BHRT For OB/GYNs – Why it Matters for Your Practice Part I 

by Krista Russ

As a practicing OB/GYN, you have surely heard of Bioidentical Hormone Replacement Therapy (BHRT), or perhaps even know fellow colleagues who offer this valuable service. Despite the profound relief it affords menopausal women, BHRT remains controversial. But why?  

In this article, we explore how views surrounding BHRT have evolved over time, the most current evidence regarding the safety and efficacy of BHRT, and perhaps most importantly, why BHRT matters for your practice, from both a patient and provider perspective.  

In Part II, we’ll address the specific conditions that BHRT has been proven to help as it relates to OB/GYNs—but before we can explore that subject, we must address the elephant in the room—the shifting politics surrounding BHRT. 

Medical Field Stance on BHRT

Many providers within the medical field are opposed to HRT (Hormone Replacement Therapy)—even Bioidentical HRT, which differs dramatically from synthetic HRT. Bioidentical hormones are analogues of what our endocrine glands make. Derived from plants like yams and soy, they are modified in the lab to exactly mirror human hormones. Synthetic hormones like Premarin, Provera, norethindrone, and others are not structurally identical to human hormones—unlike bioidentical versions.   

This fact is comparable to another hormone—insulin. At one point, insulin was derived from pigs and cows to treat children and young adults living with juvenile diabetes; now, with recombinant DNA technology, bacterial cells can be genetically modified to produce human insulin that exactly matches its molecular structure [1]. The differences were staggering. Although the animal-derived insulin saved many lives, it was far from perfect and often caused allergic reactions, as it was not an exact duplicate of human insulin.  

So, while no one would contest that the insulin from a pig is the same as the insulin from a genetically human equivalent, that is precisely what happens when misinformed healthcare providers falsely assert that synthetic HRT is equivalent to bioidentical HRT. Both therapies are lumped into the same category when they are, in fact, categorically different, with very different metabolic effects. 

Much of this fearmongering concerning HRT was related to the infamous 2002 Women’s Health Initiative trials, which reported a link between synthetic hormone replacement and ill health effects like breast cancer and blot clots; it was terminated early as a result. Although these associations were later determined to be spurious, and HRT does not increase cancer, all-cause mortality, CVD, or cancer, the horse was already out of the barn [2]. Many medical institutions stopped training medical students on HRT due to these unsubstantiated claims of HRT “dangers” like deep vein thrombosis and stroke.  

In reality, no study has shown that BHRT has the same deleterious effects as synthetic HRT. In fact, quite the opposite has been demonstrated in several interventional RCTs. 

Standards of care often dictate that if BHRT is deemed necessary by a provider, it should be given “in the lowest dose for the shortest amount of time”—but this places unnecessary restriction and hampers much of the health benefits offered from longer-term treatment. Many of the potential benefits outside of menopause management, such as lower risk for CVD, fractures, and dementia are only realized with long-term treatment. 

Worst of all, these restrictive standards of care are at the crux of why so many OB/GYNs are so reluctant to offer BHRT to their patients in the first place. There is also a fallacy that BHRT only benefits menopausal symptoms, but BHRT is vital to long-term health, as you will learn in Part II of this blog.  

Fortunately, substantial progress has been made in recent years when it comes to the views of influential organizations on BHRT. For instance, Stephanie S. Faubion, MD, MBA, and NAMS medical director who led the advisory panel for the most recent NAMS 2022 guidelines stated, “Since our last Position Statement on hormone therapy published in 2017, there have been important additions that further clarify the balance of risks and benefits of hormone therapy options for [managing] menopause symptoms.” Following extensive research and systematic review of the literature over the past half decade she added, “we have found that what hasn’t changed is that hormone therapy remains the most effective treatment for vasomotor symptoms and genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture [3].”  

Furthermore, NAMS 2022 guidelines states, “the benefits of hormone therapy outweigh the risks for most healthy symptomatic women who are aged younger than 60 years and within 10 years of menopause onset [3].” 

And that for women experiencing primary ovarian insufficiency or early menopause who are thus at greater risk of heart disease, osteoporosis, and cognitive or affective disorders, they state, “hormone therapy can be used until at least the mean age of menopause unless there is a contraindication to its use [3].” 

Lastly, NAMS emphasized that HRT does not need to be routinely discontinued in women older than 60-65 years and can even be continued beyond age 65 for managing persistent VMS or for prevention of osteoporosis. However, patients should be closely observed and counseled on the benefits and risks of long-term hormone therapy [3]. 

While these statements are not necessarily a resounding yes to hormone therapy—particularly in older women who want to start HRT more than ten years post menopause onset—they are indeed great progress compared to former years.  

The opposition to older women using HRT beyond age 65 is simply due to a lack of randomized controlled data on these populations or observational studies that might suggest rare, unfavorable outcomes and not based on interventional trials; thus, causality cannot be determined, and older women who forgo HRT could be missing important benefits [3]. 

How BHRT Can Help Your Patients

Now that you see how viewpoints on BHRT have shifted in its favor over time, with greater acceptance among influential organizations, it’s important that you understand how BHRT can benefit your patients. 

Indeed, offering BHRT provides solutions to two problems—one for patients, and the other for you, as a provider.  

When your female patients are no longer of childbearing age and topics like pap smears, birth control, and pregnancy are no longer primary concerns, most patients transitioning into menopause are afforded few options from their care providers. They have essentially “aged out” and fall through the cracks of the healthcare system, which is profoundly unfortunate because these patients have very pressing needs. In fact, scientific literature would argue that their needs become greater—not lesser—as they age.  

Over 40 percent of women try compounded bioidentical hormone therapy at some point in their lives [4]. An estimated 26-33 million prescriptions are written for compounded hormones every year [5]. This is no small number, and it shows how pressing the need for BHRT is.  

How Adding BHRT To Your Practice Can Help You

While helping patients is all good and dandy, there must also be a benefit for you as a provider. We have all heard the saying, “there is no mission without margin.” Will offering BHRT help your practice? Will it help you personally? The answer to both questions is a resounding yes. Not only because BHRT is a large area of potential and unmet need in the healthcare system, but also from a personal standpoint.  

Many OBGYNs express they are sick of 24-hour days, with little time left for family, self-care, vacations, or a social life outside of work. Many are also tired of the short, rushed interactions with patients that they only see once or twice a year, with appointment slots triple and quadruple booked, leaving little time to really get to know their patients on any personal level to be of real service to them.  

What if you could spend as much time with patients as you like and still earn the same income or more while seeing fewer patients? What if you could have your weekends and holidays back, not having to spend them in a hospital triage rushing from one childbirth to the next? There is a time and place for that. Of course, the miracle of birth is probably why you entered this field, but many providers find as they age, they desire a change, or they want to help women going through the same changes they are.  

You can be of real service to these women, and the impact you will have on their lives is just as impactful. And using BHRT, you can still play an important role in the miracle of birth if you so desire, helping women who struggle to get pregnant realize their dreams. With BHRT, you can do all of this and more.  

In Part II of BHRT For OB/GYNs, we’ll explore all the surprising ways that BHRT can help your patients—both young and old—as backed by only the most up-to-date research and evidence-based medicine, so be sure to take a look. If you are interested in adding BHRT to your practice now, sign up for our comprehensive, CME-accredited BHRT training, where we teach you the ropes of BHRT from A to Z.  

References   

1.  The History of a Wonderful Thing We Call Insulin. American Diabetes Association. Updated July 1, 2019. Accessed December 1, 2023. https://diabetes.org/blog/history-wonderful-thing-we-call-insulin#:~:text=Insulin%20from%20cattle%20and%20pigs,bacteria%20to%20produce%20the%20insulin). 
2. Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. JAMA. 2017;318(10):927–938. doi:10.1001/jama.2017.11217 https://jamanetwork.com/journals/jama/fullarticle/2653735  
3. Kean N. NAMS Releases 2022 Guidelines for Hormone Therapy. Clinical Advisor. July 07, 2022. Accessed December 1, 2023. https://www.clinicaladvisor.com/home/topics/ob-gyn-information-center/nams-releases-2022-guidelines-hormone-therapy/#:~:text=According%20to%20NAMS%2C%20%E2%80%9Cthe%20benefits,bone%20loss%2C%20heart%20disease%2C%20and  
4. Gass, Margery L.S. MD, NCMP1; Stuenkel, Cynthia A. MD, NCMP2; Utian, Wulf H. MD, PhD, DSc(Med)1, et al. This survey was developed by The North American Menopause Society (NAMS) Advisory Panel consisting of representatives of the NAMS Board of Trustees and other experts in women’s health:. Use of compounded hormone therapy in the United States: report of The North American Menopause Society Survey. J Menopause 22(12):p 1276-1285, December 2015. | DOI: 10.1097/GME.0000000000000553 https://journals.lww.com/menopausejournal/Abstract/2015/12000/Use_of_compounded_hormone_therapy_in_the_United.4.aspx  
5. Pinkerton, JoAnn V. MD; Constantine, Ginger D. MD. Compounded non-FDA–approved menopausal hormone therapy prescriptions have increased: results of a pharmacy survey. J Menopause 23(4):p 359-367, April 2016. | DOI: 10.1097/GME.0000000000000567 https://journals.lww.com/menopausejournal/Fulltext/2016/04000/Compounded_non_FDA_approved_menopausal_hormone.4.aspx