138(8):1137-41.

Scarabin PY. Hormone therapy and venous thromboembolism among postmenopausal women. Front Horm Res. 2014;43:21-32.

Espeland MA, Rapp SR, Manson JE, et al. Long-term Effects on Cognitive Trajectories of Postmenopausal Hormone Therapy in Two Age Groups. J Gerontol A Biol Sci Med Sci. 2017;72(6):838-845.

Hodis HN, Mack WJ, Henderson VW, et al. Vascular Effects of Early versus Late Postmenopausal Treatment with Estradiol. N Engl J Med. 2016;374(13):1221-31.

Santoro N, Allshouse A, Neal-perry G, et al. Longitudinal changes in menopausal symptoms comparing women randomized to low-dose oral conjugated estrogens or transdermal estradiol plus micronized progesterone versus placebo: the Kronos Early Estrogen Prevention Study. Menopause. 2017;24(3):238-246.

Yazici K, Pata O, Yazici A, Akta? A, Tot S, Kanik A. [The effects of hormone replacement therapy in menopause on symptoms of anxiety and depression]. Turk Psikiyatri Derg. 2003;14(2):101-5.

Doty RL, Tourbier I, Ng V, et al. Influences of hormone replacement therapy on olfactory and cognitive function in postmenopausal women. Neurobiol Aging. 2015;36(6):2053-9.

Jacobs EG, Kroenke C, Lin J, et al. Accelerated cell aging in female APOE-?4 carriers: implications for hormone therapy use. PLoS ONE. 2013;8(2):e54713.

Kingsberg S. Testosterone treatment for hypoactive sexual desire disorder in postmenopausal women. J Sex Med. 2007;4 Suppl 3:227-34.

Davis SR, Wahlin-jacobsen S. Testosterone in women–the clinical significance. Lancet Diabetes Endocrinol. 2015;3(12):980-92.

Achilli C, Pundir J, Ramanathan P, Sabatini L, Hamoda H, Panay N. Efficacy and safety of transdermal testosterone in postmenopausal women with hypoactive sexual desire disorder: a systematic review and meta-analysis. Fertil Steril. 2017;107(2):475-482.e15.

Simon J, Klaiber E, Wiita B, Bowen A, Yang HM. Differential effects of estrogen-androgen and estrogen-only therapy on vasomotor symptoms, gonadotropin secretion, and endogenous androgen bioavailability in postmenopausal women. Menopause. 1999;6(2):138-46.

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89 thoughts on “The Pros & Cons of Hormone Replacement Therapy for Primal Women”

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  1. I’m one of those “lucky” ones who never had much in the way of menopause problems. It came and went and I scarcely noticed. I think one of the main reasons for that is probably heredity. My mother never had problems with it either. I think another factor is that I always ate a relatively healthy diet, all the way back to early childhood. I ate a lot of good protein, fruit, and vegetables, and never cared much for pasta, pizza, junk food, processed foods, etc.

    I did not do any HRT. I didn’t need to. Some women do need it, but if it were me, I’d try natural approaches first.

  2. Thanks Mark! This is the article I have been looking for for YEARS. There’s more good information here than anywhere else I looked, and certainly way more than I got from my doctor. I have the subcutaneous pellet HRT. It has relieved hot flashes but not much else. Also it is expensive and not covered by my insurance, which is another story altogether. You can get viagra on any street corner practically but if it’s for women’s health, forget it.

    1. Susan–I did the pellets for about a year. It always seemed like they could never get my levels right. And yes, it was expensive and not covered. I eventually quit it, found a good OB-Gyn who was versed in bio-identicals and now I am feeling better. I’m with you on the lack of coverage for us too.

  3. I’m actually on progesterone only HRT and a very low dose, and only because my hormones were all over the place and triggering migraines. A small bit seems to have brought some balance which has improved quality of life. Cleaning up my diet several years ago improved most of the symptoms like hot flashes, but losing full days on a regular basis to migraines was not acceptable and the homeopathic options my natural path tried first weren’t enough

  4. Thanks for this post Mark! I hit menopause at age 50 and really wanted to avoid hormones at all costs. I tried all the natural methods and after 6 months of no sleep, waking up 3x a night soaked to the skin, 7-8 hot flashes a day in meetings with rooms full of men I had to do something. I was such a wreck at that point I would have done just about anything. I think we need to open up the conversation more. When I mention that I’m in menopause people are shocked that I “admit it”. People judge my choice to take hormones for 2 years which were a life saver for me. Let’s remove the shame/stigma/judgment and help one another!

  5. Bio identical hormone replacement has been the best thing I ever did for myself and those I love. I was in my early 40’s when I became peri-menopausal it was affecting my health and my relationships. Once I began treatment I immediately felt better and my hormone levels were good around 6 months after beginning BHRT. I’ve been using BHRT for almost 10 years and I am a very healthy, happy woman with a great marriage and sex life. The key is to finding a practitioner who tests regularly, prescribes to your individual needs and listens to you about how you are feeling, not just what the numbers say. It is not a one-size-fits-all cure. Different people feel better at different levels. I truly believe that many marriages could have been and still could be saved if this was more available. (It is hardly ever covered by insurance and it isn’t cheap!) I encourage men and women in their 40’s and 50’s to look into it.

    1. I completely agree with you, Lori. I’ve been on BHT for several months now and the difference in all menopause symptoms makes the price well worth it.

      I am also taking BHT to increase bone density as I have *osteoporosis* as defined by the WHO (so suspect) and my clinician has other patients who are improving dexa scores on BHT. So far so good.

      Thanks Mark for addressing this issue.

    2. I agree. It has taken almost a year to feel better since I started bioidentical hormones, but I was miserable for about 3 years before that. I have always been healthy and active, thankfully, so I was confused by all the sudden pre-menopause symptoms. These included severe aches and pains, 6 months of hives, brain fog, depression, loss of muscle strength, etc. All blood work and doctor visits and tests said I was “fine”. I am astounded that pre-menopause could destroy my health, fitness, and well being so suddenly. While I still can’t drop the extra weight yet, I am able to think and exercise again. I’ve done a lot of reading to educate myself. I eat healthy and do everything recommended but that’s only a small drop in the bucket. I needed the extra help. I’ll keep getting my blood work done and track my health. Good luck, everyone. I empathize.

    3. I’m with Lori! I have been doing BHT with an attentive, expert hormone specialist since my hysterectomy in 2015. My uterus was destroying my life— adenomyosis, PMDD, depression. I probably lost six months or more of my life in week-long chunks of abject, debilitating misery. Once the offending organs were gone, obviously so were my hormones, and that was a whole new nightmare. BHT has given me my life back. I would never have believed that things like depression could be cured by balancing my hormones, but it sure did! I replace estradiol, progesterone and testosterone, and get regular blood work to make sure the levels are where they need to be. I am healthy, happy and active in ways I could never have dreamed possible before this. I tried everything out there to deal with this before I resorted to surgery and BHT, for close to ten years. If other solutions work for you, that’s fantastic and I envy you. If you’re suffering and other things aren’t working, find a good hormone doc. You’ll never look back!

    4. Lori, I’m curious as to how BHRT differs from regular HRT from the user’s standpoint. I read somewhere (written by an MD) that there’s actually no difference, and that the “bio-identical” label is just a marketing gimmick.

      In other words, if you tried both, did you notice a distinct difference with the way you felt on the bio-identical versus the older stuff (like Premarin) that they’ve prescribed for years? I know the older stuff never worked well for some women, although I have no personal experience with either one.

      1. I would surmise the medical doctor would say its a gimmick, he gets a kickback from the pharmaceutical companies on his sales. You can look that up too. The fact that women have to pay out of pocket for bio-identical is criminal. Like a previous poster wrote, Viagra is available on the web and every street corner without a prescription, but when it comes to women no deal. To answer your question, yes there is a difference, I was on both and bio-identical has vastly enhanced my life as in the ability to continue to mountain bike, lift heavy and continue on with my physical lifestyle, something men don’t have to worry about. Fake hormones made me feel old, so what really is the gimmick? I am currently on Bi-Est and Progesterone and thinking of adding the lowest amount available of testosterone. I have been on this for the past 10 years, since age 50 and I’m still competing.

        1. Thanks, Anna. That’s good to know. I’m sure other women have wondered the same thing. It was actually a female MD who wrote the article. That doesn’t mean she knew what she was talking about.

          Over the years I’ve paid for quite a few things out-of-pocket that worked better than conventional treatment but insurance wouldn’t cover. It’s just one of the many flaws in our health care system.

  6. Thank you, Mark, for tackling a difficult subject and for simply taking into consideration that there are concerns specific to peri-menopausal and menopausal women. It is very much appreciated.

  7. Mark, there is a paucity of good, quality research on bio identical, transdermal HRT options. I believe the Danish and French have a few studies out that support the efficacy and safety of bio identicals. But more updates studies need to be done!

    The WHI study’s results were horribly misrepresented and virtual ‘soundbites’ of info that should never have been released publicly, were poured forth to the media, creating unnecessary hysteria. The data had not been properly analyzed or interpreted and yet info was released.

    You would need to read Dr. Robert Langer’s paper (one of the PI’s in CA working on/with the WHI study to appreciate how poorly the study results were handled : http://www.imsociety.org/manage/images/pdf/9a32c2843c497e275d1851b2bdff46a3.pdf

    Every woman should carefully read this paper before deciding on HRT. It is nothing short of a revelation about what the WHI study was actually looking at, how the data was gathered, who the results really applied to, and how information disseminated to the public was grossly misconstrued. It will make you rethink everything you ‘know’ about the WHI study and the collateral damage that resulted from the mishandling of communication about its results.

    of I’m not speaking of compounder creams as these can be uncertain I terms if potency and most Insurance will not cover it. Bio identical estrogen patches are readily available, FDA approved/tested and at this point, no one should be using old generation, synthetic oral HRT preparations. Progesterone is the tougher hormone to use transdermally in terms of adequate absorption to offset the effects of high or moderate dose estradiol. But oral, micronized natural progesterone has been available for years. Between the estradiol patch and oral progesterone, very good bio identical options exist that eclipse the old school use of Premarin, Prempro, etc.

    1. Having a good doc is key. We had to experiment with different delivery methods to get my levels dialed in. In theory, oral progesterone absorbs better. In my body, that is not the case, and a custom compounded cream works great. I get my estradiol and testosterone in pellets (subdermal), again because that’s what is working for me. Just because the stats say a thing works does not mean it works for YOU. A good doc will test your levels regularly and help you get exactly what you need, how you need it.

    2. In regard to progesterone. My body does not like it. I swear it raises my blood pressure and when I tried the estrogen/progesterone batch I thought my heart was going to explode. Now I’m on estrogen/testosterone pellets and I take the progesterone vaginally at night. It dissolves nicely and I have no issues. I was told by a doctor about 10 years ago that this is something done in Europe.

  8. Like Shary, I didn’t think I was experiencing any overt symptoms of menopause and counted myself lucky, but a naturopath that I trust suggested I try progesterone for my insomnia (at age 55). Turns out that insomnia was my symptom and I sleep beautifully with progesterone. I’m paying close attention, however, to your comments about oral vs. transdermal and will be discussing that issue with my naturopath and/or pharmacist because I do tend to suffer swollen ankles and that issue has been more pronounced in that last year or so, and might correlate with starting the progesterone. Thank you for the article!!

  9. I’m 49, and in perimenopause. Occasional hot flashes, loss of libido, and panic attacks (which have almost disappeared on their own) have occured. Unfortunately, or fortunately, I can’t afford health insurance so I will be going through it drug free. It’s a natural process, and it will be what it is.

    1. That’s what I said at 49. I’m 64 and not sorry. But I recognize that it’s not the right choice for everyone.

  10. Mark, thanks for this write up. To properly put into perspective the near-hysteria that was created by the WHI study in 2002, every woman (and/or man) owes it to themselves to read Dr. Robert Langer’s paper published last year that breaks down the reality of exactly WHAT this study was designed to do, who the results applied to, and how these results were grossly misrepresented in the ensuing ‘soundbites’ that hit the media which were then picked up by doctor’s offices across the country, changing protocol and practice recommendations nearly overnight.

    His paper is seminal in understanding the behind-the-scenes of this study not least of all because he was one of the PI’s (in California) working on/with the WHI study. He was there, he was on the inside, and the information is both fascinating and, at the same time, infuriating. It is truly a must read.

    I do use HRT, in low dose. I use bio identical estradiol patches and natural, micronized progresterone capsules. They are FDA approved and tested, are not synthetic and do not have some of the same risks as the older, first generation synthetic HRTs used in the WHI study. Much, much more research needs to be done with studies using current generation HRT. I believe the Danish and French have done some studies with validate the efficacy, safety and health-benefits of current generation formulations.

    Here’s the link to Dr. Langer’s aritcle: http://www.imsociety.org/manage/images/pdf/9a32c2843c497e275d1851b2bdff46a3.pdf

  11. A very interesting article. Thank you. I’ve been on HRT since about 50 and it works for me. I am interested in the transdermal and will probably discuss this with my doctor. I’ve also been wondering about my testosterone levels and plan to check those out as well. Thank you again for this information.

  12. Mark, thanks for this write up. To properly put into perspective the near-hysteria that was created by the WHI study in 2002, every woman (and/or man) owes it to themselves to read Dr. Robert Langer’s paper published last year that breaks down the reality of exactly WHAT this study was designed to do, who the results applied to, and how these results were grossly misrepresented in the ensuing ‘soundbites’ that hit the media which were then picked up by doctor’s offices across the country, changing protocol and practice recommendations nearly overnight.

    His paper is seminal in understanding the behind-the-scenes of this study not least of all because he was one of the PI’s (in California) working on/with the WHI study. He was there, he was on the inside, and the information is both fascinating and, at the same time, infuriating. It is truly a must read.

    I do use HRT, in low dose. I use bio identical estradiol patches and natural, micronized progresterone capsules. They are FDA approved and tested, are not synthetic and do not have some of the same risks as the older, first generation synthetic HRTs used in the WHI study. Much, much more research needs to be done with studies using current generation HRT. I believe the Danish and French have done some studies with validate the efficacy, safety and health-benefits of current generation formulations.

    The link to Dr. Langer’s aritcle can be found at the imsociety dot org. You would down through the articles to find Dr. Langer’s piece in the March 2017 section. I’m not sure if websites are allowed to be put in the comments, hence the way I’m directing you.

  13. I apologize for the multiple posts!! I was getting error messages when trying to post so had to retype my responses again and again. Sorry!

  14. Menopause is not natural! Women live longer and as a result have more toxins and less minerals. If a body IS NOT full of toxins and IS full of the right minerals and ratios of minerals, the hormones will remain in balance. For example, an out-of-balance ratio of sodium to potassium can cause tissues to swell. High copper symptoms mimic almost all symptoms of PMS, like ‘irrationa’l anxiety and insomnia, and electrical hyper-sensitivity. You can take all the synthetic hormones your doctor can convince you that you need, but if your minerals are out of balance your symptoms may persist.

    1. Can you guide us to more information about this mineral balancing, and maybe how to go about it?

  15. No mention of BHRT in the form of pellet therapy. Would love to hear thoughts and know study info on that.

    1. I get my estradiol and testosterone as pellets. It’s expensive, and it’s a bit inconvenient to go in for “surgery” (Which it technically is albeit very minor and quick) every 4 months. And that butt cheek hurts pretty bad for a day or two. LOL. But all the rest of the time, it is the BEST THING EVER. One interesting thing about it is that pellets are not “time release” As you would expect, but rather the hormone releases based on your activity level. So if you’re mostly pretty sedentary, it releases more slowly and one pellet lasts a bit longer, whereas if you are very active your body will burn through the hormone a little sooner. This doesn’t seem to affect how the hormone works, at least for me, but I do notice when I have a particularly active or busy calendar quarter, I’m wanting my new pellets sooner. You can definitely feel the difference as the level gently increases and decreases over the life of the pellet, and you will know when it’s time for your next one. Hope this helps. I’m happy to answer questions about pellets, as a happy user….

      1. Tracy,
        I am also getting pellets, the first surgery I felt most better but the second time I am not getting the same results. I am gaining weight, more Moody, gaining facial hair, not sleeping well and more anxious. Now I don’t know what to do.

  16. Mark,
    If you’re comfortable, I’d love to hear a little more specifically with which hormones you supplement. I’m 25 years behind you on the calendar, but I would love to have the energy (and body!) you have today.
    Thanks for all you do,
    Sam

  17. Thanks for addressing this, Mark! I had to have my uterus and one ovary removed when I was 43, as I had a benign mass growing that took over. The remaining ovary produced enough hormones that I avoided full-blown menopause until I was 52. I started taking BHT not long after that due primarily to insomnia. I take transdermal estrodial/testosterone and progesterone in a capsule at night. I am now 58 and enjoy still an athletic lifestyle, lean and muscular physique, healthy libido and my sleep is generally ok, though not what it was prior to menopause. I can enthusiastically vouch for BHT.

  18. I’m in my second year of symptoms and have concerns about taking HRT therapy due to both breast cancer and heart disease in my family. I’d love to hear more on alternative options. I dabbled a bit with some essential oils but probably didn’t try it long enough to see if I would get good results.

  19. A good book to read about this is “The Estrogen Window” by Dr. Mache Seibel, I recommend this book for every woman over 40 so they understand all the pros and cons of taking HRT. The book convinced me to get bioidentical HRT when the time comes. But it should also be noted that it’s very important to get tested and monitored when doing HRT, and not to self-medicate. Going overboard with too many hormones can have disastrous health consequences. You really don’t want to create a hormone imbalance in your body.

  20. Thank you for mentioning the importance for apoe4’s to strongly considerIng BHRT. More information is available at APOE4.info.

  21. Because I have ridiculous health insurance ($12.5K deductible, basically no coverage), I opted to go natural. I am researching natural solutions, and do believe that Eastern medicine has always had the answers, but not much is said about it in the mainstream. I’m just taking Shatavari powder right now, but it’s not a whole solution. Ellie’s comment about mineral balance is interesting…

  22. Pregnenolone…OMG. Life changer.

    Perimenopause, late 30’s and full-on menopause early 40’s…tried the balancing act of HRT and just*couldn’t*get*it*right.

    Somehow during Internet rambling, stumbled across an interesting term…”precursor hormone.”

    Further digging led me to pregnenolone.. which is a precursor of the more-familiar hormones like cortisol, estrogen, progesterone, testosterone, and DHEA. Started out high end dosage–50mg x1 a day for 2 weeks..hot flashes calmed down, went away, and then teenage acne..wow, full circle indeed.

    Started backing down the dosage, and now I take 10mg first thing in morning with my coffee. VERY reasonably priced…no prescription needed; can find at health food stores or trusty Amazon too: https://www.amazon.com/Swanson-Pregnenolone-10-Milligrams-Capsules/dp/B00068U8OO/ref=sr_1_32_a_it?ie=UTF8&qid=1536183693&sr=8-32&keywords=prenenalone&th=1

    BTW…I’m 58, in good health & this is what works for me; like anything else…your mileage may vary but worth a shot 😉

  23. Excellent article, Mark. I went into Menopause at 46 and have not done anything. At the time, I was unsure of conventional HRT. I considered bioidentical hormones, but thought I’d see how it went. I’m 63 and I have night sweats, trouble staying asleep several times per week, but I’ve managed. Although the Primal Diet hasn’t eliminated these experiences, I feel extremely healthy and vibrant, as you mentioned in this article. So, my zest for living outweighs my issues with a perfect night’s sleep every night.

  24. I would oppose the claim that natural selection has determined that middle-aged women aren’t worthy of pregnancy, that natural selection is the rationale for your claim that humankind is better off without middle-aged women reproducing.

    The reality is that only in the last century or so, have women regularly survived past menopause. Worse, for all of human existence, women regularly didn’t survive childbirth. As well, evolution needs much more time than a century or two, to show the results of natural selection.

    So to use the argument that natural selection compels the elimination of unworthy middle-aged women from reproduction while worthy males make contributions to the gene pool unto the end of their lives, without first explaining how natural selection didn’t discard women altogether considering the lethality of childbirth, as it was for most of humankind’s existence … seems like incomplete, confused.
    pretty discriminating conclusion-jumping.

    Also noticing that the claim is illustrated by a model middle-aged male with implied virility, as the article writes that middle-aged women are basically discards of natural selection.

    Not admirable at all.

    1. (continued)

      If not for the appalling and author-unflattering pre-amble, the article might be construed as having merit. But the pre-amble / premise puts a halt to any charitable reading.

    2. I think you have seriously distorted and misconstrued the intent of Mark’s article. Never did he intimate women past child bearing years were ‘unworthy’ or being ‘discarded.’ In fact he made the opposite claims about their importance in society. And did it not occur to you that as the body ages, perhaps the decline in fertility is a natural physiological protective mechanism to both mother and potential child? Not only are there vastly increased chances for serious genetic abnormalities in the fetuses of women who get pregnant (naturally) closer to menopause, but the risks to the health of the woman also increase quite a bit. Food for thought.

  25. Hi Mark & Carrie,

    I’m 54 & am perimenopausal although I see my periods dwindling recently. Due to vaginal dryness, brain fog, emotional lability, & severe night sweats I started low dose Prempro last May. At first I saw immediate positive results. Now 4 months later I feel I’m slipping back to my former symptoms. I’m consulting my gyn re: BRT as I feel the testosterone added to the mix may help me. Love your blog!

  26. I’m glad you posted this article. It’s timely for me because I’m unhappy with the topical I was prescribed. I am eager to read any follow-up articles.

  27. I am firmly in perimenopause with 6 “months to go” before I can be called menopausal. I was having some hot flashes and night sweats before trying a 24 hour water fast for some other health issues. I was really surprised when my menopause symptoms went away! After a couple weeks, they came back, so I fasted 36 hours. The symptoms are still gone about a month later. I do experience fatigue and brain fog, but those could be resulting from my autoimmunity or my fast paced, physically demanding job. So, I haven’t even looked at HRT. Now I wonder if I should explore it.

  28. Love the shame free approach. I really despise when “alternative medicine/health” sites act as though modern medicine is something akin to the devil. A blend of the two modalities can be just the ticket and wise especially when dealing with the long-term effects of perimenopause/menopause. Women need to stop being martyrs and doctors, especially male doctors, need to start listening more carefully to their concerns about symptoms.

  29. It’s all too complicated and we are the guinea pigs.
    Even natural things have effects – my aunt developed breast cancer after doing that yam cream thing.
    If there are other natural oestrogen/ testosterone/ progesterone alternatives please do an article on that.

  30. Mark can you direct me to information for men who are in testosterone suppression as a prostate cancer treatment?

    My husband is on it now and he’s a mess at times.

  31. I have been taking “Wiley” protocol BHRT now for 9 years. I have blood tests every six months with my dr and when I choose to I do at 24 hr Dry urine test (DUTCH). Before going on BHRT at 51 I was a hot mess ALL the rotten symptoms…
    One month in and still continuing, I feel like a 20 year old. I am very healthy and active at 60, I lift weights, do a Ketogenic diet, and am loving life.

  32. Thank you for this informative article.

    One small error I’d like to point out – the progestin used in the WHI was Provera. Prempro is a combination of Premarin and Provera.

    My physician prescribed me transdermal estrogen patches when I began menopause and it helped combat the hot flashes I was experiencing, as often as four or five an hour. With DHEA spray I was eventually able to transition to the lowest dose available of the patch.

    My physician at the time suggested that I only be on HRT for five years. When that time arrived I tried weaning myself off. However, after about six months of using Black cohosh and Estrovera and having miserable sleep from the dang hot flashes I finally threw in the towel and resumed HRT.

    Now I’m weaning myself back down to the lowest possible dose of the patch. I sleep much better and I’m not miserable from the constant flashes.

    While I wish I didn’t have to take HRT it allows me to live comfortably. Opinions have changed about keeping women on hormones, which I’m glad about. Constantly flashing is no way to live one’s life. Thank you, Mark, for putting this in context with the Primal lifestyle.

  33. I was so glad to see this article, thank you! I follow a primal lifestyle but just couldn’t shake the brain fog and then started having such bad night sweats that I was waking up every two hours in a puddle. During the day I was having multiple hot flashes and kept gaining weight even while being primal and exercising like normal. I couldn’t take it anymore and finally tried BHRT after blood tests showed my hormone levels were extremely low. I was desperate and felt I had tried everything else.

    I can’t tell you how much better I feel after just one month. I am sleeping through the night and no longer have hot flashes during the day at all! Hopefully my brain fog will lift as well and some of this extra weight will start to come off too! I have more energy and feel eager to work out, whereas before I did it because I had to but without as much energy.

    I will say that most insurance companies do not cover BHRT, so depending on which hormones you need it can be expensive. I had to weigh the cost of being miserable over the cost of feeling better and it was worth it for me personally.

    It may not be right for everyone, but it is worth a try if you have tried everything else and are still miserable!

  34. I had surgical menopause (due to cancer) 34 years ago. I agreed to removing the ovaries as well as uterus, but insisted that I would not take anything ‘foreign to by body’ when prescribed Premarin, aka horse urine. (I also refused radiation, etc.) One year later I was back in the doctor’s office begging for the Rx. My symptoms went WAY beyond hot flashes. I would not answer the phone, I thought everyone was against me…a basket case. I should stop here to mention that I was always what is known today as a health nut. So much so that I was washing my hair with egg yolk to avoid the products with sodium laurel sulfate. This was before the onslaught of toxins needing to be dodged today. The Premarin did the job & I had my quality of life back. When the study results came out, I switched to natural HRT and was given testosterone, progesterone, DHEA, & thyroid in addition to my Bi-est form of estrogen. I have since cut out the estrogen as it was medically assessed as the probable cause of the cancer from having taken birth control pills for a year, 10 years before I discovered my uterine cancer. Today I use just progesterone & testosterone creams in about half dose of what is prescribed.

  35. Thank you, Mark. I too really appreciate this article, as well as your other recent pieces on menopause. I started BHRT at age 45 after a complete hysterectomy. Before starting the hormones, I hadn’t even filled a prescription in years, and I generally try to stay away from medication. But I admit that HRT has made a huge difference in quality of life for me. My original plan was to use it to bridge through to when I’d likely have gone into menopause, and I’m now 50 and deciding next steps.

    The quantity of cited sources here will be useful for me, and I’ll read through them. My doctor wants me off progesterone and doing estrogen-only, and I’ve been reluctant to make that change and uncertain that the combo is actually a problem (higher risk of breast cancer) when using bioidentical. In general, as others have said, this is a thorny and confusing topic. I’m glad to have resources.

    I’d love to hear about non-hormone options for those of us who cycle off hormones and those who choose not to use HRT at all. Keep ’em coming! We women are grateful!

  36. Good lord, Mark-are you a wizard? Peering into my anxiety soaked brain? At mid-50s I feel lucky coming to disruptive peri-menopausal symptoms later than most, but it stomped on my head this week, for sure. My quality of life has declined immensely and so precipitously this week that it is alarming. I am running to my practitioner for options on BHRT.

  37. I use bioidentical hormone therapy by pellets and natural progesterone by capsule. It works. I had hair loss and stopped for 10 months. Went back on due to severe hot flashes. I feel better. My hair is a bit better. I’m on a lower dose now. It’s an out of pocket expense but so are herbs and supplements. Those didn’t work well for me. My mother had terrible flashes and sweats until she was 76! My quality of life is much better. Alcohol and caffeine worsen hot flashes as well as vitamin b 6.

  38. Great info Mark! Thank you for delving into this generally unpopular conversation due to the reality it brings to the aging process of women! And none of us enjoy that convo much I suspect ?
    I am most interested in any future studies and general information you come across.
    As you said, it really is a personal & unique experience for each woman and as such is the decision about HRT. I’m 55 & post for 5 yrs with no HRT. I don’t suffer like some women but my dilemma is SHOULD I consider HRT for future health! I’ve avoided due to family history.
    I lost both my mother (@69) and her sister (@62) to breast cancer after having been on Premarin for YEARS.
    I ALWAYS felt that was the culprit and only in the last 10 or so years has anyone had the guts to allude to it.
    Emotionally there’s deep anger…but I also realize we don’t know what we don’t know at the time and if we’re better now, then ok. What will we know 20 years from now? It’s just the circle we humans travel in it seems. The conspiracy theorist in me thinks the side effects were known ….by I can’t prove that 😉
    Anyway. I digress. Again please keep sharing what you’ve learned. It’s so valuable and so appreciated 🙂

  39. Excellent synopsis Mark.
    I am a nurse practitioner and postmenopausal
    I am am often baffled by the misinterpretation of the study. In many ways it’s not well done and leaves many things unanswered
    Starting older post menopausal women on Premarin for the first time in their lives is not the same as women today who have often been exposed to oral contraceptives from their teen years and the majority of their lives . Nobody I know would even consider taking Premarin. Topical is very different than oral .
    Well done and I am sharing your comments with several friends

  40. HRT never worked on me. tried it for 6 months, but hot flashes, nightsweats, weight gain and irritability never stopped. Now I just sit it out and wait that it might be over sooner or later, after three years it is time 🙂
    I feel better to not taking any pills/medicine anyway, because that does not feel natural to me.

  41. I’ve been taking bio-identical hormones for about a year now, and haven’t looked back. They’ve taken care of all of my menopause symptoms (I was having hot flashes every 30 minutes to the point where I drowned my computer mouse in a puddle of sweat). Thanks for a great article! It’s cleared up some of my questions.

  42. Also to throw into the mix – Premarin (PREgnant MARe urINe)- obtained from the urine of horses, is obtained in a most unpleasant way. The mares are kept much like battery hens, confined to collect urine and put constantly into foal. As soon as possible after birth the foals are removed and the cycle begins again.

  43. Hello Mark,
    Thank you for this very informative article. I would be very interested to hear about other methods and interventions to deal with menopause symptoms in order to avoid long-term complications that you mention in the end of the article. I live in a country where HRT is not readily available and very rarely prescribed by doctors so learning about other methods of alleviating the symptoms would be a life saver.

  44. Very informative article, as usual. Thanks for taking the time to research and write about this topic, and also provide the references! I’m facing this particular stage in my life and have been wondering how to best tackle it, you have given me some pointers to consider for my journey! Much appreciated.

  45. I did bio identical hormone therapy that was supervised by an M.D. I did minuscule amounts of testosterone or progesterine and estradiol. After about nine or 10 months of that therapy I ended up in the emergency room with a spontaneous cardiac artery dissection. SCAD. I was immediately taken off all hormone therapy and it was told to me that the testosterone and the other hormone therapy had thinned my arteries to the point where they were tearing. I’m not saying this is going to happen to everyone but it did happen to me and scad is definitely hormone related. There was a study done years ago on the birth control pill Provera that had to be ended early because too many of the participants Were having heart attacks. I just want to warn women out there that no amount of anti-aging benefit is going to be worth having a heart attack. I was lucky I survived my scad but 80% of women who have this situation are diagnosed at autopsy.

    1. That’s terrifying, and I’d never heard of it. Even though it’s rare, it’s a potential risk worth knowing about. Thanks for sharing.

  46. “Smoking gun” difference between synthetic and bio-identical estradiol
    Redox Cycling of Catechol Estrogens Generating Apurinic/Apyrimidinic Sites and 8-oxo-Deoxyguanosine via Reactive Oxygen Species Differentiates Equine and Human Estrogens

    Abstract
    HTMLFull Text HTML
    PDFHi-Res PDF[864 KB]
    PDFPDF w/ Links[374 KB]
    Zhican Wang, Esala R. Chandrasena, Yang Yuan, Kuan-wei Peng, Richard B. van Breemen, Gregory R. J. Thatcher and Judy L. Bolton*
    Department of Medicinal Chemistry and Pharmacognosy (M/C 781), College of Pharmacy, University of Illinois at Chicago, 833 South Wood Street, Chicago, Illinois 60612-7231
    Chem. Res. Toxicol., 2010, 23 (8), pp 1365–1373
    DOI: 10.1021/tx1001282
    Publication Date (Web): May 28, 2010
    Copyright © 2010 American Chemical Society
    * To whom correspondence should be addressed. Fax: 312-996-7107. E-mail: judyb@uic.edu.
    Abstract

    The greater redox activity of the equine catechol estrogen produces rapid oxidative DNA damage via ROS, which is enhanced by redox cycling agents and interestingly by NADPH-dependent quinone oxidoreductase

  47. Hi Mark and all,
    I’ve used BHRT Pellet Insertion therapy for 15 years and I can truly say my health is better than it’s ever been in 62 years. BHRT is not the only remedy I use to feel great and look years younger than my age – I also have a supplement program based on my annual blood work along with eating a primal type diet of organic / non-GMO / antibiotic free / healthy fat / low carb foods.

    We are lucky today that we have the benefit of our ancestors, but we can also research modern techniques for treating our ailments – for me, naturally occurring remedies are always preferred! For those of you suffering – do your research and make your own informed decision. Everyone responds differently and your health is up to you first and foremost. But, if you want more information about BHRT Pellet Therapy – check out some of the information I’ve found in the past:

    This was the first site I found 15 years ago – the doc was too far away for me to see, but I had a phone interview and he helped me find a local doctor. Website has changed some since then – but still extremely informative:
    https://menopausehysterectomy.com/chats-with-dr-n/

    Do not have first hand experience with this particular doctor – but his FAQ list is awesome:
    https://derosamedical.com/hormonal-pellet-faqs/

    And if your a woman who has lost her libido like I did those many years ago – you are going to thank your lucky stars for Testosterone therapy! 🙂 The right combo of hormones will make all the difference for so many issues you may experience after menopause or even pre-menopause. Find what is right for you and a doctor you trust.

    Cheers,
    Becky

  48. Wow, excellent info! So far I have not delved into this at all. At 52 I still have regular menstrual cycles and have never experienced a hot flash. I feel extremely balanced. I think being keto most of the time has really helped me. I also incorporate maca from time to time (I’ll use it for a few weeks, then stop for awhile. Years ago I read that eating a raw carrot with the skin on every day helps to balance hormones in both men and women. I’ve been doing that for years. In fact, back in my mid 40s my cycle was shortening a bit. That’s when I started the raw carrots and very gradually it went back to 28 days. All this being said I am totally open to HRT if the need arises. But right now I feel pretty amazing.

  49. After a couple of years of following a primal/paleo lifestyle, I had reversed several health issues and stopped the progression of my osteoporosis. However, because of my bout and treatment of endometriosis in my early 20s, my hormones were too far out of whack for me to be able to reverse osteoporosis on my own. Under the supervision of a functional medicine doctor, I used compounded bioidentical HRT, with the dosages and application methods changing with my body’s changes. In about 1 1/2 years we confirmed that my bone density had increased to almost normal levels. It’s been about 2 years since I stopped the medication (side effects started outweighing benefits), and I continue to enjoy great health.

  50. Mark, I am extremely gratified that you published this article, and the timing is uncanny. As a blissfully happy Primal Woman for 7 years, I have been staunchly opposed to taking a synthetic drug to treat my burgeoning symptoms of hot flashes and brain fog. After reading this article, I am patronized, and considering a change of heart and mind. You mentioned that if there were enough interest in the long-term consequences, you would elaborate further. I AM INTERESTED! Information on that would tip the scale for me, and I may yet return to the quality of life I enjoyed for the first 50 years of my life, and especially the first five of the last seven years. Please publish more. One other comment below remarksed, “this is the article I have been waiting for for years!” That is me, too.

  51. I have SVT’s. I’ve been told by my medical team that I am not a candidate for HRT simply because they’re said to increase heart rate which might increase SVT’s or A-fib.

  52. Love the info, but can you send articles or info that would help the millions of women that take synthroid?
    No matter what food I eat, the weight stays on and continues. My thyroid was removed a few years ago and I’ve added 50lbs and can’t find the right food to keep the weight off. Any info would help..

    thank you

  53. One major concern not addressed here is urinary incontinence and UTIs. I started Vagifem early for vaginal dryness (helped greatly, along with dry eyes, by Primal) and have maintained it or similar to keep the tissues healthy and functioning. I don’t want to end up as an old woman unable to hold urine or getting UTIs and requiring catheters. I use OTC BiEstro Care and ProGest 2x day, applied to the labia as recommeded by Dr Mercola, and Vagifem obtained from an overseas pharmacy 2x week.

  54. Mark,

    This is a suggestion for a future post. I get the sense that many people do not fully understand the difference, at the molecular level, between a synthetic substance and a natural (or bio-identical) substance. This is understandable since we are led to believe that the synthetic substance is “identical” at the molecular level to the natural substance. But this isn’t strictly true. I would love to see an article flesh out the differences between synthetic and natural to help people see why they don’t have the same effects in the body.
    Thanks!

  55. Thanks Mark! I didn’t want to resort to HRT, but the symptoms after menopause were unbearable! Trans-dermal, bio-identical hormones from a compounding pharmacy, prescribed by my Functional Medicine Doc were totally the answer for me. It was like flipping a light switch! I will experiment at some point with a lower dose, but for now I reach for that bottle every morning like a thirsty Mother Grok in the desert!

  56. I’m fairly active in the menopause community and am on several large, worldwide menopause forums. I see a number of women here talking about pellet therapy. I don’t really know anyone on the boards I’m involved in using pellet therapy. With transdermal patches and topical creams/pessaries/vaginal progresterone, it seems odd that anyone would choose an implant which has to stay in place for months. I’ve also read the efficacy and safety of pellet therapy has not been well documented, whether or not users are getting the good results they want. This article highlights some of the issues with pellet therapy.

    https://www.healio.com/endocrinology/hormone-therapy/news/online/%7Bc3d60b3e-70a0-45d8-aa57-ca90b1e45800%7D/significantly-higher-side-effects-with-pellet-vs-fda-approved-ht

  57. Thank you, Mark, for this great article. It’s just what I needed.
    I started on bio-identical HRT several months ago & use estrogen & testosterone topical creams, oral progesterone (3 weeks on & 1 off), & an estriol suppository. I’m 4 years post menopausal, & my sex hormones were measured to be well below normal for a menopausal woman. I was very skeptical & fearful of HRT but must say that trying it has been life changing in a very positive way. I never expected it to make me feel as good & “whole” as I do now. I didn’t suffer night sweats or hot flashes much but did have insomnia & anxiety that were at times debilitating. Though sleep still eludes me at times, I am sleeping better & my anxiety is gone. I just feel all over healthier in a subtle way.
    For me the risks are worth taking for the benefits.

  58. It is uncanny how posts on MDA seem to parallel my life almost perfectly. I turned 49 this year and the perimenopause symptoms started and there was Mark with a post about Primal women getting older (April 2018). Now I’m a few weeks into taking HRT and he’s got another perfectly timed piece!

    I use estradiol topical cream 3x/day and 100mg oral progesterone. So far so good – the hot flashes are gone. I’m convinced by the science on bioidentical hormones to stick with the progesterone for the long-term.

  59. What a truly wonderful article and great informational comments from women in this stage of life. I believe like so many here that this topic should be discussed more openly between men and women and not be stigmatized. There is so much to learn. Anecdotally, I am in menopause and have been for a year and a half (I am almost 51). I have noticed that a keto diet and intermittent fasting since March 2018 has not only helped me lose the extra 25-30 pounds I put on in my 40’s, this diet has alleviated my issues with night sweats, hot flashes, headaches, and insomnia. I periodically have mild hot flashes and morning headaches when I have consumed (as an exception to my generally strict LC regime) something sugary like a few glasses of wine or some rando dessert. Do any other menopausal women notice this about keto diet and sugar?

  60. Great article, but I think you want to include the data in the recently published study by Yoon, et al., which demonstrates potential cognitive benefit estradiol, EVEN when started very late, after a window of not taking it. Certainly my experience: women nearly weeping with gratitude to have their estrogen returned to their brains. Not all, but some.
    Always worth a try.
    https://europepmc.org/abstract/med/29914035

  61. I was running ~20 miles a week at around 10 minute miles, and strength training for an hour a week when I began menopause. Eating a whole food low grain mostly plant-based diet. Hiking a couple of times a week. I experienced hardly any of the unpleasantness most of the women in my family experienced (e.g. I think I had maybe 1 hot flash), so seems unlikely to be hereditary. I honestly barely noticed.

    I attributed my painless transition to my activity level more than my diet. Over the 14 years since then, both diet (now keto and pretty high protein and fat) and activity level (walking many many miles a week, weekly strength training) combine to keep me feeling strong and happy. No HRT, never seemed necessary.

  62. “I also know women who do the opposite, who either are lucky enough to not experience any profound symptoms in their transition or who prefer to use other methods and interventions to deal with their symptoms in order to avoid any increased long-term complications. (I’ll delve more into this in the future if there’s interest.)”
    Ooh, ooh ????? I’m interested!

  63. I’m a 45 y/o woman that is significantly estrogen dominant and so I take bioidentical progesterone (transdermal) and DIM (to help reduce my body’s tendency to convert other hormones into estrogen). I also take bioidentical testosterone in a small dose because it really helps with my energy and libido.

  64. Hi Mark, thanks for sharing! This is the article that I have been looking for and completely agree with your points. It’s really great to read the pros and cons of the hormonal replacement therapy for the women who’re following primal. Thanks again, for dealing the various aspects when any women go under hormonal replacement therapy and effects on them.

  65. Thanks for helping me learn more about hormone replacement therapy for primal women. It’s good to know that it’s good to start earlier if you do want to initiate HRT. It seems important to consider this kind of therapy early and possibly discuss it with a doctor, especially if they can give you a timeline when it could be good to start it.