#275 – AMA #52: Hormone replacement therapy: practical applications and the role of compounding pharmacies

The sum total of lives that have been saved due to less breast cancer as a result from the lack of HRT for the past 20 years is exactly zero.” —Peter Attia

Read Time 38 minutes

In this “Ask Me Anything” (AMA) episode, the discussion zeroed in on the practical application of hormone replacement therapy in women. Peter walks through the signs, symptoms, and hormonal changes in women approaching – and going through – menopause. He provides an overview of the FDA-approved HRT formulations and explains how women might go about choosing the right option for themselves. Peter also describes the significant changes in testosterone levels in women over time and the options, as well as the considerations and challenges of testosterone replacement therapy (TRT) for women. Lastly, Peter highlights the necessary role of compounding pharmacies in HRT, underscores concerns regarding the quality and sterility of compounded drugs, and offers guidance on locating a trustworthy pharmacy.

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We discuss:

  • Why hormone replacement therapy is such an important topic [2:00];
  • The onset of menopause: symptoms, blood tests, and when to consider HRT [6:00];
  • Tests that may provide indications of perimenopause and their implications for fertility [9:15];
  • Vasomotor symptoms: hormonal changes that cause hot flashes/night sweats, and HRT therapies that can help [13:45];
  • The role of estrogen in menopausal HRT [17:30];
  • The limited role of progesterone in HRT protocols [25:15];
  • What is a “bioidentical” hormone? [28:30];
  • Overview of the FDA-approved HRT formulations [31:45];
  • Determining HRT dosing and considerations for perimenopausal women [37:45];
  • Choosing the right HRT formulation: pros and cons [43:30];
  • Examining the link between certain forms of estrogen and breast cancer [46:45];
  • Changes in testosterone levels in women over time and why it matters [50:00];
  • Recognizing low testosterone in women: common symptoms and diagnosis [53:45];
  • Testosterone replacement therapy for women: options, considerations, and challenges [57:30];
  • The long-term use of testosterone in women: examining the limited data [1:00:15];
  • What is a compounding pharmacy? [1:09:30];
  • Reasons to opt for a compounding pharmacy over a pharmacy that adheres to stricter regulations [1:16:00];
  • The tragic incidents that heightened concerns about compounding pharmacies [1:20:45];
  • Tips for finding a reputable compounding pharmacy [1:27:45]; and
  • More.


Why hormone replacement therapy is such an important topic [2:00]

  • Today, we’re going to do is answer questions that have come through from subscribers around, hormone replacement therapy and testosterone replacement therapy as it relates to women
  • These questions really focus around the practical application of HRT and TRT for women and how you use these in your practice with your female patients
  • Wrapped up in this conversation around HRT is the topic of compounding pharmacies
    • Those who need to get HRT and custom HRT prescriptions, we’ll use compound pharmacies
  • When you talk about something like sex hormones, there’s a potential thinking that you’re only speaking to half the population, but of course, while everything we’re going to talk about is directly applicable to women, it’s obviously applicable to men who know or care about women

Why is HRT for women an important topic

Why did you feel it was important to touch on hormone replacement therapy again as it relates to women and pull more questions around this?

  • This is a very frustrating topic, says Peter
  • The mainstream medical community has committed a gross injustice over the past 20 years in the misinterpretation of the Women’s Health Initiative and the subsequent demonization of hormones in perimenopausal and postmenopausal therapy for women

“The sum total of lives that have been saved due to less breast cancer as a result from the lack of HRT for the past 20 years is exactly zero.” —Peter Attia

  • There were zero additional deaths due to HRT from breast cancer
  • There were more cases of breast cancer—1 in 1,000—but it translated to nothing in deaths 
  • In addition, Peter says “I’m positive we could point to additional deaths due to hip fractures.”
  • And all that says nothing about the quality of life that has been compromised
  • The purpose of this podcast today is to talk about the logistics of how one goes about hormone replacement therapy and what all of the options are


The onset of menopause: symptoms, blood tests, and when to consider HRT [6:00]

There’s a broad spectrum of the severity of symptoms that women will experience in menopausal transition

How will women know if it’s time for them to start considering HRT?

And what the tests are that can be done to confirm the onset of menopause?

  • Menopause is a clinical diagnosis and technically, it’s really diagnosed retrospectively—it requires 12 months of amenorrhea, so 12 months of not having a period, without any other obvious pathologic or physiologic cause
  • That said, there are a number of things that we can measure in the blood that tell us we’re heading there or if you just happen to have difficulty or for other reasons have an inconsistent period (such as the use of an IUD, which can interfere with a period) these blood tests can be particularly helpful.
  • The mainstay of looking at this is measuring follicle-stimulating hormone (FSH) and to a lesser extent, luteinizing hormone (LH)
  • FSH is perhaps the single most important hormone to look at to get a sense of where a woman is on her trajectory towards menopause

This was covered in great detail in the video that Peter made on the female sex hormone system where you’ll get a sense of what FSH and LH are doing and how they’re changing throughout a cycle:

The “gold standard”—especially in the case of a woman who is still having a period—if you can measure FSH and LH and estradiol just to round it out on day five, day one being the day the period begins so five days in, that’s a very good test

  • Once that number starts to get to 20 or 25, that’s really the surefire sign that a woman is in menopause

It’s important to understand that if a woman is sitting here and she’s not in menopause yet and wondering, well, “is that it? Is that the diagnosis?”

  • No. Again, the diagnosis is based on amenorrhea
  • But for many women, they’re going to be having symptoms even before they get there

Common symptoms

{end of show notes preview}

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  1. Hi! I listened to your podcast on HRT and I bought your book after that and I started doing HRT with an online Dr. supported site. It has totally changed my life! I am 53 years old and a model in Los Angeles and I was experiencing hot flashes, night sweats, loss of memory, and just everyday fuzziness. I’ve been on HRT for two months and all my symptoms have subsided, but the reason why I really wanted to go on HRT is because all of the benefits, as far as helping with dementia, bone loss, weight gain, everything that goes with menopause also runs in my mom side of the family. All six of her siblings and her passed away of some sort of dementia or Alzheimer’s. Also, about eight years ago, I started getting heart palpitations and from reading your book and researching and talking to the doctors at Winona . I now discovered that it was probably due to being perimenopausal, and now that I have been taking HRT along with spin classes that help with high intensity exercise, I rarely ever get heart palpitations anymore. I just wanted to drop you this note and thank you for all of the information because I too, was believing all of the things that have been said over the past 20 years about HRT causing cancer when it really helps women in many ways. Another thing my husband has the most excellent insurance here in California and they do not cover my HRT through this Dr. supported site and I told him I bet they cover medication‘s for ED and I am right! Thank you for putting the spotlight on women’s health, and how far behind we are in helping women make choices for their mental and sexual health. That is why I started in the modeling business when I was 51 because I wanted to show that women could be strong and powerful way past their 50s! Thanks! Jill

  2. Dr. Jen Gunter has long discussed bioidentical hormones and compounded hormones for perimenopause and menopause and that they are bunk and not safe. She is considered an expert as an OGBYN, and written a few books on this stuff. I have done so much reading, watching, listening and as someone in perimenopause – its all very frustrating and confusing. What is right, what works, what doesn’t. What is your take on her stance?

  3. I am wondering why estrogen is deemed as being heart protective when prepubescent girls do not have high levels of estrogen and they do not suffer from heart disease. I assume also that with no estrogen, that bone growth in young girls is enabled by human growth hormone, therefore not suffering bone loss? Are menopausal women reverting to their prepubescent hormone levels and then what makes that pathological? As I listened to the AMA, I also wondered about the heart and bone health in menopausal women in those ancient tribes that we have studied the diets for longevity. Are they suffering from heart disease? More bone loss than their male counterparts? I keep waffling between HRT as beneficial and then to maybe not necessary.

  4. Appreciate this follow-up episode so much- thank you. It also comes through so clearly the level of care that Peter has for his patients going through perimenopause and menopause. One huge issue: That level of care is hard to find. The NAMS Society includes scores of doctors (like JoAnn Manson) who believe primarily in medicating vasomotor symptoms, and in taking as low a dose as possible for as short a time as possible. You can call their offices and ask for their orientations to HRT, and the office manager/nurse will tell you they’re “pro HRT.” I went through this process early, and my gyne (from one of the top Boston hospitals) was a proponent of “short dose/short time frame.” She never took hormone levels before or during, and said it was not necessary because they would have been low. I’m wondering if this site might be willing to compile, for subscribers, a geographical list of HRT specialists who listeners have seen who actually are pro-HRT. As listeners, we could upload comments that could be integrated into a geographic compilation of docs who really are pro-HRT and who will do the kind of complete treatment that Peter offers. Thanks for considering!

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