Hormone Replacement Therapy (For All Women)
This is perhaps the most complicated subject I’ve encountered and the most important. If you are a woman (including all healthy women), I hope you’ll read this.
Now that I’ve have both ovaries removed, I’m in what’s called “surgical menopause.” So my body no longer produces its own hormones. And since I’m not yet at the age of menopause, it’s particularly dangerous for me to go without any hormones. It’s also incredibly debilitating to be without them. I had to wait 3 days after my last surgery to begin using a hormone patch, and I honestly thought I was dying. Granted, I’d just had two back-to-back surgeries, but the total and abrupt hormone depletion is no joke. Hormone depletion zaps your energy, cognitive functioning, sex drive, and effects things like organ function and muscle tone, as well as digestion, vision, skin, body shape —yes, EVERYTHING. So, it goes without saying I care a bit about these things. But hormone replacement therapy (or HRT) is very much an art form, and testing the levels is tricky and often imprecise, depending on how your hormones are administered (i.e. transdermal is easier to test than orally-administered hormones; here’s an article on the difference between oral and transdermal).
I knew I wanted bioidentical hormones, but beyond that it was all a bit confusing. But I became a devotee or HRT the minute I slapped the obnoxiously-branded hormone patch on my butt post-surgery (note: I’ve since upgraded to a smaller patch with barely visible branding — but seriously people: must our bodies be pharmaceutical billboards??) From the moment I started applying the hormones to my post-surgical body, I was like a wilted flower that had just been given fresh water, and I started to perk up immediately — that’s how fast it works. It’s instantaneous. (Makes you pay attention to everything else you apply to your skin, as it, too, is rapidly absorbed.)
The TLDR Bottomline: Ask for bio-identical, rhythmic, sequential hormones (estrogen every day, with varying amounts to mimic a natural cycle; progesterone 12 days a month; you will bleed monthly). Consider a cream + patch for estrogen; pills or a troche (lozenge with fast sublingual delivery) for progesterone. Avoid combined continuous patches (with both estrogen and progesterone; you don’t want static dosing throughout the month). Unopposed estrogen (without progesterone) is dangerous, so get both, but change up the dosing throughout the month.
Dosing: Hormone dosing is an art form. Your doctor will try to give you very low doses, but sources I trust, including one of my very highly regarded oncologists, recommend higher doses of bio-identical hormones (synthetic hormones are the ones linked to cancer, particularly with unopposed estrogen). After over a year of experimenting with every delivery method and dosing you can imagine, here’s what I take:
28 Day Cycle:
Estrogen:
Baseline Patch: .1mg p/day release estrogen patch (wear constantly on my lower abdomen; change 2x per week). I use the generic Mylan version (which is covered by insurance! Hallelujah!). If you can’t get the estrogen creams, it is possible to roughly mimic the rhythmic dosing by varying the number of patches over the course of the month. Work with a doctor (like Dr. Taguchi) to do that. But know it won’t be as effective as the nuanced precision and variation available through the creams.
Creams: Apply the following doses 2x per day (I apply when I wake up and a couple hours before bed; it is slightly stimulating). They are administered in syringes, and 1 line = .1ml. Ordered from a compounding pharmacy.
Days 1-2: 6 lines, 2x p/day
Days 3-5: 8 lines, 2x p/day
Day 6-8: 13 lines, 2x p/day
Day 9-11: 14 lines, 2x p/day
Day 12: 17 lines, 2x p/day
Day 13-14: 6 lines, 2x p/day
Day 15-28: 10 lines, 2x p/day
Testosterone:
Baseline cream: 1 line, 1x p/day in the morning throughout 28 day cycle (morning is optimal because the cream is stimulating. I accidentally did an experiment to prove this: one evening on a peak estrogen day (meaning, lots of cream), I applied my testosterone instead of the estrogen. It made me super agro, irritated, and unable to sleep - like I’d just consumed 12 cups of coffee while also experiencing roid-rage. So, in case there was any doubt: this is more than placebo).
Peak days: 2 lines, 2x p/day on days 15-19 (the only days you apply more than the 1 line, 1x per day)
Progesterone: (all via 50mg and 100mg capsules; taken in the evening because it is mellowing)
Days 1- 13: nothing
Days 14-15: 100mg in the evening
Days 16-17: 150mg in the evening
Days 18-19: 200mg in the evening
Day 20-26: 300mg in the evening
Days 27-28: nothing (ideally, period begins here)
Thyroid:
Nature-throid or NP thyroid (it’s the natural formula; don’t take the synthetic - they will try to convince you, but I felt horrible on it and it’s not as aligned with your body; some countries don’t even offer the natural thyroid - do whatever you need to do to get the natural version; it’s worth it), 32.5 mg tablet 1x p/day in the morning, 30 minutes before eating. [Not everyone will need this, but it was a major X-factor for me and I recommend getting tested and seeing how you feel with 1 tablet p/day if you’re at all low.]
Application:
Estrogen cream: labia (can also do inner thighs, but more likely to rub off on things. Rub on and let dry for a minutes while you get ready).
Testosterone cream: labia (hair will grow wherever you apply it so…choose wisely)
Estrogen patch: You can put it on your butt, but I prefer my lower abdomen / bikini area. I alternate between my left and right side with each application, avoiding the midline (I’m not sure why you have to avoid your midline, but that’s what my doctor tells me.) Some countries only offer giant patches (definitely not designed by a woman). For long-term use, which is recommended, I’d encourage you to find a source for the smaller patches, which are 1/4 the size of the giant ones.
A few things of note:
This is for everyone: Yes, this particular protocol is for someone with no ovaries (though your thyroid and adrenals do produce some hormones). However, even healthy women should eventually consider some version of this protocol as they get older and their hormones diminish — or due to hormonal disruption from literally anything (i.e. post-partum, environmental changes, stress, chemo, accidents or injuries, etc.). Don’t wait until you get hot flashes or have zero sex drive or can’t remember anything to consider rhythmic BHRT. Start asking your doctor for a blood hormone panel when you turn 40. And when you get the results, don’t let them tell you the levels are fine “for your age” — you don’t want to feel like an old person, you want to feel (and look) young! Not to mention how rapidly your heart health and bone density will deteriorate if you continue to get suboptimal hormones supplementation. So ask to supplement with hormones that put you at those younger levels. As long as it’s bioidentical, you should be fine (EVEN if you have a history of cancer; bioidentical hormones don’t cause cancer). If your doctor won’t prescribe it, find a doctor or naturopath who will. See my resources section for some of the people I’ve consulted with and who have prescribed this protocol for me, but I’d start with Dr. Taguchi. I recommend emailing her [dr.t@thriverawellness.com], asking which lab results she wants you to have, and then scheduling a virtual consult with the lab results to develop your optimal protocol.
Hormones for life: I plan to take hormones for the rest of my life (some women taper off eventually, usually becuase they are on static, low-dose hormones and the only real difference they feel is diminished hot flashes. Like nearly everyone who discovers rhythmically dosed BHRT, I plan to continue so I can enjoy the benefits). Will I reach a point where I think, “Gee, I don’t really need to have energy, mental clarity, beautiful skin and hair, or any sex drive, and my bones and heart health are no longer important”? I WILL NOT. I want to be ALIVE for as long as I’m alive, and this particular type of hormones and this dosing protocol of hormones is the key.
Insurance: Once you decide to go the BHRT route, know that you are signing up for a significantly higher price tag, as insurance will only cover part of it. (It costs me around $100 per month for the compounded estrogen cream.) However, it will cover some things: The bioidentical estrogen patches (which cap out at .1 mg p/day), are covered, as are the 100mg capsules of progesterone. The various creams and 50mg progesterone capsules from the compounding pharmacy are not covered. But honestly, it’s the best money I spend each month and I would go broke paying for these hormones if that were the only option. That’s how much they work.
Delivery methods: Patches need to be changed weekly (in most cases) whereas transdermal creams or gels are applied daily. I started out with the Climara Pro patch with estradiol (estrogen) and levonorgestrel (progestin). The estrogen is bio-identical, but the progestin is not. It’s also combined continuous, as opposed to sequential (sequential dosing involves varying levels of estrogen and progesterone only 2 weeks per month, which more closely mimics how our bodies operate naturally). The inferiority of combined continuous hormones, coupled with the visible branding on the patch, led me to seek out an alternative. To be clear: your doctor will likely try to push you into something like this. You will almost certainly NOT feel the kind of results women on rhythmically cycled hormones feel. I promise it’s inferior, because I’ve tried and thousands of other women have tried it and sought a better alternative when they still didn’t feel the kind of vitality they knew they once had and wanted again.
Testosterone: Our ovaries produce not only estrogen and progesterone, but also testosterone. And that ovarian testosterone contributes to maintaining sex drive, muscle tone, and cognitive functioning. (Read more about it here.) And yet, most doctors will not proactively suggest that you add testosterone into the mix, nor are there any patches/pills that offer all three hormones, and it almost certainly won’t be covered by your insurance. So you must take matters into your own hands. Ask your doctor for a testosterone cream (which you’ll likely need to get at a compounding pharmacy). Just like I felt an instant boost when I applied the patch, I felt a similar boost in energy when I started applying the testosterone cream — so it’s worth the effort (and money).
Wiley Protocol: The dosing and protocol I’m following closely mimics the Wiley Protocol, a bioidentical, rhythmic (meaning it varies over the course of each month, as opposed to being static) hormone protocol, which replaces your hormones with a formula that mimics the hormonal cycle of a young woman in her 20s. I’d recommend discussing it with your ObGyn or endocrinologist (my original endocrinologist at UCLA was willing to try to replicate and experiment with it on me to see how I feel (per my request), my ObGyn was not open to it. It wasn’t until I switched to the goddess Dr. Julie Taguchi [dr.t@thriverawellness.com] that I was really able to find the dosing that works for me. If you want to hear more about this approach, check out T.S. Wiley’s interview with Dave Asprey on the Bulletproof Executive for a more in-depth explanation. I also recommend reading Sex, Lies, and Menopause by T.S. Wiley, with Dr. Taguchi. It’s admittedly not great literature, but it does explain the rationale behind the protocol (ignore the one hysterical Amazon reviewer. Not every protocol works for everyone, but for most women, this is the superior option. And the alternative — feeling horrible for the rest of your life — is not appealing. A better book option is Suzanne Somers’ Ageless: The Naked Truth About Bioidentical Hormones (she follows the Wiley protocol and works with Taguchi).
Other reading: I recommend reading Dr. Winnifred Cutler’s book, Hormones and Your Health, for a good explanation of HRT research and the importance of bio-identical, sequential dosing (I think her explanation is a good start, but not as spot-on as what Somers lays out in her book - if you just read one of these, read Ageless). She is a reproductive biologist and has been researching this for decades. And Estrogen Matters by highly-respected physician Dr. Avrum Bluming offers a ton of compelling research. However, Bluming is tied to phamaceutical companies and doesn’t go so far as to distinguish between synthetic and bioidentical (and the superiority of the latter), and he is yet to embrace rhythmic protocols. He’s also a man who’s never gone through menopause. So, there’s that. This recent article in the NYTimes seems to have taken people by storm, as it does the best job I’ve seen of laying out just how grim things are when it comes to women and hormone therapy (confirming, no, it’s not just you; it really is this bad) — and yet!: the author ultimately settles for a low-dose birth control pill to manage menopause. Honestly, when I read stuff like that, I have a dual impulse to bang my head against a wall and cry. She, like all of us, deserves better.
Thyroid: My thyroid was also disrupted during this process, which further depleted my energy levels (it’s a wonder I’ve been able to get out of bed in the morning). My treatments at Q360 and with Maya helped with this, as have the liquid minerals I’ve added to my routine (they were totally depleted), and I’ve started using the Japanese toothpaste and switched to Kangen water, both of which further aid in thyroid regulation (see my explanation of both here). You can ask your doctor for a more in-depth thyroid panel than the basic one that is ordered. I’ve also started running a diffuser with myrtle oil, which has thyroid-regulating benefits (and it smells lovely).
If I haven’t convinced you to love and embrace rhythmically-cycled BHRT yet, consider this story from my doctor: She observed a study of elderly women and analyzed the various medications the participants were on. All of them took many different pharmaceutical drugs for various ailments — EXCEPT the woman who was still on HRT. That was the only “drug” she took, and that one drug kept her body functioning well enough to avoid all the other drugs necessary to counteract what happens to our bodies once the hormones diminish. This is why doctors try to dissuade women from taking higher doses of hormones and encourage them to taper off entirely as they get older. Drug companies rule everything, sit on the boards of hospitals, and have a say in how doctors are trained. But now you know better. Knowledge is power — and in this case, it’s the the key to vitality.
I’ll add one more recent experience: I’d been on my rhythmic BHRT protocol for years, finding great stability, vitality, and health. Then, when I moved to the Netherlands, I tried to source my hormones there. The patches were 4x the size of what we can get in the U.S. and there are NO compounding pharmacies (after much pushiness and endless research, I found one pharmacy in the entire country that technically will make compounded estrogen cream, but convincing a Dutch doctor to prescribe it to me is a battle I am currently fighting - TBD). So, I stocked up on a year’s worth of the smaller patches, 50mg progesterone caps, and compounded testosterone cream last time I was in the U.S., and in the absence of the compounding pharmacies, I attempted to replicate my rhythmic estrogen dosing using the estradiol gel (the progesterone 100mg caps are available here). You’d think that swapping the cream for the gel would not be a big deal, right? WRONG. In a matter of weeks, after years of feeling great, I once again felt horrible - we’re talking no energy, no sex drive/arousal, skin and hair deterioration, gut health suffered, messed up menstruation and persistent cramping, I no longer had ovulation-style cervical mucus (which you get with the cream), my breasts shrunk, I lost weight (not in a good way), I wasn’t sleeping, and, perhaps most significantly, deep, dark depression - we’re talking suicidal sort of “why keep living?” thoughts. (It’s important to note I do NOT naturally suffer from depression and have no history of depression; it is entirely hormone-related; if you do naturally experience depression, slipping into this state via imbalanced hormones will be even worse.) Why the difference? Because estradiol gel is alcohol based - it is absorbed rapidly, causing your estrogen levels to spike, then crash just as quickly. The cream is lipid-based, so it absorbs and is released more slowly. That makes a world of difference. By month 2, I had my hormones tested: Even when I increased the gel to doses that went beyond my cream dosing, I had the hormone levels of a geriatric woman in menopause. It was keeping them just high enough to stave off hot flashes, but that was literally the only benefit I was getting. It was demoralizing. So for 4 months, unable to get the compounded meds I needed, I suffered through with the gel. Unable to take it anymore, I ordered my compounded cream from California, had it sent to a friend in Paris (because France - along with Spain and some other EU countries - allows medication to be shipped into the country, whereas the Netherlands does not), paid an exorbitant amount of money to ship / pay import taxes / travel to pick up my hormones, not to mention the stress of coordinating this multinational affair. For 6 months, this entire venture cost me $2k (which, in case you’re wondering, was a LOT of money for me to drop). That is NOT ok. But you know what? It was STILL worth it.
- within 2 days, cervical mucus returned
- within 3 days, non-premenstrual cramping stopped
- within 5 days, energy returned to normal
- within first week, depression alleviated (despite the persistence of other non-hormone-related stressors)
- within 3 weeks boobs filled out slightly
- within first month, my skin was glowing again
- perhaps most significantly, my overall vitality returned in that first month. That is what women on this protocol report: they simply feel ALIVE again for the first time in a long time.
I’m not alone in these results. I’ve surveyed and interviewed dozens of other women with wildly diverse medical backgrounds / ages / hormone needs, and the rapidity and seemingly miraculous efficacy of these results are consistent.
However, it’s important to note that going from full, robust hormones to post-menopausal hormones and then back to full hormones within 4 months took a massive toll on my body. Even after I returned to the cream that works and started to feel better again, I had residual issues - night sweats, digestive issues, insomnia, intense menstrual cramps, and chronic fatigue set in. One’s body is not meant to swing to those extremes so rapidly. It’s physically and emotionally overwhelming. It’s important to get on a routine that works and stick with it.
So wherever you are, and whatever you need to do to get this type of hormone treatment, I would argue it’s the most important thing you can do for yourself. There is actually nothing else in your life that should take precedent. Why? Because if you are a walking zombie (or just powering through, thinking that’s how older age is supposed to be), you will not be serving yourself or anyone you love. This is not (yet) available everywhere, but as I’ve proven by experimenting on my own body and fighting my way to health multiple times, where there’s a will there’s a way.
You cannot “diet” your way through menopause, “lifestyle management” is not the answer, and there’s not an herbal supplement out there that can replace properly dosed, rhythmic BHRT. I hope every woman will one day have access to the kind of hormones they deserve. Until then, it’s up to you to make it happen for yourself.
