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

by Krista Russ

In Part I, we discussed evolving perspectives on BHRT, including the most up-to-date stance on BHRT by influential organizations like NAMS, and the evidence to support its safety and efficacy.  

Now, we will detail the incredible benefits that BHRT can offer your patients—both young and old—and the science backing it up, so buckle up and get ready to be astonished.  

How BHRT Helps Older Patients

BHRT & Menopause

It’s no secret that BHRT can help menopausal women. And while you are likely familiar with the symptom-related benefits of BHRT like easing hot flashes and night sweats,  BHRT can also treat or prevent more serious ailments such as: 

• Cognitive Decline/Dementia (Estrogens influence the expression of Alzheimer’s genes and early initiators of HRT (before menopause completion) perform better on cognitive tests, per a 2023 review [1] that went so far as to conclude “HRT appears to be a potent and effective therapeutic option for protecting against AD in young women.”  
• Depression and brain fog   
• Reducing Colon Cancer (~30 percent reduction) [2]  
• Reducing risk of CHD and atherosclerosis [2]  
• Improved skin elasticity/less wrinkling  
• Improved insomnia (progesterone, estradiol) [2]  
• Increasing energy/reducing fatigue [2]  
• Reducing menopause-associated weight gain [2]  
• Increasing muscle mass/slowing sarcopenia [2]  

Menopause-Drive Depression & Mood Instability

One lesser-known consequence of menopause is depression and mood changes. Many women entering the changes of life experience drastic, unsettling changes in their mood.  

Unfortunately, these women are often left to either suffer or are instead treated with antidepressant medication, typically SSRIS, which not only fail to treat the underlying cause of their depression but can also worsen existing problems such as sexual dysfunction that already plague menopausal women. SSRIS are also known to increase the risk of osteoporosis and lower bone mineral density values, something menopausal women are already at heightened risk for [3]. Who wants to trade one problem for another?  

Few practitioners understand that all the major hormones play a role in our mood: estradiol, progesterone, thyroid, and testosterone—and all these hormones rapidly decline in menopause, the implications of which are often staggering.  

Testosterone is well known for its euphoric effect on mood, and is theorized to be one reason why men tend to suffer half the rate of mood disturbances like depression compared to women worldwide [4]. Studies show that testosterone can protect against both anxiety and depression by enhancing the release of dopamine from the mesolimbic system [4]. It is also well known that hypogonadal men suffer higher rates of anxiety and depression compared to men with normal testosterone levels, which is alleviated with testosterone replacement across the majority of studies [4]. Unfortunately, few women understand that testosterone is important for them too.  

Progesterone, another hormone that declines in menopause, is also important for mood. In fact, its sudden and dramatic decline following childbirth is now implicated as the primary cause of postpartum depression. The enzyme 5-alpha-reductase converts progesterone to the calming neurosteroid hormone allopregnanolone which has anxiolytic, antidepressant, and sedative effects on the brain by activating and modulating GABA receptors, improving both mood and sleep [5], [6]. This is a double benefit because insomnia and sleep disturbances are also common in menopausal women. Progesterone and its active metabolite, allopregnanolone, are indeed so effective at improving depression they have been used successfully, often when nothing else worked, to treat PPD (Post-Partum Depression) and PMDD (Pre-Menstrual Dysphoric Disorder) as well.  

Abnormal Vaginal Bleeding & Endometrial Stripe

Abnormal vaginal bleeding that occurs after menopause or a thickened endometrial stripe, which is a risk factor for endometrial cancer, is often treated with synthetic progestins like norethindrone, Provera, or birth control pills by conventional OB/GYNs. This is a problem because progestins have potential to result in very deadly effects such as blood clots, strokes, heart attacks, and even cancer.  

In fact, many well-meaning OB/GYNs will take patients off bioidentical progesterone and put them on progestins like Provera or norethindrone instead, a mistake that can have deadly consequences. Bioidentical progesterone can be used safely without these potential deadly health effects, which you can learn more about in our BHRT training series. Women without uteri also benefit from progesterone, contrary to conventional training.   

BHRT & Bone Health

Coinciding with menopause follows a rapid increase in bone loss and reduced new bone formation, dramatically increasing the risk for osteoporosis. Fortunately, estradiol replacement therapy can reduce osteoporosis by nearly a third [2].Testosterone protects and strengthens bones as well.  

How BHRT Helps Younger Patients

BHRT & PCOS

Polycystic Ovarian Syndrome (PCOS) is very common, affecting 15 percent or more of women [7]. It is the leading cause of infertility in women [8]. Sadly, PCOS is poorly understood, often resulting in delayed treatment or no treatment at all.  

This patient pool is commonly underserved (see our blog series [9]) and take our one-hour course [10] for more on PCOS) but can be greatly helped with certain forms of BHRT. At Worldlink/APIM, you are taught how to treat PCOS using a multidisciplinary approach with a conglomerate of powerful and effective techniques including insulin-sensitizing agents (metformin, GLP1-agonists), lifestyle changes (diet, exercise), and hormones (micronized progesterone, thyroid) to help regulate the menstrual cycle and boost the lagging metabolic rate that drives much of the insulin resistance seen in PCOS.  

Treating PCOS correctly is extremely important for managing both the short-term (hirsutism, acne, infertility, etc.) and long term (fatty liver, diabetes, endometrial cancer, etc.) complications of PCOS [11] that are so often ignored in conventional practices. As a result, there is a great need to help this patient demographic, and through BHRT training, you can become one of few practitioners to actually help these patients.

BHRT & Postpartum Depression + PMS Management

While Postpartum Depression (PPD) is complicated and not completely understood, we do know that dramatic hormonal fluctuations following childbirth (specifically a sudden drop in progesterone) likely contributes significantly to its etiology [12], especially as progesterone has shown to contribute significantly to mental wellbeing in women.   

Nevertheless, PPD remains challenging to treat. Using Worldlink’s BHRT protocols, our OB/GYNs have helped countless women suffering from PPD who were on the verge of suicide with progesterone replacement therapy.  

In fact, the importance of progesterone therapy for treating PPD is so well-documented that drug manufacturers have recently created the first FDA-approved drugs for PPD called Brexanolone (IV infusion) and Zuranolone (pill), which both happen to be metabolites of progesterone. These drugs are far more expensive than bioidentical progesterone, which cannot be patented so that the drug companies can make a lofty profit. They also have more side effects. The reality that many women are left to suffer because they cannot afford these drugs is very sad, especially because there is a better, more affordable alternative that few women are ever informed about—bioidentical progesterone!  

Bioidentical progesterone has also been used to treat bothersome PMS symptoms that plague many women such as food cravings, irritability, tender breasts, and mood swings.  

How BHRT Helps Younger and Older Patients

BHRT & Sexual Health

Common sexual health issues in women include Female Orgasmic Disorder and Hypoactive Sexual Desire Disorder (HSDD) that remains challenging to treat, with few effective interventions available. Often, these patients are left to suffer in silence due to embarrassment or shame despite the fact that ten percent of women are affected by HSDD, and nearly three out of four women are unable to reach orgasm with penetration alone [13], [14].  

While this is often attributed to unfavorable anatomical alignment during intercourse (lack of clitoral stimulation) than having a “disorder” per say, testosterone has still proven successful at increasing the chances or orgasm during penetration regardless, leading to a more satisfying sex life [14],[15].  

In fact, a large meta-analysis that included 36 randomized clinical trials and over 8,000 patients found that testosterone effectively treated sexual dysfunction in women, resulting in significant improvements in many important metrics, including sexual intercourse frequency, pleasure, desire, arousal, orgasm, and self-image as compared to placebo or other medications [15].   

Furthermore, a 2022 meta-analysis of randomized controlled trials published in the journal Menopause. on compounded bioidentical hormone therapy found that vaginally administered testosterone and DHEA compared with placebo resulted in a significant improvement in vaginal atrophy symptoms in postmenopausal women and also did not result in any adverse changes in lipid or glucose metabolism [16].   

With regards to HSDD, many women don’t understand that they too need testosterone and that it decreases sharply with age (starting in the 30s and 40s) [2]. Testosterone (along with estradiol) can be used to treat both the physical ailments that drive sexual dysfunction in menopause (vaginal dryness, atrophy, anorgasmia) as well as the psychological aspects (low desire) that is of particular importance for treating sexual dysfunction in women. Along with improving vaginal health, both vaginally administered estradiol and testosterone helps to treat the bothersome non-sexual symptoms of GSM (Genitourinary Syndrome) like increased urgency, dysuria, incontinence, and recurrent UTIs so common in menopause (per K. Hales, Pharmacist [17]). 

So how exactly does testosterone produce all these wonderful effects? Testosterone works to improve sexual health in menopausal women via several important mechanisms. For one, it helps to maintain the necessary acidic pH of the vagina, which not only protects against opportunistic infections of the vaginal origin (BV, candida albicans, etc.), but also protects against UTIs, preventing potentially severe complications like kidney infections and sepsis.  

As women age, they lose the vaginal glycogen necessary to feed their lactobacillus bacterium (per K. Hales, Pharmacist [17]). This bacterium helps to maintain the necessary acidic vaginal pH, decreasing the risk for opportunistic infections that thrive in alkaline conditions. Furthermore, testosterone improves sexual function by increasing vaginal lubrication, strengthening the vaginal tissues, and increasing blood flow to the entire area (not just the vagina but also the vulva and clitoris). It also increases sensitivity, allowing for a more robust sexual response (per K. Hales, Pharmacist [17]).  

Even before menopause, many women struggle with HSDD due to prolonged use of birth control pills, which shut down ovarian production of testosterone (besides Merina IUD).  

Testosterone has important non-sexual benefits for women as well, such as increasing bone density, reducing fat mass, and improving mood, energy, and well-being for women who are not concerned about sexual function but can still reap the benefits of testosterone replacement [2].  

Unfortunately, there is no commercially available testosterone for women to date, but there are high-quality, compounded testosterone options.  

BHRT & Weight Management/Metabolic Syndrome

While healthy diet and physical activity are the crux of any successful weight management strategy, BHRT can certainly help patients who are fighting the battle of the bulge.  

Testosterone and thyroid have robust evidence to support their use in boosting a lagging metabolism, resulting in a loss of visceral fat that can improve a variety of downstream health conditions such as: 

• Insulin Resistance/Type Two Diabetes 
• Dyslipidemia 
• Fatty Liver (Non-Alcoholic) 
• Hypertension  
• Low grade inflammation (caused by obesity) 
• PCOS  
• Cardiovascular Disease  

For instance, it is well documented that thyroid insufficiency, whether due to primary, secondary, or tertiary hypothyroidism, can intensify insulin resistance [18]. As insulin resistance contributes to many of today’s chronic diseases (dyslipidemia, hypertension, diabetes, obesity, CHD, dementia, gallbladder disease, gout, etc.), this has important clinical implications.  

What’s Next?

As you can see, a variety of health conditions can benefit from the proper application of BHRT: menopause, PCOS, infertility, osteoporosis, postpartum depression, dyslipidemia, insulin resistance, and sexual dysfunction are just a few.  

Now that you know how BHRT can help your patients, your next step is to sign up for a reputable BHRT training program that will teach you the ropes of BHRT from start to finish and provide continued support after the training.  

For more on the benefits of adding BHRT to your OB/GYN practice, we strongly recommend take Dr. Malaika Woods’ thought-provoking, one-hour course: BHRT from an OB/GYN’s Perspective [2], which is approved for one CME credit hour until December 31, 2023.  

References   

1. Mills ZB, Faull RLM, Kwakowsky A. Is Hormone Replacement Therapy a Risk Factor or a Therapeutic Option for Alzheimer’s Disease? Int J Mol Sci. 2023 Feb 6;24(4):3205. doi: 10.3390/ijms24043205. PMID: 36834617; PMCID: PMC9964432. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9964432/#:~:text=HRT%20initiated%20pre%2Dmenopause%20was,and%20that%20of%20premenopausal%20women 
2. Worldlink Medical. BHRT from an OB/GYN’s Perspective. Vimeo; November 10, 2020. Accessed December 10, 2023. https://members.worldlinkmedical.com/bhrt-from-an-ob-gyns-perspective/  
3. Zhou C, Fang L, Chen Y, Zhong J, Wang H, Xie P. Effect of selective serotonin reuptake inhibitors on bone mineral density: a systematic review and meta-analysis. J Osteoporos Int. 2018 Jun;29(6):1243-1251. doi: 10.1007/s00198-018-4413-0. Epub 2018 Feb 12. PMID: 29435621. https://pubmed.ncbi.nlm.nih.gov/29435621/  
4. McHenry J, Carrier N, Hull E, Kabbaj M. Sex differences in anxiety and depression: role of testosterone. J Front Neuroendocrinol. 2014 Jan;35(1):42-57. doi: 10.1016/j.yfrne.2013.09.001. Epub 2013 Sep 24. PMID: 24076484; PMCID: PMC3946856. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3946856/  
5. Briden L. Cyclic Progesterone Therapy for PCOS. Larabriden.com. December 26, 2022. Accessed December 12, 2023. https://www.larabriden.com/cyclic-progesterone-therapy-for-pcos/  
6. Diviccaro S, Cioffi L, Falvo E, Giatti S, Melcangi RC. Allopregnanolone: An overview on its synthesis and effects. J Neuroendocrinol. 2022 Feb;34(2):e12996. doi: 10.1111/jne.12996. Epub 2021 Jun 29. PMID: 34189791; PMCID: PMC9285581. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9285581/#:~:text=ALLO%20treatment%20exerts%20anxiolytic%20and%20anti%E2%80%90stress%20actions.&text=Activation%20of%20GABAA%20receptors,be%20responsible%20for%20these%20effects.&text=Interestingly%2C%20corticotrophin%E2%80%90releasing%20hormone%20(,are%20regulated%20by%20GABAergic%20inhibition  
7. Polycystic Ovary Syndrome (PCOS). Cleveland Clinic. Last reviewed by a Cleveland Clinic medical professional on 02/15/2023. Accessed December 12, 2023. https://my.clevelandclinic.org/health/diseases/8316-polycystic-ovary-syndrome-pcos  
8. Mobeen H, Afzal N, Kashif M. Polycystic Ovary Syndrome May Be an Autoimmune Disorder. J Scientifica (Cairo). 2016; 2016:4071735. doi: 10.1155/2016/4071735. Epub 2016 May 5. PMID: 27274883; PMCID: PMC4871972. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4871972/  
9. Russ K. Why Low-Calorie Diets Don’t Help PCOS & What DOES. Academy of Preventative & Innovative Medicine. August 17, 2023. Accessed December 9, 2023. https://worldlinkmedical.com/why-low-calorie-diets-dont-help-pcos-what-does/  
10. Worldlink Medical. Why You’re Treating PCOS Wrong & How to Make It Right – A Comprehensive Guide to Evidence-Based Treatments. Vimeo; August 28, 2023. Accessed December 1, 2023. https://members.worldlinkmedical.com/courses/why-youre-treating-pcos-wrong-how-to-make-it-right-a-comprehensive-guide-to-evidence-based-treatments/  
11.  Polycystic Ovary Syndrome (PCOS). John Hopkins Medicine. Accessed December 9, 2023. https://www.hopkinsmedicine.org/health/conditions-and-diseases/polycystic-ovary-syndrome-pcos#:~:text=Women%20with%20PCOS%20are%20more,to%20get%20pregnant%20(fertility).  
12. Pietrangelo A. Wilson DB. Everything You Need to Know About Postpartum Depression: Symptoms, Treatments, and finding help. Healthline. Updated on March 31, 2022. Accessed December 9, 2023. https://www.healthline.com/health/depression/postpartum-depression  
13. Pachano Pesantez GS, Clayton AH. Treatment of Hypoactive Sexual Desire Disorder Among Women: General Considerations and Pharmacological Options. Focus. J Am Psychiatr Publ. 2021 Jan;19(1):39-45. doi: 10.1176/appi.focus.20200039. Epub 2021 Jan 25. PMID: 34483765; PMCID: PMC8412154. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8412154/#:~:text=Hypoactive%20sexual%20desire%20disorder%20  
14. Schwartz P. Female Orgasmic Disorder. American Sexual Health Association. Accessed December 8, 2023. https://www.ashasexualhealth.org/orgasmic-disorder/  
15. Ingram CF, Payne KS, Messore M, Scovell JM. Testosterone therapy and other treatment modalities for female sexual dysfunction. J Curr Opin Urol. 2020 May;30(3):309-316. doi: 10.1097/MOU.0000000000000759. PMID: 32205812. https://pubmed.ncbi.nlm.nih.gov/32205812/  
16. Liu Y, Yuan Y, Day AJ, Zhang W, John P, Ng DJ, Banov D. Safety and efficacy of compounded bioidentical hormone therapy (cBHT) in perimenopausal and postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. J Menopause. 2022 Feb 14;29(4):465-482. doi: 10.1097/GME.0000000000001937. PMID: 35357369. https://pubmed.ncbi.nlm.nih.gov/35357369/  
17. Russ, K. and Hales, Pharmacist, K. (2023) ‘Subject Matter Expect Interview: How Hormones Impact Sexual Health as Women Age’. 
18.  Vyakaranam S, Vanaparthy S, Nori S, Palarapu S, Bhongir AV. Study of Insulin Resistance in Subclinical Hypothyroidism. Int J Health Sci Res. 2014 Sep;4(9):147-153. PMID: 25580384; PMCID: PMC4286301. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286301/#:~:text=Thyroid%20hormones%20T3%20and%20T4,can%20lead%20to%20insulin%20resistance