Hormone Therapy

Me-What are the risks of hormone therapy after 60?

Starting hormone therapy (HT) after age 60, or more than 10 years after menopause onset, generally carries higher health risks compared to starting it earlier (in your 40s or 50s). This is often referred to as the “timing hypothesis,” suggesting that initiating HT later in life increases vulnerability to certain complications. 

Key Risks of Starting HT After 60

The primary concerns for women starting HT over age 60 include:

• Cardiovascular Risks:
  • Heart Disease: Research, particularly from the Women’s Health Initiative (WHI) study, suggests an increased risk of coronary heart disease and cardiovascular events when starting HT later in life, particularly for women over 70. The protective cardiovascular effects seen in younger postmenopausal women are generally not observed in this older age group.
  • Stroke and Blood Clots: There is an increased risk of ischemic stroke and the formation of blood clots in the legs (deep vein thrombosis) and lungs (pulmonary embolism). The risk of blood clots is particularly elevated with oral (pill) forms of estrogen, whereas transdermal patches or gels may have a lower risk.
• Cognitive Risks:
  • Dementia: Studies have indicated an increased risk of developing dementia in women who initiated combined estrogen-progestin therapy after the age of 65.
• Cancer Risks:
  • Breast Cancer: Long-term use of combined estrogen-progestin therapy is associated with a slightly increased risk of breast cancer. The risk increases the longer HT is used and the older a woman is at the time of use.
  • Endometrial Cancer: For women who still have their uterus, taking estrogen alone (without progestin) significantly increases the risk of endometrial (uterine lining) cancer. A progestin is typically added to prevent this risk. 

Factors Influencing Risk

The risks of HT are not the same for every woman over 60 and depend heavily on:

• Individual Health History: A personal history of heart disease, stroke, blood clots, or certain cancers (especially breast cancer) typically makes HT unadvisable.
• Type of HT: Transdermal forms (patches, gels) may pose lower risks for blood clots and stroke compared to oral pills.
• Time Since Menopause: The general guideline is that risks are lower if HT is started within 10 years of menopause onset.
• Duration of Use: Using HT for the shortest time necessary to relieve severe symptoms helps manage risks. 

Recommendation

For women over 60, especially those more than a decade past menopause, the benefits of HT for managing symptoms (like hot flashes and vaginal dryness) generally need to be significant enough to outweigh these elevated health risks. 

It is crucial to have a thorough discussion with a healthcare provider, such as a certified menopause practitioner, to weigh the potential benefits against your individual risk factors and explore non-hormonal treatment options if appropriate.

Me- Years ago, hormone replacement therapy involved horses. It was a fairly horrible life for them, constant breeding, standing in a stanchion their entire lives… it was horrible. What is it now?

While the equine-derived drug Premarin (conjugated equine estrogens or CEE) is still available and used today, modern hormone therapy has largely shifted towards using plant-derived, synthetic, and bioidentical hormones that replicate the exact chemical structure of hormones produced by the human body. 

The hormone replacement therapy (HRT) landscape is no longer solely reliant on products derived from pregnant mare urine (PMU).

Modern Hormone Therapy Options

Today, women have a wide range of options for estrogen and progestogen that are not sourced from animals, the most common of which is estradiol. Estradiol has the same chemical structure as the primary estrogen produced by human ovaries and is derived from plant sources, such as soybeans and yams. 

These modern options come in many different forms:

• Tablets/Pills: Common oral options include those containing estradiol (e.g., Estrace) or other synthetic estrogens.
• Transdermal Patches: These patches are applied to the skin (e.g., Vivelle-Dot, Climara) and gradually release a steady dose of hormones directly into the bloodstream, bypassing the liver.
• Gels and Sprays: Estrogen can be absorbed through the skin via gels (e.g., EstroGel) or sprays applied to the arm or thigh.
• Vaginal Inserts: For women whose primary symptoms are vaginal dryness or urinary issues, low-dose creams, tablets, or rings can be inserted directly into the vagina. These target the local area with minimal systemic absorption.
• Bioidentical Progesterone: When a progestogen is needed (for women with an intact uterus), the preferred option is often micronized progesterone (brand name Prometrium), which is also plant-derived and bioidentical to the hormone produced by the human body. 

Summary

The suffering of the horses used in the historical PMU industry was a significant ethical concern, and modern medical advancements have provided numerous effective alternatives that have reduced reliance on these animal-derived products. 

If you are considering HRT, you can discuss these various options with your healthcare provider. They can help you choose the best type and delivery method based on your specific symptoms, health history, and ethical preferences.

Me- What is an average cost for a synthetic HRT?

The average out-of-pocket cost for synthetic or bioidentical manufactured hormone replacement therapy (HRT) typically ranges from $10 to over $500 per month, with generic pills being the least expensive option. The final cost depends heavily on the form of the medication and whether you use insurance or discount cards. 

Here are the general cost ranges without insurance for common synthetic/plant-derived HRT options:

• Pills/Tablets (Generic Estradiol): Generic oral tablets are the most affordable option, with monthly costs as low as $10 to $50 per month using discount cards or at certain pharmacies. Brand-name pills can cost significantly more, ranging from $130 to over $200 per month.
• Patches (Transdermal): The cost for patches typically ranges from $60 to $100 per month for generic versions (e.g., generic Vivelle-Dot). Brand-name patches can be more expensive, upwards of $300 per month.
• Gels and Creams: Topical gels and creams usually cost between $50 and $150 per month for generic options. Brand names or specific formulations can cost more, sometimes over $200 per month.
• Vaginal Rings/Inserts: These can be a more expensive option, ranging from $150 to $600+ per month, depending on the brand and specific product.
• Pellet Therapy: This involves a minor procedure to insert pellets under the skin. It is often a cash-pay option not covered by insurance, with an annual cost of around $1,050–$1,400 for women, which breaks down to roughly $100–$125 per month, though initial costs can be higher. 

Additional Costs:
Beyond the medication itself, you may also encounter costs for initial doctor consultations (up to $200-$500) and lab tests to monitor hormone levels ($100-$500 without insurance). 

Tips for Managing Costs:

• Generic medications are substantially cheaper than brand names.
• Discount cards from services like GoodRx can significantly lower prices at local pharmacies.
• Check with your insurance provider to understand your specific coverage, as many standard, FDA-approved HRT methods are covered, reducing costs to a typical co-pay of $5–$30 per month.