When Should You Consider Hormone Replacement Therapy?

Taz Bhatia, MD, is a board-certified integrative medicine physician and bestselling author. Her new book, The Hormone Shift: Balance Your Body and Thrive Through Midlife and Menopause, is available for preorder. She’ll be in conversation with Gwyneth and answering your questions live on October 3. Get a ticket to join us (virtually). Her advice on hormone replacement therapy is excerpted below. As always, consult your doctor for a personalized hormone assessment.

One of the biggest setbacks in hormonal treatment came about thanks to a distinctly flawed study of hormone replacement therapy (HRT) that caused screaming headlines and panic around the world, and it continues to cause women to fear hormones.

Initiated by a division of the National Institutes of Health, the Women’s Health Initiative Study monitored 27,347 U.S. women ages fifty to seventy-nine who had enrolled in hormone trials between the years 1993 and 1998. The focus was on investigating whether the effects of combined hormones or estrogen alone could prevent coronary heart disease and osteoporosis, and if there was an associated risk for breast cancer. Women in the study took hormone pills or a placebo, and they were expecting to be tracked for many years.

Researchers soon found that instead of there being a decreased risk, the rates of overall illnesses and death, particularly of estrogen- based diseases like breast cancer, were 12 percent higher in women taking the estrogen plus progestin than in women taking the placebo. When the news came out that the estrogen-plus-progestin and estrogen-alone trials had been stopped early (in July 2002 and March 2004, respectively), doctors were stunned and women were terrified. They had been told that HRT was good for their health and strengthened their bones. Instead, this study implied that HRT was a risk factor for early death.

What was the biggest flaw in this study? It tracked postmenopausal women only! These women already had low levels of estrogen and progesterone. The estrogen these women were given was Premarin, synthesized from horse urine, which isn’t even an estrogen that biochemically and structurally resembles what women naturally make in their bodies.

Over twenty years later, many women are still afraid of doing HRT in any form, owing to the hysteria that arose about this study. Lost in the media firestorm were the findings that women in their fifties who took estrogen alone had a 16 percent reduced risk of overall illness and death. In fact, it was the women in their 70s who took estrogen alone who had a 17 percent increased risk of overall illness.

Since then, researchers have found that women really need hormones. Brain volume decreases without hormones. Vibrant hair and skin, libido, cognitive function, joint health, bone health, and energy levels—are all highly dependent on hormonal health.

So, hormones and HRT should not be feared. Over two decades ago, I had to go on bio-identical progesterone (BHT). The cumulative effects of stress and poor diet, altered sleep patterns, and poor gut health had left my body depleted. I did not, like many of the women I continue to meet, have the raw materials to make hormones on my own. I took progesterone for about six months. But as I learned to rebalance my body, replenish my nutrients, restore my gut health and sleep, and balance my other hormones, I found I didn’t need it anymore. My journey made it clear: I need to be gluten-free, balance my thyroid hormones, supplement my diet with protein and B vitamins, and get good sleep to have happy hormones. When the synergy of biochemistry works, hormones and hormone replacement therapy add to our superpowers.

As with all medications, there can be risks with HRT. When HRT is prescribed with a one-size-fits-all, aggressive approach, that should signal caution. The increased risk of blood clots, breast cancer, gallbladder disease, heart attack, or stroke is small, but it is still something to be considered. This is why I prefer bio-identical hormones, whereby I can tweak the doses and start with very low doses that do, indeed, give the desired clinical benefits and improved quality of life.

These bio-identical formulations usually have more protective estrogen (estriol) than estradiol, which is more biologically active but also has to be watched more carefully. If the bio-identicals aren’t working and I’m not seeing results, though, I’ll go to some of the conventional hormone formulations, like prescription estrogen patches, which are gentler than pills using Premarin. This approach usually works beautifully as long as I am constantly monitoring my estrogen levels.

There are pros and cons to HRT, and they should be discussed as part of an informed conversation with your provider, during which you weigh all the options. The Thirty-Day Hormone Reset (which I outline in Chapter 9 of my book) provides guidance to determine whether you may want to consider HRT.

Excerpted from The Hormone Shift, copyright © 2023 by Tasneem Bhatia, MD. Used with permission from goop Press, an imprint of Random House, a division of Penguin Random House LLC, New York. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher. 

This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.