BHRT Updates Matter – Oral E2 vs Transdermal

BHRT Updates Matter – Oral E2 vs Transdermal

BHRT Updates Matter – Oral E2 vs Transdermal

Recently EMERGENCY MEDICINE NEWS published discussions concerning continuing medical education (CME) and whether current requirements are sufficient to keep practitioners up to date. There are yearly requirements to read a series of papers and then take an open-book exam. After completing the yearly requirements, then there is a certification exam taken every 10 years in order to maintain board certification. Criticism and concern were voiced in that physician extenders (NPs and PAs) are not required to suffer through this stringent review process, yet they commonly see the same patients and do the same procedures as ED docs. In the end, there was a tug-of-war between those that felt more training and education is needed in comparison to those that felt the current requirements are way too much and are driving docs away from their specialtySo, just how much is adequate for all practitioners was the point of contention. 

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BHRT Updates Matter

I struggle with the same issue/concern with our specialty. Practitioners that attended WLM training 10 years ago and have not attended any WLM Summit Conferences since may be well behind the curve as to current knowledge of HRT replacement. Through WLM webinars and annual conferences I have tried to keep clinicians up to date on matters that I find most compelling in our specialty. Furthermore, the amount of disinformation, misinterpretation, extrapolation, speculation, and negativism in our industry is truly alarming. Each and every hormone that we prescribe can be complex and a good understanding of all the literature pertaining to every hormone is a must as we will be challenged by both patients and peers. “I read, I saw, I heard, my doctor says…,” are common daily scenarios that we have to contend with. Sometimes we just have to walk away, however, before you go, here, read this! Our patients and peers don’t understand that they don’t understand, and their confirmation bias will prevent them from ever understanding what they don’t understand. I have found the best and most successful method in explaining what we do and why we do what we do with medical literature that supports our treatment methods. Nevertheless, some peers will still just not get it because it was not the way we were trained 

Review of the Most Controversial, Confusing and Problematic Issues

In past years, each annual summit dealt with a specific organ: the brain, heart, pancreas, gut, and cancer. This year will be slightly different as I chose to present an update on the most controversial, misunderstood, confusing, and problematic issues and topics as they pertain to hormones. Unfortunately, there is no venue for all our fellow peers from all specialties to attend so that they get to review and discuss all pertinent recent medical literature that is of importance to our specialty but also for the health and wellness of our patients. So, don’t expect your peers to know and understand what we share at the WLM conferences. And the most advantageous is that we will provide the complete journal articles that we will present at this year’s conference. It is my endeavor to provide you with the latest and most important CME updates as was alluded to in the first paragraph. A thorough discussion of the literature and topics will follow along with case discussions to further our understanding of the complexities that we face daily. What I find to be straightforward and obvious, our peers will not grasp at all. In subsequent blog posts I will introduce many of the topics and articles that I will discuss at this year’s annual summit meeting in San Antonio 

Oral vs Transdermal E2 Case #1

For a case in point, Connie Casad relates a recent patient encounter that was challenging because the patient is a physician, and we know that physicians make the worst patients. The physician-patient was on the usual BHRT which included oral E2. The patient attended the annual AAFP conference where she listened to a lecture on menopausal HRT and learned that menopausal women must avoid taking oral estrogen due to the increased risk of blood clots which can be avoided by simply taking transdermal E2 instead of oral E2. The patient then confronted Connie that she wanted to be switched to transdermal E2 to avoid the blood clot risks of oral estrogen. Connie politely explains that the blood clot issues pertain only to CEE and not to oral E2. The patient then contacts the lecturer, an esteemed member of ACOG/NAMS, and was told that the blood clot risk also applies to oral E2, as well as all oral hormones. So, how can Connie (Ob/Gyn) be right, and this esteemed lecturer on menopausal hormones be wrong? Unfortunately, what the patient and esteemed lecturer did not understand was that 1) transdermal E2 does not provide the cardiovascular and neuro protective effects as does oral E2, and 2) oral E2 does not increase the risk of blood clots, either arterial or venous. Here, read this! The amount of incorrect disinformation in our industry is something that I have not seen in any other medical specialty. The patient should be advised of the lack of the protective effect on the vasculature and neurons when transdermal E2 is used. If the patient-physician cannot understand the science and literature, then so be it. However, it is our duty and responsibility to inform and to document our attempt to inform. 

Oral vs Transdermal E2 Case #2

Recently a newly menopausal woman presented for BHRT and was experiencing severe HF, NS, insomnia, and temperature dysregulation. Years ago, the patient was diagnosed with Factor V Leiden thrombophilia and was told that she could never take hormones. To this day she still has it in her head that she cannot take any hormones but wants to know if I can provide her with anything that might give her some relief. It would have been the simplest and easiest to just walk away. However, it is my duty to inform and that is why she has come to see the “expert.” What the patient should have been originally told by her PMD was that she should never take oral estrogen, but that transdermal was safe and efficacious in patients with congenital thrombophilia. However, the disinformation provided by the PMD has now done irreparable harm by scaring the patient into never taking “hormones.” The look of anger and disbelief was evident on her face when I informed her that she can take hormones and should take hormones. It was obvious that her confirmation bias would be difficult to overcome. However, avoiding estrogen and menopausal hormones will take years off her life as well as take away quality of years. So, here read this! It took many office visits and hours of discussion to get her to grasp the difference in hormones and to overcome her confirmation bias. I never once tried to convince her to take BHRT. All I did was review all the studies and data as to what she is going to encounter from hormone deprivation, particularly estrogen. I was actually hoping that she would choose not to take BHRT as I had invested way too much time, effort, and energy on her trying to dispel the disinformation from her former PMD. In the end she was very appreciative of the time I spent providing the medical literature that ultimately resulted in her not only wanting BHRT but becoming a strong proponent of it. She has become the spokesperson for BHRT. Transdermal E2 eliminated all the temperature dysregulation, but we had to forgo the CVD protective effects of oral E2 in lieu of avoiding any thrombotic risk from her congenital thrombophilia. (Notice that I did not say thrombotic risk from oral E2).  We’ll review the studies demonstrating the physiology of oral E2 reversing and preventing plaque that is not provided by transdermal E2. 

Initially, the patient requested hormones to help with her NS and insomnia that started in menopause and continue unabated despite many other treatments, SSRIs, etc. Vaginal dryness and sexual dysfunction were all a part of her symptom complex. Testosterone would have provided improved libido, reversal of vaginal dryness and atrophy, and maturation of the vaginal mucosa. However, I advised her that I would not prescribe testosterone unless I simultaneously prescribed E2. The reason is the significant suppression of estradiol to zero which would make her further estrogen deprived and susceptible to illnesses of estrogen deficiency/deprivation. She already was insulin resistant and at risk for CVD and diabetes. Suppressing what little estradiol level she had to zero was not in her best interest. Other experts and authors have alluded to the aromatization of testosterone to estradiol thereby eliminating the need for even prescribing E2 to women. Wrong! Testosterone profoundly suppresses E2 levels in menopausal women, the complete opposite as that seen in men. Listen to the most recent webinar on testosterone in women. So, again, I provided her the literature demonstrating the harm of taking testosterone alone without E2. Here, read this!  

The amount of harm to women’s health that medical society causes is unsurpassed. MHT is not advised for prevention of chronic disease and should only be taken in the smallest doses for the shortest period of time. For CEE/MPA I agree. For E2, P4, and testosterone I strongly disagree. How can they get this so wrong. Here, read this.  

Please find the attached journal article which is a most recent discussion of the treatments available for menopausal women. Despite the completeness of the paper in reviewing the risks/benefits of MHT, there is no discussion or reference as to the difference between oral CEE and oral E2. A distinction was made between P4 and MPA but was not emphasized by the authors. Of course, I am very biased as to the concept that MPA should not be used due to all the side effects and complications of progestins. Preferentially, P4 should be used over any progestin due to the lack of side effects, problems, and complications in contrast to progestins. Where I feel emphasis should have been made, it wasn’t. Lastly, all the literature demonstrating the safety and efficacy of oral E2 in contrast to oral CEE in the context of preventing thrombosis was seemingly also ignored. Their mantra that HRT should NOT be used for CVD protection is unsettling. The scientific literature and studies proving the overwhelming safety and efficacy of oral E2 & P4 for CVD prevention demonstrated in RCT outcome studies beg for an explanation. Why and how this information is ignored remains a mystery.



Interested in taking a deeper dive into the enthralling topic of Modern Chronic Disease Management other evidence-based solutions for Chronic Disease? Consider attending our 8th Annual Academic Summit: Root Cause Solutions to Modern Chronic Disease Management and Mitochondrial Health.

Join us for our 8th Annual Academic Summit: Root Cause Solutions to Modern Chronic Disease Management and Mitochondrial Health to learn about alternative therapies to prevent and treat chronic disease.