16. What to Expect When Starting Hormone Replacement Therapy
Don’t Miss An Episode!
In this episode, we covered:
- How to find an HRT provider
- Different deliveries of hormone replacement therapy
- Why hormone injections and pellets are not recommended
- Side effects of hormone replacement therapy
- Progesterone hormone replacement therapy
- Estrogen hormone replacement therapy
- Testosterone & DHEA hormone replacement therapy
The last couple episodes were about hormone replacement therapy, my experience with it, the benefits of HRT, myths, and more. Check them out if you missed them.
How to Find a Provider for Hormone Replacement Therapy
Today I’ll cover what to expect if and when you start HRT, because so many women are scared to start, they don’t know what’s gonna happen, and quite frankly, in the online space, many tout HRT as being a “must-have” or a “silver bullet’.
And while I have certainly found a lot of relief using HRT, I realize not everyone will have my same experience. So like I always say, when it comes to your health, it’s important to be knowledgeable and then make an informed decision that works for you. Health is not black and white.
Finding a Provider for Hormone Replacement Therapy
First things first: you may be wondering how the heck do I find a provider who will prescribe hormones! Many women ask their doctor or OBGYN and they often say no, hormones aren’t necessary or they may even tell you they’re dangerous. I explained the reasoning for this in my last episode. So let me give you some tips on how to find what I call a “hormone-savvy provider”. This may be a doctor or even a nurse practitioner.
But please know just because someone can prescribe hormones doesn’t mean they’re hormone literate. So it’s important to work with someone who understands hormones, and knows that it’s a process. He or she shouldn’t just prescribe hormones and send you on your way. It can take several months to find your sweet spot – it requires patience, assessing symptom improvement, and frequent check-ins with your provider to make sure you optimize your regimen.
Ways to Find a Hormone-Savvy Provider
In The Hormone Rescue program, as non-licensed practitioners, we don’t prescribe hormones. We educate, guide clients on their journey so they know what questions to ask, what to avoid, and how to advocate for themselves. And since searching for a provider can be overwhelming, we give our clients access to an HRT Providers Directory, which we constantly update and is organized by state. But I’ll give you a few tips if you want to start looking for a provider.
I’m all about the path of least resistance, especially in our peri years. We have enough on our plate. So if you love and trust your doctor, ask him or her about their experience with bioidentical hormone replacement therapy. You don’t ask, you don’t get. Sometimes they just don’t think to offer it, unless you’re complaining of symptoms.
Please know that most PCPs, OB/GYNs, and even endocrinologists do not have in-depth expertise or experience with HRT. So while he or she may be an awesome doctor, they just may not have the knowledge to help you. Truthfully, it’s MORE than likely that you’ll have to seek out a hormone specialist to get the support you need.
Here are a few ways to do that and I’ll link to these in the show notes:
- Call your local compounding pharmacy – you may want to go in and speak directly to the pharmacist. Ask who he/she recommends for bioidentical hormone replacement therapy in your area. Compounding pharmacists work with practitioners every day, so they should be able to refer you to someone who is well-versed.
- Contact a national pharmacy – such as Women’s International Pharmacy.
- Institute of Bioidentical Medicine (IOBIM)-trained providers – the founder is Dr. Daved Rosensweet who I just have so much respect for – I love learning from him. He founded IOBIM’s provider BHRT training program.
- The Academy for Preventive and Innovative Medicine – by Worldlink Medical they educate providers on Hormone Replacement Therapy. They have a provider directory.
- Check out the Institute for Functional Medicine and use the “Find a Practitioner” tab to search for a hormone specialist.
Different Deliveries of Hormone Replacement Therapy
So once you find a provider, know that there are many Different Deliveries of Hormone Replacement Therapy. Let’s go over them…
- Pills – progesterone, DHEA and estrogen are available in pill form; estrogen in pill form isn’t typically recommended as it can increase risk of clotting, but there’s more research coming out on that and it seems more providers are fans of this option
- Troches – small lozenges you place between your cheek and gum and you let them dissolve
- Transdermal or topical – these are hormones mixed into a gel, cream, oil, or even a spray and applied to your skin
- Patches – also considered “transdermal” because they’re a sticker-type delivery system applied to your skin. The estradiol “patch” is left in place for a specific period of time on the abdomen, hips or butt
- Transmucosal – creams and gels that are applied to the vaginal area, or mucus membranes, like inside the labia or vagina
- Injections – may be injected under the skin or in muscles.
- Pellets – compounded hormones like estradiol or testosterone are pressed into a solid compound about the size of a grain of rice and inserted under the skin.
Starting Hormone Replacement Therapy: What to Expect
Once you start HRT, it’s an ongoing process. Patience is definitely required. And you may even feel worse before you feel better. There are some side effects, like tender breasts, weepiness, oily skin, acne, grogginess, your cycle length may vary and more, depending on which HRT you’re on. I shared how when I started testosterone my skin got very oily, I broke out and my periods changed a bit.
But symptoms are typically relieved in a few weeks or so…or you may need to adjust your regimen, until you find what works for you.
Most women start with progesterone (typically in an oral micronized form), then add estradiol (typically in a patch or gel), followed by testosterone (in a cream). That’s not always the case, as some providers will prescribe progesterone and testosterone first, as some are hesitant to give women estrogen. So please find a provider who is not afraid of estrogen.
Progesterone
So let’s break down each of these further…
Progesterone: most women start with this hormone, because it declines rapidly after the age of 35 and a reason behind many symptoms like anxiety, sleep disruption, PMS, heavy/painful periods, bloating, breast tenderness, and even hot flashes.
Consider discussing oral micronized progesterone with your provider. You’ll want to avoid PROGESTINS, which are synthetic progesterone, found in IUDs and other forms of hormonal birth control. There may be a time and place for that, but it should be a last resort in my opinion.
Progesterone is meant to be taken at night to help with sleep, but some providers will also recommend you take a low dose during the day if you experience anxiety. Most providers will suggest you take it during your luteal phase (around days 14-28 of your cycle, if you’re cycling regularly). But others may recommend you take it continuously. At the time of this recording, I take progesterone continuously and I feel much better when I do. The standard dosing for progesterone is 100 mg, but many if not most women need more than that. 200-300 mg is pretty standard.
If you cannot tolerate oral progesterone, it could be due to the inactive ingredients in the commercial prescription, such as peanut oil. In this case you may want to ask your doctor for oral micronized progesterone via a compounded pharmacy. But some women opt for a topical cream. There is some school of thought that topical does not offer the same benefits or protection of the uterine lining as oral, but typically this is because the dose isn’t high enough. I encourage you to check out the work of Dr. Phyllis Bronson and compounding pharmacist, Carol Petersen, on their extensive progesterone research.
Estradiol
Moving along to estrogen…after you fine tune your progesterone, you may want to consider estradiol (or a combination of estradiol and estriol, known as Biest). Because of the fluctuations of estrogen in this stage of life, it’s advised to give the body some estrogen to communicate to the brain that you have enough on board. Essentially, it helps mitigate the erratic fluctuations of estrogen in this stage of life. If you struggle with low estrogen symptoms such as vaginal dryness, waking up in the middle of the night, frequent urination or UTIs, dry skin, achy joints…you would likely benefit from estrogen.
If you happen to have menstrual migraines, they can be triggered by low estrogen at the end of the luteal phase (as you transition into your period). Low estrogen can cause prostaglandin release (causing pain/inflammation), and low serotonin (which has to do with your perception of pain). Some women experience joint pain or flares before their period – I used to get these and since starting estrogen HRT, it has helped me so much.
So consider discussing estradiol in a topical cream or gel, or an estradiol patch with your provider. They all come in a variety of doses, depending on your needs.
Lastly, some providers prescribe oral estrogen, but because it goes right to your liver to be processed (known as first-pass liver effect), versus your bloodstream (like transdermal forms) and can increase risk of clotting, it’s not typically advised. That said, more research is coming out on the benefits of oral estrogen, such as lowering lipid levels, so as always, it’s important to weigh your individual risks and health history vs. benefits with a trusted provider.
Vaginal Estrogen
Vaginal Estrogen: in addition to or in lieu of transdermal estrogen, your doctor may suggest vaginal estrogen. This is typically given to women with symptoms such as vaginal dryness, burning, irritation, lack of lubrication, pain with intercourse, urinary urgency and frequent UTIs. This does not enter the bloodstream, so it’s safe for all women.
Testosterone and DHEA
Testosterone: there are no FDA approved commercial testosterone options available for women; however, you can get it via a compounded pharmacy. The cream can be applied to the lower abdomen, behind the knees, forearm, or shoulders – anywhere hair does not grow. It’s typically used in the morning and taken continuously.
Like I mentioned earlier, many providers do not recommend testosterone pellets, as you cannot titrate the dose once they are inserted. It’s a surgical procedure every time you need them, which can increase risk of infection. Once the dose tapers off, you can experience symptoms of very low testosterone.
Some providers will prescribe DHEA to support adrenal health and to help with fatigue. But it shouldn’t be used in place of testosterone. They are typically prescribed together.
Starting Hormone Replacement Therapy
When it comes to HRT, low and slow is the way to go! Make sure your provider understands this and doesn’t start you on high doses right off the bat. Like I said, it’s a process and takes some time to fine tune your regimen. And you’ll know that your doses aren’t optimal, b/c you won’t feel better! Symptoms don’t lie. Some providers will test your hormones once you’ve started HRT to gauge your levels, but it’s best to pay attention to your symptoms.
Conclusion
So that was a very basic overview of HRT – this barely scratches the surface, as it’s a complex and nuanced topic. Every woman is different and has unique needs. In The Hormone Rescue program, we provide more education, help you find a prescribing provider or better advocate for yourself with the one you have, and guide you during the process.
We also help you optimize your nutrients so hormones can do their job, as well as support gut and liver health so you can properly metabolize the hormones efficiently – and so you can feel your best.
DONT MISS THE UPCOMING MASTERCLASS: You’re Not Crazy…it’s Perimenopause! How to Navigate Hormone Changes After 35
REGISTER HERE – claudiapetrilli.com/masterclass
WORK WITH US: The Hormone Rescue Program
Sources:
Women’s International Pharmacy
Institute of Bioidentical Medicine (IOBIM)-trained providers
The Academy for Preventive and Innovative Medicine (Worldlink Medical)
Institute for Functional Medicine
Carol Petersen, RPh, CNP
Dr. Phyllis Bronson
Claudia Petrilli is a Functional Health Coach, Integrative Nutrition Coach, Women’s Health Educator, and creator of The Hormone Rescue program. Having experienced debilitating periods, digestive issues, a sluggish thyroid, a pituitary tumor, and perimenopause symptoms in her late 30s, she knows exactly what it’s like to get dismissed by doctors and spend years searching for answers.
To connect with Claudia Petrilli:
FREE GIFT: Peri-What?! The Must-Have Guide for Navigating Hormone Changes in Your 40s
WORK WITH US: The Hormone Rescue Program
QUESTIONS? EMAIL: claudia@claudiapetrilli.com
LOVE THE SHOW?! Please subscribe, leave a 5-star rating, review, and share, so that other women can find this podcast for guidance and support through their perimenopause journey!
