This article was published under the title “The Hormone Shuffle” in the 2023 July August issue of Cityview Magazine.
We blame and credit hormones for major life changes—and for some questionable decisions, and usually regard them with hopelessness: it’s the hormones driving us! However, studies in endocrinology and Hormone Replacement Therapy (HRT) showed that we can control and adjust hormones to improve quality of life. And while HRT is not recommended lightly or widely used as an anti-aging tool, the practice has well-documented merits for both men and women.
As previously mentioned, there are many theories about aging, the neuroendocrine hypothesis being one of them. The hypothesis looks at the connection between the nervous system and endocrine glands, which produce hormones. The hypothalamus in our brain controls the pituitary gland, which regulates other major glands like adrenal, thyroid, ovaries, and testes and their release of hormones. This system becomes less functional with age, which can negatively affect our metabolism, insulin processing power, blood pressure, and sleep quality.
To address some of these issues, hormone replacement therapy (HRT) started in the 60s and gained popularity in the 90s. Initial studies showed that the detriments outweighed the benefits; however, new studies showed that the use of HRT in younger women or in early postmenopausal women had a beneficial effect on the cardiovascular system, reducing coronary disease and all-cause mortality. Similarly, HRT showed positive results for men, especially in their later decades in life.
“The main goal I have for any patients is quality of life—and that applies to HRT too,” said Dr. Raye-Anne Ayo, MD who offers concierge medicine services at her private practice, Family Health Center, PLLC in Farragut, Tennessee. “Age-related changes are normal—we can’t be 15-year-olds again no matter what we do. However, HRT has some clear benefits improving perimenopausal/menopausal and andropause symptoms, but it’s important to set specific goals and monitor the results closely. I work to find the right dosage and combination of hormones that are best for each individual—it’s not a one size fits all. I focus on FDA-approved HRT treatments, which are just a handful, then branch out as needed. I also point out that even if most HRT treatments are not covered by insurance, there are many affordable options.”
Aging and our hormones
The neuroendocrine system is complex and involves intricate connections between our nervous system and endocrine glands, which produce hormones. With age, the brain becomes less efficient at maintaining a fine balance of stimuli for glands, which can lead to high blood pressure, impaired sugar metabolism, and sleep abnormalities. We are probably aware of the normal drop in estrogen for women as they go through menopause and testosterone for men as they go through andropause. Beyond sex hormones, we need to be aware of other equally important types of hormones, such as metabolic (insulin and glucagon), stress (cortisol, adrenaline, noradrenaline), thyroid (triiodothyronine T3 and thyroxine T4), and growth hormones (insulin-like growth factor 1 IGF-1). Certain afflictions associated with aging should be on our priority watch list, such as diabetes, dementia, cardiovascular disease, bone density, and certain types of cancer.
Most HRT addresses symptoms of menopause in women and andropause in men. After menopause, women’s body stops making estrogen and progesterone, while for men, a drop in testosterone can be bothersome. Some of the symptoms for women include hot flashes, night sweats, sleep problems, vaginal dryness, anxiety, moodiness, brain fog, and low libido, while men can experience low libido, depression, lack of energy, and muscle loss. Many of these symptoms are par for the course, however, HRT can be an option when the symptoms are severe or significantly impact quality of life—aka when we’re simply miserable.
Types of hormones and HRT
First, let’s talk about types of hormones used in HRT. There are synthetic hormones (such as Premarin and Provera), animal-derived hormones (such as conjugated equine estrogens or CEE), and bioidentical hormones (such as estradiol, estriol and progesterone), which have the same molecular structure as the hormones made by your body. There has been debate regarding the efficiency and safety of synthetic vs bioidentical hormone use. According to the US Food and Drug Administration and as stated by Dr. Tatnai Burnett for Mayo Clinic, “there is little or no evidence to support claims that bioidentical hormones are safer or more effective.” However, some clinical outcomes showed lower risks associated with bioidentical hormones, including the risk of breast cancer and cardiovascular disease. So, while the jury is still out, most practitioners will opt for the “natural” bioidentical hormones.
HRT for women uses estrogen, progestin (a type of progesterone), or both; sometimes testosterone is also added. For men, HRT focuses on testosterone. There are many ways to receive HRT, including nasal sprays, pills, topical gels, skin patches, injections, vaginal creams or suppositories, intrauterine devices, and subcutaneous pellets.
Many specialists saw positive results with pellets. However, the administration mode will also depend on your personal comfort you. As Dr. Casey Page, a seasoned endocrinologist with Endocrinology Consultants of East Tennessee, pointed out, patients’ skin has different levels of absorption, so a topical application might not work best for some. Also, while taking a pill is easy and unintrusive, the content of the pill must be processed by our body through intestines and the liver before reaching our system, so there is a delay or potential loss of efficiency in the process. Some patients prefer a quick at-home injection, while others are irked by the thought of needles. The advantage of pellets is a slow and steady release of hormones, along with no impediment for absorption.
“It’s important to have the right combination and dosage of hormones. I tell my male patients that if they start crying at Hallmark movies, they need to come back in to see me,” shared Dr. Ayo. “While topicals are easy to apply and pellets metabolize easier since they don’t have to go through the digestive system first, if you don’t get the dosage right, you might have to live with unwanted side effects such as moodiness or irritability and more.”
The good and the bad: positive results vs risks of HRT
According to a study published in 2022, evidence indicates that HRT effects depend on timing of initiation (as related to menopause) and duration of therapy. “HRT for women <60 years of age and/or at or near menopause significantly reduces all-cause mortality and cardiovascular disease (CVD), whereas other primary CVD prevention therapies fail to do so […]. HRT-associated risks, including breast cancer, stroke and venous thromboembolism are rare (<10 events/10,000 women), not unique to HRT and comparable with other medications.” (Menopausal Hormone Replacement Therapy and Reduction of All-Cause Mortality and Cardiovascular Disease: It’s About Time and Timing by Howard N. Hodis, MD and Wendy J Mack, PhD)
Medical experts disagree about the significance of a testosterone level decrease, as it doesn’t affect one’s health any more so than the natural aging process does. Commonly used to treat men with symptomatic hypogonadism, HRT (specifically testosterone hormone therapy—TRT), benefit bone density, strength and muscle mass, heart health, as well as increased libido and energy level. “However, TRT is contraindicated in men with untreated prostate and breast cancer. Men on TRT should be monitored for side-effects such as polycythemia, peripheral edema, cardiac and hepatic dysfunction.” (Risks of testosterone replacement therapy in men by E. Charles Osterberg, Aaron M. Bernie, and Ranjith Ramasamy)
Hormones are personal; HRT should be too.
Hormones are complicated, so having access to the right professional for consultation is crucial. “We are aware of both the positive implications and the potential risks of the different dosage and combinations of hormones, so we are always carefully testing for levels of specific hormones and discuss a patient’s health background before we recommend a hormone therapy. In the end, this is a very personal decision and different patients have different levels of comfort with HRT,” shared Dr. Page. Lab work and regular check-ins are important during the entire process to assess changes and drive adjustments in dosage and mix.
“For me, number one is treating the patient not the numbers, so whenever someone asks me if HRT is an option for them, I evaluate them wholistically and work with them on a very personal level to outline the best course of action,” shared Dr. Ray-Anne Ayo. “I usually don’t recommend HRT unless someone has severe symptoms. However, I work with my patients to consider when the benefits outweigh the risks, then have a trial period for HRT. We set specific goals and monitor for changes.”
In addition to being a qualified specialist, your HRT provider should be a good fit for you. “Most menopausal women are comfortable sharing their discomfort with hot flashes or weight gain, but not about a low libido or vaginal dryness. These symptoms are important, and we strive to make our patients comfortable talking about all issues,” said Dr. Debra Durst, founder of Revitalyze MD. As an emergency medicine physician and mother of three, she understands the importance of getting professional help as we age to continue living our best lives. “My passion is to educate other women and men, and also to provide solutions and treatments that might not be available at their regular GP or OB/GYN office,” she added.
HRT is not a panacea, and hormone modifications are normal as we age. Most doctors will recommend HRT only when symptoms of hormone loss are severely affecting one’s quality of life, and few as a preventative action. According to a 2021 article published by Mayo Clinic, “positive lifestyle modifications such as regular aerobic and resistance exercise programs and/or healthy calorically restricted diet can favorably affect endocrine and metabolic functions and act as countermeasures to various age-related diseases.” A change in hormones as we age is normal and inevitable, while a change in our lifestyle is something we can control.
Anti-aging Tips from Pros
Board-certified family medicine practitioner Raye-Anne Ayo, MD recommends taking a holistic look at anti-aging care. Likewise, husband-and-wife Scott and Michelle Williams founded Totally Living Well personal training and health coaching business based on a comprehensive approach to wellness. Here are their healthy aging tips.
- A traditional Mediterranean diet can lower the risk of cardiovascular disease and other chronic conditions.—Dr. Ayo
- Don’t aim for perfection, but be consistent in making healthy diet choices; keep your food fresh and free of chemicals.—Michelle Williams
- Hydrate! We recommend at least half of the body weight in ounces of water intake prior to any exercise.—Michelle Williams
- Stay away from alcohol. The body sees alcohol as a toxin and will focus on metabolizing it first, instead of absorbing useful nutrients from food.—Scott Williams
- Low-impact exercises are easy on the joints but effective maintaining mobility and increasing muscle mass, which in turn will increase the metabolic rate.—Dr. Ayo
- The American Heart Association recommends 20-30 min. of cardio three times a week. A combination of cardio and resistance training is best; integrate the two by spiking your heart rate then taking shorter breaks in between your resistance training reps.—Michelle Williams
- Don’t think “all of nothing.” Don’t give up on your health-conscious efforts and know that every movement counts; you’re better off doing something rather than nothing.—Scott Williams
- Learning a new skill or hobby, staying socially active, meditating, and having a sense of purpose in life are very important to one’s health.—Dr. Ayo
- Limit screen time one hour before going to bed, bring in air purifying plants, and let Himalayan salt lamps purify your air and neutralize harmful electromagnetic radiation from your electronic devices.—Michelle Williams
- Create rituals to decompress in a health way, be it meditation, listening to calming music, stretching, or aroma therapy (essential oils such as lavender or sage are calming, while beeswax candles help detoxify the air).—Scott Williams