Understanding Hormone Therapy (HRT)
4. What is Hormone Therapy or Hormone Replacement Therapy (HRT)?
Hormone Therapy/HRT replaces the hormones that your body makes before menopause. This includes estrogen, often progestogen, and, in some cases, testosterone to relieve symptoms of perimenopause and menopause. The replacement of these hormones have been shown to improve the symptoms of perimenopause/menopause AND significantly decrease the risk of cancer, osteoporosis, heart disease, diabetes, and dementia, in women, especially when started prior to the age of 60 or within 10 years of menopause.
Estrogen
Estrogen can be given in various ways, such as a patch on your skin, a gel, a spray, or a tablet. The type of estrogen most used is 17 beta-estradiol, which has the same molecular structure as the estrogen you produce in your body. It is derived from the yam root vegetable.
Progesterone
If you still have a uterus (womb), then you will need to take a progestogen alongside the estrogen - this is known as combined HRT. Taking estrogen on its own can thicken the lining of the uterus and increase the risk of uterine cancer; taking a progestogen keeps the lining thin and reverses the risk of uterine cancer. The most commonly used type of replacement progestogen is called micronized progesterone. It comes in a capsule that you swallow (occasionally, this progesterone can also be used vaginally). An alternative way to receive a progestogen is to have the Mirena IUD.
Testosterone
For women who experience symptoms such as fatigue, brain fog, and lack of libido, testosterone can be beneficial to bring about improvements. It has shown to be important in bone and muscle health for women. It is available in gels, creams, and injection form.
Benefits and Risks of HRT
5. What are the benefits of HRT?
Symptom Improvement
Your symptoms will improve – most women start to feel improvement within a few weeks and most feel a return to their 'old self' within 3-6 months of starting HRT.
Osteoporosis Prevention
Your risk of developing osteoporosis will reduce – your bones will be protected from weakening due to lack of estrogen.
Cardiovascular Health
Your risk of cardiovascular disease will be reduced – you will be less likely to develop heart problems, stroke, or vascular dementia.
Other Health Benefits
Your risk of other diseases will be reduced. Women who take HRT also have a lower future risk of type 2 diabetes, osteoarthritis, bowel cancer, and depression.
6. What are the risks?
For the majority of women who start taking HRT under 60, the benefits outweigh the risks. If a woman has a history of blood clots, liver disease or migraine, there is a small risk of a clotting if taking the tablet form of estrogen, but taking it through the skin as a patch, gel or spray does not have these risks and is safe for women. There is no medical treatment that is right for everyone. Your provider will review your medical history in depth at your first video visit (and with any changes afterward) so that you can determine a treatment plan together.
Side Effects and Expectations with HRT
7. What are the side effects of HRT?
Side effects with HRT are uncommon but might include breast tenderness, headaches, irritability, bloating, and bleeding. If they do occur, they usually happen within the first few months of taking HRT while your body is adjusting. Your provider will be in touch with you for follow-up visits and is always available by messaging. If you have bothersome side effects, you do not have to wait for the next visit. We can adjust treatments at any time.
8. What can I expect with HRT?
Our goal is to relieve your symptoms by AT LEAST 80%. This can often happen with the first treatment but can be trial and error as everyone's body is different. There are many forms and ways that hormones can be given, so we have plenty of options to find the best treatment plan for you.
9. When is the best time to start taking HRT and do I only take HRT for a certain time period?
HRT is most effective to start when you are perimenopausal – this is before your official 'menopause' – which is 12 months after your last period. This means you don't have to wait for your periods to stop before starting HRT. Don't wait until symptoms become unmanageable before you seek advice. The most health benefits from taking HRT are in women who start taking HRT within 10 years of menopause (decreased risk of cardiovascular disease, decreased risk of osteoporosis, decreased risk of dementia, decreased risk of diabetes etc.) There is no maximum length of time you can take HRT – you can take it forever if you choose. You may hear that you should not take HRT after a certain age, but that is outdated information. HRT does not 'delay' menopause. If you start HRT and want to stop, you always have that option. If you have menopausal symptoms after stopping HRT, this means you would still be having symptoms even if you had never taken it before. The benefits of HRT have to be balanced against any risks. You have to decide what is right for you depending on your circumstances and in discussion with your healthcare professional.
Addressing Concerns About HRT
10. Why is there negativity around HRT?
The adverse reports are largely due to a large trial that was reported in 2002 (called the Women's Health Initiative (WHI) Study), which has since been shown to be flawed. It studied older women (in their 60s-80s) and they were given types of HRT that we do not prescribe. Interestingly, the authors of this study apologized in a mainstream medical journal (NEJM) as they admitted that people misinterpreting the results of their study is one of the main reasons that women are unnecessarily worried about taking HRT. For the majority of women who start taking HRT when they are under the age of 60 years, the benefits of HRT really do outweigh any risks. This means that it is safe to take HRT, and taking HRT can provide you with positive effects on your future health, especially your bones and heart.
Of note: there are many myths and misconceptions about hormone therapy, even with healthcare providers. Perimenopause and menopause are not educational topics provided to physicians or nurse practitioners in depth in school. In fact, most providers receive only 3 hours of education on these topics in medical school and NP school. Providers that offer these treatments have frequently sought out additional education to focus on the needs of women experiencing perimenopause and menopause and have knowledge (based on research studies) that may conflict with other medical providers. Please note that our practice is based on evidence-based research. We can provide you with studies showing evidence upon request.
Please take a look at this video: Oprah, discussing some of the myths and misconceptions about menopause: 1. VIDEO: https://www.youtube.com/watch?v=y1xb9ZmtHR8
Please also take a look at this video where Maria Shriver talks to the Director of the National Institute of Health: https://www.today.com/video/a-closerlook-at-hormone-replacement-therapy-for-menopause-174632005682
11. What if I am over 60 and want to start HRT?
While we know that for the majority of women under the age of 60, benefits outweigh the risks for HRT, that does not mean you are not a candidate. If you are over 60 and have bothersome symptoms, it's important to discuss with your provider because you do have options. You have a major part in deciding your treatment plan, and we can discuss all options, risks, and benefits to you so you can make the most informed choice possible.
The Menopause Clinic: Services and Resources
12. Is lab work needed before starting HRT?
Even if other doctors have told you that your lab results look "normal" or that perimenopause can be diagnosed solely through lab tests, that may not be entirely accurate. During perimenopause, hormone levels, particularly estrogen, can fluctuate significantly throughout the day and from one day to the next. For instance, your estrogen level might be 300 in the morning and drop to 100 by the afternoon. While both numbers might fall within the normal range, it’s the dramatic swings in these levels that often cause symptoms and leave you feeling not like yourself. According to The North American Menopause Society (now The Menopause Society), testing is rarely needed before starting HRT. However, for some women it may be important to know baseline levels and some women prefer to know their baseline levels (even if not required), and we are happy to send in orders for simple or complex blood panels, depending on the individual patient. After a treatment plan has been started, lab work is required to monitor hormone levels to ensure levels are stable. Labs can be done via health insurance or at a discounted cash price (typically $45-100 for initial simple or complex baseline labs and approx. $50 for follow-up lab work).
13. What is the cost of HRT at The Menopause Clinic?
The initial visit cost is $50. In the initial consultation, you will meet with your healthcare provider via video. This includes a comprehensive review of your medical history, a collaborative discussion to develop a personalized treatment plan and shared-decision making. Your provider will send you a summary of the visit afterwards. Please note that the initial visit fee does not include any prescriptions. If you choose to move forward with prescriptions and a treatment plan, you can enroll in our membership. This step-wise approach allows you to meet your provider and discuss possible options before committing to a month's membership. Membership includes implementation of your treatment plan, access to prescriptions, - *monitoring of blood work, follow-up visits to ensure your treatment is effective and to monitor for any potential side effects, and unlimited messaging with your provider for ongoing support. The cost of monthly membership is $85 or you can choose the 3-month membership for $225 ($75/month). This is a recurring charge and you may cancel at any time prior to the next charge. You can choose between monthly membership and a 3-month membership.
* Blood work can done using health insurance, or paid with discounted cash-price. We send your prescriptions to your local pharmacy so your medications can be covered by your insurance. If your insurance requires prior authorization, we can do that. After your visit, your provider will send you a summary of possible treatment options with costs without insurance included, for those that choose not to use insurance for medications. Upon request, we can provide you with a superbill to provide to your insurance provider for possible reimbursement. If you do not have insurance, we can help with compounded medications (compounded medications are not included in the above charges).
Your Personalized Treatment Journey
Initial Video Visit Schedule your initial video visit, pay $50 to meet with the healthcare provider. You will receive a consent to sign and a questionnaire to fill out. After payment, consents, and questionnaire are completed, your appointment will be confirmed. Personalized Plan Meet with your healthcare provider by video to develop a personalized plan. After the visit, your provider will provide a written summary, detailing your treatment options. Membership Program If you want to move forward with your treatment plan, enroll in our membership program which is $85 per month and includes implementing your treatment plan, access to prescriptions, monitoring blood work, unlimited messaging with your provider for ongoing support, and follow-up visits with your provider to ensure your treatment is effective and to monitor for any potential side effects. Follow-up Support Follow up with your provider to continue your treatment plan and ensure your treatment is effective and to monitor for any potential side effects. *Prescriptions are sent to your local pharmacy and are typically covered by insurance. If you do not have insurance, we can send your prescription to a compounding pharmacy *Blood work can be done using health insurance or paid with a discounted cash price. *We do take HSA/FSA cards. *We can provide you with a superbill to submit to your insurance company for possible reimbursement upon request. *Membership fee is a recurrent monthly charge. You may cancel at any time.
Why doesn't The Menopause Clinic participate in-network with insurance providers?
We have chosen not to participate as “in-network” with any insurance providers and are self-pay only. We keep our costs down so that care is affordable to you. The reason we do this is simple. On average, healthcare providers that are "in-network" with insurance spend 13-15 minutes with each new patient, and sometimes less. We do not file insurance claims or negotiate with insurance plans, so we can spend that time with our patients. We have 60-minutes available for each new patient. We can provide you with a superbill to submit to your insurance company upon request. We accept all major credit cards and FSA/HSA cards. We send your prescriptions to your pharmacy so they can be covered by insurance. If your insurance requires a prior authorization, we are happy to do that. You may use your insurance for your labs (please check with your insurance carrier for coverage) or can have labs done at a discounted cash price. Please discuss any insurance questions relating to lab work or imaging with those organizations as we are a separate entity. If you do not want to use insurance for labwork, you can have lab work discounted at LabCorp or Quest (initial labs approx $50-100 and follow up lab work approx $50). Lab work is not needed for everyone and depends on your personal medical history and treatment plan, which will be discussed in your visits.
Understanding The Major Long-Term Benefits of Hormone Replacement Therapy
Understanding the Risks of Hormone Replacement Therapy
Reading Suggestions
- Estrogen Matters: Why taking hormones in menopause can improve women’s well-being and lengthen their lives-without raising the risk of breast cancer. Author: Dr. Avrum Bluming
- The New Menopause: Navigating Your Path Through Hormonal Change With Purpose, Power, and Facts Author: Dr. Mary Claire Haver
- Unlock Your Menopause Type. Author: Dr. Heather Hirsch
Video Suggestions: