Thinking (and Thinking and Thinking) About HRT

For several years now I’ve been interviewing experts and reading research and literally changing my mind between days and even some hours on this one thing: menopause hormone therapy, aka HT aka HRT.

Is it good for you? Is bioidentical better than synthetic? Should I take it if I am managing my symptoms? What about the risks? Disease prevention? These are the questions I am asking every expert I can get my hands on. And their answers are all over the place. 

In my experience, most people working in this field will tell you the 2002 Women’s Health Initiative was a bad study, with poor methodology, and that the risks of HRT were overblown, and hormone therapy is great. Lots of experts focus on hormone therapy exclusively, as a cure-all, and they make me wary. Lots of experts focus on the "natural" route exclusively, and they make me wary too. (I'm going to start calling them HRT Hysterics and Natural Nonces. Do you like it?) 

But overall, scientists and doctors are not united on this, and as usual, the integrative world is miles ahead of the mainstream on the longevity/disease prevention front. The risks (cardiovascular, breast cancer etc) seem to have been overblown dramatically, while evidence supporting the protective benefits for brain, heart, bones and more continues to accumulate – something official menopause bodies could take years, if not decades, to officially recognize. As I just mentioned, mainstream medicine often lags behind the integrative world; heck, studies have shown that scientific evidence can take 17 years to translate into mainstream medical practice.

So we are a long, long, long way off from a consensus on this. In the meantime, while we are all going through this right now, I recommend reading Avrum Bluming & Carol Tavis’s book Estrogen Matters for the deep dive –  and keeping an open mind. And if you don’t have time, check out their 2019 interview on The Peter Attia Drive Podcast; it’s jaw-dropping and while not a replacement for the book, it does explain a lot.

Bluming and Tavris are outliers who need to be listened to; such important voices, with no apparent conflicts in place other than book sales and possibly appearances (please correct me if I'm wrong and I'll ask them myself if I get the chance), bringing common sense and critical thinking to a shouty, emotion-filled online debate. And I have to admit that I feel immense relief when I hear a relatively impartial longevity specialist like Attia speak on the topic, too.

On an August 2022 episode of the Huberman Lab podcast, for example, Attia admits he doesn’t know enough about testosterone – that not enough evidence exists – to recommend its use for women. (How refreshing it is these days to hear people say ‘I don’t know’, right?). But when it comes to estrogen and progesterone? Based on the literature, he tells Huberman: “I’ll happily go toe-to-toe with anyone who wants to make the case that it's dangerous.” 

No, I am not trusting a man’s opinion over those of women. I am saying that unlike so many people in this space, he has no skin in the game. 

No bias that I can perceive, other than wanting everyone to live longer; no social media profile built on trumpeting hormone therapy, no star doctor operating a private clinic; no personal bias a la the latest celebrity nabbing a headline or cover story hooked on how transformative hormone therapy was for them. Etcetera. 

Attia is that rare podcaster who doesn’t even take ads. Sure, he’s spotted a growth area in menopause care along with the rest of us; but overall, as a functional medicine specialist I work with in Dubai put it: “he’s uncompromised”.

Bonus: he’s not telling us menopause is a disease and that hormone therapy is the answer, but rather menopause is a transition connected to diseases of aging and hormone therapy can be a key tool when it comes to managing both. It’s not unlike many of the messages myself, my partner Andrea Donsky and an audience of more than 6,000 women got at our first Menopause Shift Summit in June 2022, from multiple forward-thinking integrative and functional physicians. 

Another thing I learned from the Attia-Huberman interview (most of the good hormone stuff for us is in the first half-hour) is that when we get our hormone labs, none of the measurements are comparable – you have to standardize all the units into picograms to get a true sense of how we function. And when you do get that comparable view, you see clearly that women make more testosterone than estrogen.

You heard that right. And considering that bombshell, the fact that there is such a dearth of evidence on testosterone is even more mind-boggling. And not one single person among the dozens and dozens I’ve interviewed – nor author in a book I’ve read – has mentioned this fact, or seems to know much about testosterone at all. Why the singular focus on estrogen when this is the case, you and I ask the wall? Just another item for the growing list I like to call WTF is up with women’s health?

So. In this screeching mess we are in right now, where it’s very hard to see the truth in all the narratives and must-be-binary positions, I think more unlikely but credentialled people talking about our hormones from a place of obsessive scientific interest and wanting to find the truth and do the right thing by their patients and readers and followers might just be the kind of angle we need right now, to cut through the noise.  

I know it’s been just what I need to address my personal biases toward anything Pharma-related and most medical interventions, let alone hormone therapy. 

And so while I’m not running out and getting hormone therapy  just yet, I am thrilled to find more of the kind of voices I’ve been searching for. Because in every case there is the narrative – the story about what is happening – and there is the truth. And then there is us, somewhere in between, just trying to figure out what to do and then wondering if it was the right thing we did.