Table of Contents

What is the relationship between hormones and osteoporosis? What role do hormones play in bone health during all stages of life — including puberty, pre-menopause and post-menopause?

I will discuss each of these in today’s blog post. I will also cover compounded bioidentical hormone replacement, bioidentical hormone replacement therapy (HRT) for osteoporosis, how to find a hormone replacement therapy doctor, the costs of bioidentical hormone replacement therapy, benefits of hormone replacement therapy, and my personal experiences with HRT.

Before we start I need to point out that the whole area of hormones, hormone replacement, and hormones and osteoporosis can be very confusing for the reader. You will find the terminology inconsistent and contradictory. Unfortunately, several different terms referring to largely the same item appear in this article when I use direct quotes from researchers. I apologize in advance!

To help you navigate these waters, I have curated a Glossary at the end of this post that you can refer to while you read. The terms are extracted from the online glossary at the North American Menopause Society (NAMS).

Hormone Replacement Therapy (HRT)

In their comprehensive review, Gina Harper-Harrison and Meaghan Shanahan of Creighton University, define Hormone Replacement Therapy (HRT) as “supplementing women with hormones that are lost during the menopausal transition. To relieve the symptoms associated with menopause, conventional HRT includes an estrogen and progesterone component to mimic hormones created by the human ovary.” (1)

Why Hormone Replacement Therapy for Osteoporosis?

Hormone replacement therapy can offset the effects of osteoporosis (by slowing down the thinning of bones). It can counteract other symptoms caused by the decline in estrogen.

Estradiol is the main estrogen produced by your ovaries prior to menopause. Estrogen and progesterone are mainly made in the ovaries. For most women, the ovaries gradually stop making estrogens between the ages of 45 and 55.

Body estrogen levels drop and menopause sets in. During this period, some women develop symptoms such as feelings of warmth in the face, neck and chest. Sudden episodes of overheating (hot flushes) occur.

After the age of 40, the bones of men and women start to become thinner. However, women lose bone faster than men after menopause. This can lead to osteoporosis, osteopenia or low bone density.

Let’s discuss estrogen therapy and progesterone in a bit more detail.

Estrogen Therapies

A number of estrogen therapies are available. Estradiol (a major female sex hormone involved in the regulation of the women’s menstrual reproductive cycle) is produced by the human ovary. Estriol (a minor female sex hormone) is also produced by the human ovary. Estrogen plays a key role in preventing bone loss.

Conjugated equine estrogen (CEE) is a mixture of sodium salts of estrogen conjugates found in horses. CEE is available in tablets and sold under the commercial name, Premarin.

In their publication, Harper-Harrison and Shanahan point out that CEE is the most commonly prescribed estrogen in the United States. Most bioidentical hormone replacement physicians do not prescribe CEE. Dr. Jerilynn Prior, Professor of Endocrinology and Metabolism, founder and Scientific Director of the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) is not a proponent of CEE.

Estrogens can be administered either in oral or transdermal form. The transdermal (gels or patches) bypasses the hepatic metabolism, thereby reducing the risk of blood clotting.

Progestogen

Progestogen includes human made progesterones and progesterone-like substances known as progestins. Progesterone is used in combination with estrogen therapy “to protect [the] uterus from endometrial hyperplasia or malignancy”(1) According to Dr. Jerilynn Prior at the University of British Columbia, in her presentation Women’s Fracture Prevention, progesterone plays a key role in bone formation for women.

Progesterone is available in either oral or transdermal form.

Definitions of Synthetic and Bioidentical Hormones

Bioidentical hormones are defined by Dr. Sara Gottfried in her book, The Hormone Cure, as hormones “that are the exact replicas of the hormones your body makes during your fertile years, including estradiol and progesterone.”

Dr. Gottfried defines synthetic hormones as having “a different chemical structure” than indigenous hormones. As a result, they can be patented by pharmaceutical manufacturers.

Risks of Hormone Replacement Therapy

According to the North American Menopause Society (NAMS) 2017 Position Statement, the risks of menopausal hormone therapy differ depending on type of hormone, timing of initiation, route of administration, and whether a progestin (synthetic progesterone) is used.

Timing Risk

Timing of initiation is important. Unlike in the Women’s Health Initiative Study, where the average age was 63, for women who are younger than 60, or within 10 years of menopause onset and have no contraindications, the benefit of hormone therapy outweighs risk.

A meta-analysis of randomized controlled studies has shown that women who begin hormone therapy within 10 years of their menopause have a 48% lower risk of coronary heart disease, and a 30% lower risk of cardiovascular death. (2). However, it is important to note that the North American Menopause Society (NAMS) explicitly states in its 2017 Positioning Statement that “hormone therapy should not be used for primary prevention of heart disease.”(3)

Age Risk and Timing of Initiation

Women who initiate hormone therapy after the age of 60, or greater than 10 years from menopause onset, have less favourable benefit risk ratio because of greater risks of:

  • Coronary heart disease.
  • Stroke.
  • Venous thromboembolism.
  • Dementia.

There appears to be a window of opportunity to initiate menopausal hormone therapy. In general, initiation by women older than 65 years, requires careful consideration. (3)

Breast Cancer and Treatment Option

Breast cancer risk may depend on the type of treatment used (in the WHI trial, estrogen alone without progestin had lower risk), dose, duration of therapy, and type of progestogen used.

Progesterone Risk

Progesterone has lower risk than progestins.

Ovarian Cancer

According to the American Cancer Society, women who take estrogen alone (without progesterone) after menopause for a period of at least 5 to 10 years have an increased risk of ovarian cancer.

Conclusion

It is important that you work with a team of healthcare professionals knowledgeable in hormone replacement therapy. You should discuss these risk items with your health care team. The team should include a physician and pharmacists who understand hormone replacement therapy and know how to administer the appropriate dosages.

Hormone Replacement Therapy Contraindications

Contraindications for menopausal hormone therapy according to the North American Menopause Society (NAMS) include:

  • Undiagnosed endometrial genital bleeding.
  • Known, suspected or history of breast cancer except in appropriately selected patients being treated for metastatic disease.
  • Active or history of deep vein thrombosis or pulmonary embolism.
  • Active liver disease.
  • Known or suspected pregnancy.
  • Active or history of (within the past year) of heart attack or stroke.
  • Hypersensitivity to estrogen/progestogen therapy.

A Brief Background on the Women’s Health Initiative Study

Since 2002, there has been confusion around menopausal hormone therapy. It was then that the initial results of the Women’s Health Initiative Study (WHI) were released.

Panic and concern arose immediately because of the published risks – increased rates of breast cancer, heart disease, stroke, and dementia. Women abruptly stopped taking their hormones.

However, the results were misinterpreted. Women in the WHI were on average 63 years old (when the average age of menopause is 51). Most women in the study were not suffering from typical menopausal symptoms such as hot flashes.

The point of the study was to assess long term use of menopausal hormone therapy to prevent chronic disease. The results should not have been extrapolated to women in their 40s and 50s seeking treatment for bothersome symptoms.

If you and your physician decide that HRT is the path for you, you next need to choose between an FDA approved hormone therapy or use a compounding pharmacy. Let’s discuss compounded bioidentical hormone therapy in the next section.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

But what exercises should you do and which ones should you avoid? What exercises build bone and which ones reduce your chance of a fracture? Is Yoga good for your bones? Who should you trust when it comes to exercises for osteoporosis?

A great resource on exercise and osteoporosis is my free, seven day email course called Exercise Recommendations for Osteoporosis. After you provide your email address, you will receive seven consecutive online educational videos on bone health — one lesson each day. You can look at the videos at anytime and as often as you like.

I cover important topics related to osteoporosis exercise including:

  • Can exercise reverse osteoporosis?
  • Stop the stoop — how to avoid kyphosis and rounded shoulders.
  • Key components of an osteoporosis exercise program.
  • Key principles of bone building.
  • Exercises you should avoid if you have osteoporosis.
  • Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
  • Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Enter your email address and I will start you on this free course. I do not SPAM or share your email address (or any information) with third parties. You can unsubscribe from my mail list at any time.

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Exercise Recommendations for Osteoporosis

Hormone Replacement Therapy might be a viable treatment option for you — depending on your medical history. However, exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

But what exercises should you do and which ones should you avoid? What exercises build bone and which ones reduce your chance of a fracture? Is Yoga good for your bones? Who should you trust when it comes to exercises for osteoporosis?

A great resource on exercise and osteoporosis is my free, seven day email course called Exercise Recommendations for Osteoporosis. After you provide your email address, you will receive seven consecutive online educational videos on bone health — one lesson each day. You can look at the videos at anytime and as often as you like.

Compounded Bioidentical Hormone Therapy

A question many women confront is whether to use compounded bioidentical hormone therapy or FDA approved hormone therapy?

Bioidentical hormones were once only available through compounding pharmacies.  However, large pharmaceutical companies, whose products have been FDA approved, have been in the business of bioidentical hormones for a number of years.  This includes products such as micronized progesterone (Prometrium) pills and the estradiol skin patch, Estradot.

In a study published in October of 2017 by Thompson, Ritenbaugh and Nichter, Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making, the authors note that “compounded bioidentical hormone therapy (CBHT) has emerged as a popular alternative to manufactured, FDA approved hormone therapy (HT)—despite concerns within the medical community and the availability of new FDA approved ‘bioidentical’ products.” (4)

Compounded Bioidentical Hormone Therapy: Push and Pull

Dr. Thompson and her fellow researchers found that women were “pushed” away from conventional hormone treatments because of an aversion to conjugated estrogens and reservations with the medical system. They found that women were attracted, or “pulled”, to compounded bioidentical hormone therapy (CBHT) because is was perceived as safer and more effective than the traditional treatment route.

While the authors acknowledge that physicians have limited time with their patients and that hormone therapy is complex, they encourage more consultation between patient and clinician regarding which path, compounded or conventional, is best suited for that patient.

They state: “We argue that women making menopause treatment decisions of all kinds would benefit from a clinical context in which they are explicitly invited to share their experience of menopause, and voice their treatment preferences and priorities. This would also provide an opportunity for clinicians to discuss the pros and cons of conventional HT, CBHT, and other approaches to managing menopause.”

A further challenge is that it can be difficult finding a physician who understands HRT and can work with you to provide the solution that works for you. I discuss this point in more detail later in this blog.

New Standards for Compounding Pharmacies

There is a push for updated standards for compounding pharmacies. I’ll cover the status of these standards on a country by country basis.

Canada

New standards for compounding pharmacies in Canada are mandatory by 2020. These standards apply to all pharmacies that compound any quantity of medication whether they do it periodically or on a regular basis.

The standards (National Association of Pharmacy Regulatory Authorities, NAPRA), are an important way to protect patients, and increase safety. Pharmacies that compound will be inspected regularly by provincial regulatory bodies (for example, pharmacies in Ontario will be inspected by representatives of the Ontario College of Pharmacists) to ensure that they are NAPRA compliant.

As a result of these regulations, several pharmacies in Canada have ceased compounding operations. In Ontario, Nutrichem Pharmacy has adopted the NAPRA standards in their new facility and compounding lab.

 

United States

While the federal Food and Drug Administration is responsible for most commercial pharmaceutical activity in the United States, compounding pharmacies are regulated at the state level, by the state boards of pharmacy.

Regulators in the United States have been rewriting safety guidelines for compounding for the past several years.  Regulations have been in the works for the past 6 years, and will be governed on a state by state basis with a high level of enforcement.  Regulations and guidelines are expected to roll out in December, 2019.

 

Australia

The regulators in Australia are watching what Canada is doing and will be making appropriate changes.

Hormones and Osteoporosis

There are, in general, four variables that affect the health of your bones:

  1. Your genetic makeup. Have you inherited strong bones from your parents? Unfortunately, you cannot control this one so you have to learn to live with the skeleton that you were given. The good news is that you can influence the remaining three variables.
  2. The food you eat. In past blog posts, I have spoken about different nutrition topics including: vitamin K2 for osteoporosis, milk for osteoporosis, nitrate rich foods, calcium and osteoporosis, prunes for osteoporosis, sodium and osteoporosis, omega 3, and protein and bone health. Here is a diet plan for osteoporosis that you can follow.
  3. Your osteoporosis exercise program. There are over 100 blog posts on osteoporosis exercise on this site. For most readers, a good place to start is Exercise for Better Bones.
  4. Your hormones. The balance of this blog post is dedicated to hormones and osteoporosis.

Studies that examine bone formation during puberty, pre-menopause, and post-menopause demonstrate that there is a strong relationship between bone health, hormones and osteoporosis.

hormones and osteoporosis | bioidentical hormone replacement therapy

Hormones and Osteoporosis:  Puberty and Bone Health

Over a quarter of the bone that a person will build in their entire life happens during the two years surrounding the start of puberty. (5) By the end of adolescence an individual’s skeletal mass has almost doubled. (6)

In addition, sex steroids play an important role in the optimal development of muscle and bone. (7) Unfavourable body composition during sexual maturation results in sub-optimal bone mass and strength in both early adulthood and later life. As a result, it is important that young people attend to their bone health.

Hormones and Osteoporosis: Premenopausal and Postmenopausal Women

Studies show postmenopausal women are never able to build bone as effectively as premenopausal women who have a healthy estrogen levels. A postmenopausal women can exercise just as hard as A premenopausal women, and follow the same nutrition plan, but they do not have the hormones that the premenopausal women have to help support the growth of the bone.

When you think about hormones and osteoporosis, you need to consider your stage of life and your hormonal level.

Puberty, Hormones and Osteoporosis

As we mentioned above, puberty is an important time in bone formation. Young women need to pay attention to when they start their menstrual cycle.

Activities such as ballet, gymnastics or may keep their percent body fat very low and delaying the onset of menarche. This is not good for bone health since it restricts the critical time during puberty when bone formation is rapid.

Unless these young people are considering a lifetime career in athletics or ballet, you may want to help them understand the importance of having sufficient amount of body fat in order to allow the body to feel that it’s surviving well enough that it can actually start having a regular menstrual cycle.

Finally, the regular occurrence of a menstrual cycle indicates that hormones are likely supporting bones development.

osteoporosis in young women

Depo Provera and Osteoporosis

Is there a relationship between Depo Provera and osteoporosis? It turns out that there is.

Certain birth control choices, such as Depo Provera, can stop menstrual cycles from occurring. This is practical for young athletes. However, Depo Provera can be detrimental at an important time in life to build bone.

Young women in puberty and women close to menopause have limited time to rebuild bone. Depo Provera can rob them of this critical time.

Transgendered Youth, Estrogen, Testosterone and Osteoporosis

Transgendered youth who are either given estrogen or testosterone during sex change can lose bone. It is important that they work closely with their physician and they stay on their hormonal prescriptions that they are given. These hormones will have a really significant impact on their bones.

In the article, Hormone Therapy for Transgender Patients, Unger states: “Bone and cardiovascular health are important considerations in transgender patients on long-term hormones, and care should be taken to monitor certain metabolic indices while patients are on cross-sex hormone therapy.” (8)

Hormone Replacement Therapy for Osteoporosis

Hormone replacement therapy has been shown in double-blind randomized controlled trials (the gold standard) to prevent bone loss, reduce fractures in post-menopausal women and improve osteoporosis.

Bone quality, bone density and consequently, bone strength, are all products of hormonal balance, exercise, diet and good genetics. If one is lacking or weak, it impacts the effect of all the others to be able to build bone to it’s optimum level.

By taking bioidentical hormone replacement therapy, you are trying to reduce the effect of your own hormonal decline. At the same time, it becomes more important to optimize your nutrition and exercise. They all play an important role.

During the first seven to ten years of menopause, your body is adapting to the loss of hormones. This is why women lose the most bone during this period. Without hormones, it is very difficult to build bone. Your goal should be to maintain bone — and if you are “maintaining” you are “gaining”.

Hormones and Osteoporosis • Is HRT the Way to Go?

Bioidentical hormone replacement therapy can be an important treatment option for women with osteoporosis or osteopenia. A review by three American Gynaecologists, published in March, 2018, proposes that hormone therapy (HT) “should be considered for the primary prevention and treatment of osteoporosis in appropriate candidates. Hormone therapy (HT) should be individualized and the once ‘lowest dose for shortest period of time’ concept should no longer be used. ” (9)

The decision to take hormone replacement therapy is an important one and the treatment can be expensive. You need to work closely with a bioidentical hormone replacement therapy doctor skilled in this treatment before you commit to this path.

The age you start hormone replacement is an important consideration. As I mentioned earlier in the article, HRT is a potential treatment option for women under the age of 60 who are at risk of an osteoporotic fracture.

Benefits of Bioidentical Hormone Replacement Therapy

I have been on bioidentical hormones for a number of years. There are four main benefits of bioidentical hormone replacement therapy:

  1. Increase in Strength
  2. Better Bone Quality
  3. Better Sex
  4. Improved Sleep

Benefit #1: I Feel Stronger

One of the main reasons why I started bioidentical hormones was to maintain the strength of my bones and muscles and reduce my risk of osteoporosis. I found that once I hit menopause, I was not able to lift as hard and I did not recover as well from my workouts.

Tests showed that my bone loss was at a very high rate because of my genetics, my petite stature, and my race (Caucasian). We know that, in general, women will lose bone between 1 and 5% a year. I was losing 5% a year. That was way too fast for me. And I had a lot of years left ahead of me.

Since starting the bioidentical hormone replacement therapy, I feel much stronger. My stamina, particularly when I exercise, has improved. My bone density scores have stopped declining.

Benefit #2: Better Bone Quality

A study of menopausal hormone replacement therapy (MHRT) by Dr. Georgios Papadakis at Lausanne University Hospital shows that not only does it have a positive affect on bone mineral density (BMD) but that it also preserves bone microarchitecture.  The positive effect on bone microarchitecture and BMD was maintained even two years after stopping MHRT. (10) In other words, bone quality is maintained with this treatment option.

Dr. Papadakis stated that “almost half of all fragility fractures can occur in subjects who have either normal or osteopenic bone-mineral density. Bone microarchitecture has increasingly been recognized as an important factor in bone fragility, so used in the right context — namely, in young postmenopausal women for whom the benefits outweigh the risks — HRT is effective for both the prevention and treatment of osteoporosis.”

Benefit #3: Better Sex

Sex was the third motivation. We have been married for over 30 years.  Sex is a really important part of that marriage. (Hope my kids aren’t reading this!)

I wanted sex to continue to be an important part of our relationship. However, having sex without hormones was like having sex with a big blanket between us. I couldn’t feel a whole lot of anything . That needed to change!

Since starting the bioidentical hormone replacement therapy, I feel much more engaged and feel the sensations during sex.

Benefit #4: Improved Sleep

The fourth benefit of bioidentical hormone replacement therapy was improved sleep. A really important part of having good health is having a good restorative sleep. I have always been a good sleeper, but with menopause and hot flashes, I wasn’t sleeping as soundly as I was used to, or as I wanted to.

Since starting the bioidentical hormone replacement therapy, my sleep is back to what it was before menopause set in. I sleep much deeper and my sleep is uninterrupted through the night.

A number of clinicians and researchers support using progesterone to aid with sleep.

How Hormones Improve Sleep

Dr. Alvin Pettle, a Canadian Gynecologist and HRT specialist, states that “bioidentical hormones especially help insomnia. The progesterone transdermal cream used in the evening has a mild sedative effect, but the oral form of progesterone passes through the liver and has an even greater degree of sedation. Oral progesterone is therefore used specifically as a treatment for insomnia and is prescribed to be used at night before sleep for this reason.”

In a 2006 study published in the journal, Current Medicinal Chemistry, the authors state that  “progesterone exerts a sleep induction or hypnotic effect and is a potent respiratory stimulant that has been associated to a decrease in the number of central and obstructive sleep apnea episodes in men.” (11)

In a more recent study published in 2013, Sleep and Women’s Health, the authors are more hesitant regarding the effectiveness of HRT for sleep: “the efficacy of HRT for sleep and mood disturbances remains unclear, with some studies finding positive results.” (12)

While I found progesterone effective for my sleep, I recommend that if you have problems with your sleep you read Richard’s review of The Sleep Solution and, if necessary, consult with a sleep specialist.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

But what exercises should you do and which ones should you avoid? What exercises build bone and which ones reduce your chance of a fracture? Is Yoga good for your bones? Who should you trust when it comes to exercises for osteoporosis?

A great resource on exercise and osteoporosis is my free, seven day email course called Exercise Recommendations for Osteoporosis. After you provide your email address, you will receive seven consecutive online educational videos on bone health — one lesson each day. You can look at the videos at anytime and as often as you like.

I cover important topics related to osteoporosis exercise including:

  • Can exercise reverse osteoporosis?
  • Stop the stoop — how to avoid kyphosis and rounded shoulders.
  • Key components of an osteoporosis exercise program.
  • Key principles of bone building.
  • Exercises you should avoid if you have osteoporosis.
  • Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
  • Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Enter your email address and I will start you on this free course. I do not SPAM or share your email address (or any information) with third parties. You can unsubscribe from my mail list at any time.

  • This field is for validation purposes and should be left unchanged.

Hormones and Osteoporosis: HRT or Medications?

In the menopausal hormone replacement therapy (MHRT) by Dr. Georgios Papadakis, Dr. Papadakis points out that “drugs used to prevent fragility fractures in women with osteoporosis really should improve both BMD as well as bone microarchitecture. However, so far current drugs used to treat osteoporosis actually have less of an effect on bone microarchitecture than they do on bone mineral density (BMD).”

Should you avoid pharmaceutical intervention and, instead, opt for menopausal hormone replacement therapy for your osteoporosis? Dr. Papdakis speculates that treatments such as HRT that “favourably influence bone microarchitecture may well have advantages over those that do not.”

According to a MedScape review of the study (11), Dr. Papadakis maintains “the idea is not to prescribe HRT to all women and I don’t think HRT should be prescribed indefinitely, either.”

“But at least in young postmenopausal women at increased risk of osteoporosis, HRT can be a very effective first-line treatment, provided the woman has no contraindications and it can be continued for at least 5 and maybe even 10 years.”

In a meta analysis published in 2017 on the effects of transdermal estrogen therapy on bone mineral density (12), the authors concluded that “one-two years of transdermal estrogen delivery can increase bone density, preserve BMD, and successfully protect the bone structure in postmenopausal women. It can thus prevent single or multiple bone fractures and their consequent disability and poor quality of life in older women.”

Further, in the study by Thompson et al, discontinuation of compounded bioidentical hormone therapy (CBHT) did not seem to cause any serious side effects. The authors note that “several women described passively discontinuing CBHT simply by not refilling their prescription, only to find that their symptoms were bearable without treatment.” (4)

A sudden discontinuation of certain osteoporosis pharmaceutical drugs, especially Denusomab (Prolia), has been shown to cause compression fractures of the spine.

Bioidentical Hormone Replacement Therapy Doctors

Once I decided that I wanted to start hormone therapy, my biggest challenge was locating bioidentical hormone replacement therapy doctors close to where I live and then choosing one. I had to find a doctor comfortable with bioidentical hormone replacement therapy who could determine the type of hormones and quantity that I should take.

It is critical that you locate a physician who knows and thoroughly understands hormone replacement therapy through all of the stages of diagnosis, research and the administration of HRT. The approach should be individualized. (15)

Bioidentical Hormone Replacement Therapy Physicians

Before locating a bioidentical hormone replacement therapy doctor, I read books (take a look at my review of The Hormone Cure) and did research on bioidentical hormone replacement therapy.

Once I had an understanding of HRT, my first thought was to consult with my general physician (GP). I approached him with my concerns. To no surprise, he did not have a lot of knowledge in bioidentical hormone replacement therapy for osteoporosis.

He was, however, sympathetic to my concerns. He was willing to do a hormone blood test on me and look at my testosterone, estrogen, and progesterone levels.The tests found that the hormone levels were very low in some areas. However, when the test results came in, he was not too sure about the next steps.

bioidentical hormone replacement therapy doctors

Naturopathic Hormone Balance

I approached a naturopathic doctor who I knew had experience in naturopathic hormone balance. Because we live in Canada, she cannot prescribe hormones. However, she wrote up recommendations for my doctor to follow.

My doctor would prescribe a couple of hormones and I would start feeling a little bit better. However, I didn’t know if I was at my optimum level.

When I asked him if he would do another blood test, he would ask, “Are you feeling better?”

I would say, “Yes.”

But I never knew if I was feeling at my optimum or if my hormones levels were at their optimum. Eventually, he wasn’t willing to do another blood test.

That was too erratic for me and, in the end, did not work. I didn’t feel like I was moving in the right direction and I wanted to move on to another approach

Found: A Bioidentical Hormone Replacement Therapy Physician!

With the encouragement of my husband, we started looking outside of Ottawa for a bioidentical hormone replacement therapy physician. With some work we found a doctor who specialized in bioidentical hormone replacement therapy in Toronto.

It has meant a four hour train trip to Toronto, but it working with him has made all the difference in the world and the long train rides have been well worthwhile.

Evaluating Bioidentical Hormone Replacement Therapy Doctors

Here are some guidelines and tips on evaluating bioidentical hormone replacement therapy doctors. When it comes to your final choice, you will need to evaluate the following:

  1. Do they have experience in bioidentical hormone replacement therapy? Not all physicians do. In fact, limited time is spent in medical school on hormones and hormone therapy. Find one who has several years of experience in this treatment area.
  2. Are they knowledgeable in osteoporosis? The medical specialties most often familiar with hormones and osteoporosis are endocrinologists and gynaecologists. My experience has been that gynaecologists are the most comfortable with hormone replacement therapy; probably because they deal with women’s health issues on a regular basis.
  3. Are they willing to perform repeated tests to determine your optimal hormone level? I found it took several test cycles before the physician achieved the optimal balance for me.
  4. Are they comfortable with bioidentical hormone replacement therapy? Hormones can be quite complex and hard to understand. You want to be with someone who understands the chemistry and potentials interactions with your body. It takes some skill and knowledge to know the types of hormones and the proper levels to prescribe to arrive at the optimal level for you.

My Advice on Bioidentical Hormone Replacement Therapy Doctors

My advice is to invest the time to find a physician who has experience with bioidentical hormone replacement therapy and I caution you to avoid a general physician not skilled in this area of therapy.

Naturopathic Doctors and Hormone Replacement Therapy

In several jurisdictions, Naturopathic Doctors (ND) are able to prescribe HRT. In Ontario, for example, NDs can prescribed 23 different pharmaceuticals including estrogen and progesterone. If you are unable to locate a physician in your area, consider working with an ND. Check to see if they are legally able to prescribe HRT.

Bioidentical Hormone Replacement Therapy Cost

Before I started down this path, I did not realize the cost of bioidentical hormone replacement therapy. The costs include the hormone treatments, the testing (and retesting), and the cost of the bioidentical hormone replacement therapy doctor.

My prescription includes six different hormone treatments:

  1. Estrogen
  2. Progesterone
  3. Testosterone
  4. Estradiol vaginal cream
  5. Dehydroepiandrosterone (DHEA)
  6. Thyroid

The total cost of these medications is about $150 (Canadian) per month (about $115 USD). Progesterone and estrogen are available from large pharmaceutical companies. Some of the other hormones are only available from compounding pharmacies.

At one point, I used a compounding pharmacies that made it difficult to figure out exactly how much medication I was supposed to take. They dispensed the medication so that it was difficult to administer. Eventually I found a compounding pharmacy that delivered a better experience and results.

Depending on where you live, some of the pharmacies will deliver at your doorstep. Some require that you to show up in person.

The lab test costs were modest at less than a $100 (Canadian) in the first year. The cost of the bioidentical hormone replacement therapy doctor was also manageable at around $300 (Canadian) per year.

Hormones and Osteoporosis Conclusion

Bioidentical hormone replacement therapy has many benefits including improved strength, better sex, richer, deeper sleep, and improved bone health.

Should you consider HRT? You should give this path strong consideration if you:

  1. Have been diagnosed with (or are at risk of) osteoporosis or osteopenia.
  2. Fit within the accepted risk guidelines.
  3. Can access a health professional who can diagnose and administer HRT.

However, bioidentical hormone replacement therapy treatment can be a frustrating process. My General Physician was not comfortable with HRT and finding a doctor who knew bioidentical hormone replacement therapy was not an easy task.  In addition, I had some troubles dealing with compounding pharmacies, and the out-of-pocket costs for bioidentical hormone replacement therapy are too high for many people.

Ultimately, the decision to follow bioidentical hormone replacement therapy is yours. It has be right for you and you need to make sure that you are within the acceptable risk profile and you work with a qualified team of health professionals. I hope that this post helps you with your decision.

Glossary of Terms

Hormone replacement is confusing enough as it is without the additional confusion caused by inconsistent usage of terms. To help the reader, I have extracted the following terms (16) from The North American Menopause Society (NAMS) extensive Menopause Glossary.

Glossary • E

Estradiol. Also called 17β-estradiol. The most potent of the naturally occurring estrogens and the primary estrogen produced by women in their reproductive years. Available in oral, skin patch, and vaginal prescription drugs government approved for treating moderate to severe hot flashes and the genitourinary syndrome of menopause and for preventing postmenopausal osteoporosis. See also Estrogen.

Estriol. The least potent of the estrogens produced in the body. Not available in government approved drug formulations. See also Estrogen.

Estrogen. A variety of hormone chemical compounds produced by the ovaries, influencing the growth and health of female reproductive organs. They are active in many cells throughout the body by interacting with estrogen receptors. The three main naturally occurring estrogens in women are estradiol, estrone, and estriol. Estrogen levels fall after menopause. Several types of estrogen therapies are available for menopause indications. Also available in some contraceptives but at much higher doses than those used for menopause treatment. See also Estrogen therapy (ET).

Estrogen patch. Also Estrogen skin patch or Estrogen transdermal delivery system. A form of estrogen therapy contained in a special patch that is adhered to the skin. The patch technology allows a gradual release of estrogen through the skin directly into the bloodstream where it circulates throughout the entire body (systemically), affecting many different tissues. See also Estrogen.

Estrogen plus progestogen therapy (EPT). Also known as combination hormone therapy. Estrogen is the hormone in this duo that provides the most relief for menopause-related symptoms. Progestogen is added to protect the uterus from estrogen stimulation and the increased risk of endometrial cancer. See also Hyperplasia, Progestogen.

Estrogen therapy (ET). General term describing a wide range of estrogen types that are available in various systemic and local formulations in oral, skin patch, and vaginal prescription drugs government approved for treating moderate to severe hot flashes and vaginal atrophy, and preventing postmenopausal osteoporosis. ET is prescribed without progestogen to women without a uterus. See also Estrogen, Progestogen.

Glossary • H

Hormone. Specifically, a sex hormone (such as estrogen, progesterone, testosterone) produced by the ovaries (in women), testes (in men), or adrenal gland (in both women and men) that affects the growth or function of the reproductive organs or the development of secondary sex characteristics. Also includes non-sex hormones such as thyroid hormone.

Hormone therapy (HT). Prescription drugs used most often when treating menopause symptoms. Encompasses ET and EPT. See Estrogen therapy (ET) and Estrogen plus progestogen therapy (EPT).

Glossary • P

Progesterone. A female hormone that is released by the ovaries after ovulation to prepare the lining of the uterus (endometrium) to receive and sustain the fertilized egg and thus permit pregnancy. If pregnancy does not occur, progesterone (and estrogen) levels fall, resulting in menstruation. Available in prescription and nonprescription therapies (as a bioidentical hormone). See also Hormone therapy.

Progestin. A class of progestogen compounds synthesized to act like progesterone in the body. Available in oral prescription drugs and combined with estrogen in prescription skin patches. See also Progestogen, Hormone therapy.

Progestogen. A naturally occurring or synthetic progestational hormone. There are various progestogen options: progesterone (identical to the hormone produced by the ovaries) and several different progestins (compounds synthesized to act like progesterone). See also Progesterone, Progestin, Hormone therapy.

Glossary • T

Transdermal estrogen. Estrogen therapy delivered through the skin into the bloodstream, such as via skin patch or topical lotion, cream, or gel. See also Estrogen patch.

Glossary Sources

  • The North American Menopause Society. Menopause Practice: A Clinician’s Guide. 5th ed. Mayfield Heights, OH: The North American Menopause Society; 2014.
  • The North American Menopause Society. The Menopause Guidebook. 8th ed. Mayfield Heights, OH: The North American Menopause Society; 2015.

Reviewer and Contributor

Grace Meehan, B.Sc Phm, Pharmacist, Certified NAMS Practitioner, reviewed this article and contributed several sections to this article. She is a licensed pharmacist and a NAMS Certified Menopause Practitioner with NutriChem’s Clinical Team in Ottawa. Grace provides supportive, caring and evidenced-based consultation to her clients to help them resolve menopausal symptoms and improve their quality of life.

Primary Reference Material

  1. Harper-Harrison and Shanahan. Hormone Replacement Therapy, StatPearls Publishing. January 2019.
  2. Pinkerton JV. Changing the Conversation about Hormone Therapy. Menopause. 2017 Sep:24(9): 991-993.
  3. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause 2017 July:24(7): 728-747 and Volume 24, No 10, p 1100, October 2017.
  4. Thompson, et al. Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making. BMC Womens Health. October 2017.
  5. Bailey, DA et al. A six year longitudinal study of the relationship of physical activity to bone mineral accrual in growing children: The University of Saskatchewan Bone Mineral Accrual Study. J Bone Miner Res 1999: 14(10):1672-1679
  6. Saggese G, Baroncelli GI, Bertelloni S, Puberty and bone development. Best Pract Res Clin Endocrinol Metab. 2002 Mar;16(1):53-64
  7. Carson JA, Manolagas SC, Effect of sex steroids on bones and muscles: similarities, parallels, and putative interactions in health and disease. Bone. 2015 Nov;80: 67-78
  8. Unger CA, Hormone therapy for transgender patients. Trans Androl Urol. 2016 Dec;5(6):877-884.
  9. Levin VA, Jiang X, Kagan R. Estrogen therapy for osteoporosis in the modern era. Osteoporos Int. 2018 Mar 8.
  10. The Benefit of Menopausal Hormone Therapy on Bone Density and Microarchitecture Persists After its Withdrawal. Papadakis G., et al. J Clin Endocrinol Metab, 2016 Dec;101(12): Epub 2016 Nov 17
  11. Andersen, et al. Effects of progesterone on sleep: a possible pharmacological treatment for sleep-breathing disorders? Current Medicinal Chemistry. 2006:13(29):3575-82
  12. Nowakowski, et al. Sleep and Women’s Health. Sleep Medicine Research. 2013; 4(1): 1-22
  13. Menopausal Hormone Therapy Promotes Bone Health. A MedScape review by Laurie Barclay, MD.
  14. Abdi, et al. The Effects of Transdermal Estrogen Delivery on Bone Mineral Density in Postmenopausal Women: A Meta-analysis. Iran Journal Pharmacy Research. 2017 Winter; 16(1): 380-389
  15. Menopause: diagnosis and management; NICE Guidelines (November 2015).
  16. Menopause Glossary. The North American Menopause Society (NAMS).

Secondary Reference Material

While preparing this article, I consulted these article on hormone replacement therapy and osteoporosis.

  1. Marjoribanks J, Farquhar C, Roberts H, et al; Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev. 2012 Jul 117:CD004143. doi: 10.1002/14651858.CD004143.pub4.
  2. Gambacciani M, Levancini M; Hormone replacement therapy and the prevention of postmenopausal osteoporosis. Prz Menopauzalny. 2014 Sep13(4):213-20. doi: 10.5114/pm.2014.44996. Epub 2014 Sep 9.
  3. Pines A, Shapiro S; Long-term menopausal hormone therapy and health consequences – how to choose sides? Climacteric. 201518(4):441-3. doi: 10.3109/13697137.2015.1041756. Epub 2015 May 11.
  4. Bagger YZ, Tanko LB, Alexandersen P, et al; Two to three years of hormone replacement treatment in healthy women have long-term preventive effects on bone mass and osteoporotic fractures: the PERF study. Bone. 2004 Apr34(4):728-35
  5. Cauley JA; Estrogen and bone health in men and women. Steroids. 2015 Jul99(Pt A):11-5. doi: 10.1016/j.steroids.2014.12.010. Epub 2014 Dec 30.
  6. Wang ZX, Lloyd AA, Burket JC, et al; Altered distributions of bone tissue mineral and collagen properties in women with fragility fractures. Bone. 2016 Jan 15. pii: S8756-3282(16)00013-2. doi: 10.1016/j.bone.2016.01.012

Osteoporosis Guidelines

For more information, check out my Osteoporosis Guidelines.

Comments

May 1, 2015 at 7:18am

fatima daniels

Hi Margaret, How is bioidentical HR diff to the HRT prescribed normally by physicians. I suffer the same 3 issues u refer to in yr blog & was put on HRT to stem bone loss( which was rapid ). This has increased my breast cancer risk as shown by my recent mammogram. Thus I am very interested to learn more abt the bioidentical HRT. Pse provide further guidance. Thanks

May 1, 2015 at 9:14am

Richard Martin replies

Fatima:

Margaret has a series of blog articles on HRT. If you are on our mailing list you will receive the series as it is released over the next months.

To join our mail list look to the signup in the sidebar to the right.

August 26, 2018 at 3:46pm

Margaret Martin replies

Hi Fatima, In speaking with my gynecologist recently, it appears that many clinicians, she being one of them, do not differentiate between HRT and BHRT. HRT was the term used in the early 2000's when the Woman's Health Initiative Study was underway.
https://cmajnews.com/2017/04/12/landmark-trial-overstated-hrt-risk-for-younger-women-109-5421/
This study, which used Premarin (derived form female horse's urine) lead to a mass hysteria on the topic and a discontinuation by many. When a few hyears had passed and progressive doctors returned to intelligently re-introducing hormones for the health of their patients they used the term BHRT. Bioidentical hormone replacement therapy. Not derived from horse urine. Initially compounded in smaller pharmacies. Now massed produced by larger pharmaceutical companies.
If you are at an increased risk for breast cancer it is not recommended. You can discuss the use of SERM with your doctor. This is a Selective Estrogen Receptor Modulator which does not increase your risk of breast cancer.
Margaret

May 1, 2015 at 12:25pm

Joanne

I am interested to know how effective is bio-identical hormones for osteoporosis..Thank you

May 1, 2015 at 2:17pm

Richard Martin replies

Joanne:

Margaret has a series of blog articles on HRT. If you are on our mailing list you will receive the series as it is released over the next months.

To join our mail list look to the signup in the sidebar to the right.

March 5, 2019 at 7:50pm

Patty

Margaret, Is there a cut-off age for using BHRT for Osteoporosis? I've heard 60, but I'm 66. I've heard that some doctors will use them in patients into their 70's. Do you know anything about age restrictions? Thank you!

March 6, 2019 at 7:13am

Richard Martin replies

Hi Patty, I have heard OB/GYN's mention it is best started within 8 years of starting menopause. Depending on the physician and the health of the client duration of use seems to vary quite a bit. This is a good conversation for you to have with your physician.
Margaret

April 25, 2019 at 8:34am

Cecil Shaffer

BHRT (Bio-identical Hormone Replacement Therapy) is basically prescribed to maintain optimal hormone levels. Usually, what happens is that hormone levels decline with age. The decreased hormone level causes significant changes in the body. Hormone deficiency brings energy level down, causes weight gain, and also leads to loss of libido. I am not saying that taking BHRT will cause reverse aging. Because reverse aging is not feasible. It only maintains a sound level of hormones in order to reduce the risk of different indispositions associated with aging. Consult a medical practitioner before taking BHRT.

May 30, 2019 at 1:36am

Dan

Gina Harper-Harrison and Meaghan Shanahan review about HRT is the best review I've seen so far. Very detailed and well explained. This article does the same thing. Explaining hormone replacement therapy in the best and easiest way to understand. It is long article, but worth the time reading it. Can be use as reference as well. Thank you for creating such wonderful article, Margaret. More power to your website.

June 11, 2019 at 1:59pm

Nancy

After 3 mild compression fractures, I spoke to an endocrinologist (about new synthetic parathyroid drug) who prescribed daily injections for two years (max allowable), after which I must continue on Forteo. I am writing here because I was taken off HRT at age 66 (am now 70) and restarted at age 70 when the fractures occurred. Even though I was high risk before the fractures, my PCP didn't see indications for Osteoporosis treatment, which did not make me a happy camper. That said, I am very healthy and functional on current meds, (some side effects) and am walking well, exercising (carefully!) etc. I have Margaret's book, too, as well as a PT so am good to go. If I had not aggressively made my case to each medical professional, I think I would have slid under the radar. Just sharing.

June 11, 2019 at 10:22pm

Margaret Martin replies

Hi Nancy, Thank you for taking the time to write and share your story. Sorry to hear about your compression fractures. As you mention, it is critical that we advocate for ourselves and learn as much as we can so that we can be part of the dialogue in our medical decision making. Wishing you many more healthy years.
Margaret

June 11, 2019 at 2:10pm

Peggy

Hi,
I would add to the contraindications list a family history of ovarian cancer, and possibly other gynecological cancers. I was on hormone therapy for osteoporosis for several years (at least 15 years ago), but my mother had ovarian cancer and three years ago, I developed ovarian cancer as well. I am unable to go on the hormone therapy anymore, and must use osteoporosis drugs (chemotherapy also increases osteoporosis).

June 12, 2019 at 4:14pm

Richard Martin replies

Hi Peggy. Sorry to hear about your circumstances and thanks for identifying this risk. We debated additional risks we found in our research but held some back because the post is already very long - almost 7,000 words.

We stated that individuals contemplating hormone replacement therapy for osteoporosis or menopause need to work with a skilled health care team and discuss the risks with their team. I have added the ovarian cancer risk to the list. Thank you for pointing this out and thanks for following us.

November 6, 2019 at 7:12am

Sophie Williams

Lack of sufficient amounts of hormones has significant influences on certain types of physiological activities of an individual. certain hormones help the bones to absorb calcium. However, the post-menopause period is very critical to a woman as the secretion of estrogen and progesterone greatly reduces during that time period which might improve the possibility of osteoporosis. So, a person should take suitable precautionary measures to optimize the secretion of different types of hormones and live a healthy life.

November 6, 2019 at 11:29am

Nancy

I re-started HRT at age 70 (in conjunction with Tymlos) in order to slow bone loss after 3 VCFs. The dosage of estrogen (via patch) and micro progesterone is safe, according to my expert physicians's exhaustive review of the literature. When I went off HRT at age 66 the bone loss proceeded from osteopenia to osteoporosis. However, it is virtually impossible to establish a direct causative connection to the cessation of the HRT, but it is worth considering (IMHO) in women who have very low risk factors and significant osteoporosis. Just my experience, of course, and not for everyone,

May 16, 2020 at 7:18pm

rima

Margaret's original post was written in early 2015. Now five years later, I'm wondering if you are still on this therapy and if you and your treatment team have discussed how much longer you may be able to continue?

May 20, 2020 at 12:51pm

Richard Martin replies

Hi Rima

We are in the process of rewriting the whole article and will be publishing the update in a few weeks. We do not use pharmaceutical intervention with our clients because we only offer physiotherapy services.

September 12, 2020 at 5:57pm

John Hayes

Hi Margaret

my wife is 63 with multiple vertebral fractures. She has not taken any medications and is contemplating Evista and Prolia. I have suggested she look at BHRT but she is reluctant due to a concern for weight gain etc. Do you think at age 63 (this month) she could consider BHRT. P.S. she is looking at Ipriflavone as well but I dont see any reference to this on your web pages.
Thank you

September 13, 2020 at 12:08pm

Margaret Martin replies

Hi John, It is very kind of you to reach out on your wife's behalf. I am sorry for her multiple vertebral fractures. It is well known that once someone has three or more vertebral fractures their risk of sustaining another vertebral fracture increases significantly.

I do not consider myself an alarmist but rather a realist. If your wife had low bone density and no vertebral fractures there would be time to look at exercise and possibly hormone replacement. However, since she has multiple vertebral fractures, she needs to work with an endocrinologist who can recommend a pharmaceutical such as Evinity or Prolia that will help her reduce her risk of future vertebral fractures. If you have not read our blog on Prolia I encourage you and your wife to do so. http://melioguide.com/?s=prolia

Ipriflavone is a synthetic isoflavone derivative. In ipriflavone showed promising results in initial animal studies, unfortunately not so in human studies. A 4-year study conducted in 4 centers in Europe investigated the effect of oral ipriflavone on the prevention of postmenopausal bone loss as well as assessing the safety profile of taking it long-term. The study group was composed of 234 postmenopausal women between the ages of 44-74 years. They took 200 mg of 3 times per day after 36 months of treatment, the annual percentage change from baseline in BMD of the lumbar spine for ipriflavone vs placebo, or in any of the other sites measured, did not differ significantly between groups. Prunes are more effective. http://melioguide.com/?s=prunes
I wish you both all the best.
Margaret

December 23, 2020 at 1:52pm

Valerie Fellows

Hi Margaret,

I am 68 years old. I've had a compete fracture of my humerus and 2 years later a wrist fracture. Both required plates and pins to mend. I had a hysterectomy in 2018. I've had 3 annual injections of zolendronic acid (a bisphosphonate). I've done quite a bit of research on bio identical hormones and convinced my family doctor, against her wishes, to prescribe estradot and progesterone to me. I have been taking for them for 3 years as well.. I don't feel that I am at my optimum and I wonder if it would be worth my while to get hormone testing? Until I read your article, I didn't even know that it was available. As well I saw the article how eating prunes can prevent bone loss and even increase bone density. Because of Covid 19 I have not been able to get a bone density follow up scan. I don't know if you can answer this but do you think that if I was to eat 100 mg of prunes daily, I could forego taking future injections of zolendronic acid? I'm sorry if I've put you on the spot, but I live in a small town in the interior of BC and we do not have doctors who specialize in hormones or osteoporosis. In fact, the community is critically short of doctors period.

December 23, 2020 at 4:31pm

Richard Martin replies

Hi Valerie: Margaret is unable to provide you with medical advice on hormone use and encourages you to look into telemedicine options to consult with a specialist. You might want to checkout NutriChem: https://app.outsmartemr.com/online-booking/1768

January 7, 2021 at 10:39pm

Laura Lucas

So happy to have discovered your website after having recently "graduated" to osteoporotic DEXA scores (T score -2.5 in femoral neck and forearm; -2.4 hip; -.09 AP spine). Researching alternatives to the recommendation from my primary care doctor to take bisphosphonates, I read about treatment with ultra low dose of estradiol (.014mcg) that documents effectiveness in reducing BMD as well as bone turnover in older postmenopausal women. I am 67 years old and consequently outside of the recommended timing of initiation of hormonal treatment. I understand that you do not provide medical advice concerning hormonal treatment, but wondered if you had were aware of this micro dose alternative and if your patients had any experience with it.
Thank you so much for sharing your exhaustive knowledge via your website!

January 8, 2021 at 8:58am

Richard Martin replies

Hi Laura. Thank you for your comment. You should discuss this question with a health professional familiar with your medical history and knowledgeable in hormone replacement therapy.

April 20, 2022 at 11:08am

gh1952

Is it better to take doctor prescribed HRT than not take any hormone replacement therapy? I simply cannot afford the cost of bio identical but has osteoporosis, am 69 and have had 3 fractures in 2 years. I am on a very limited budget and the cost of supplements (Osteokal) and good food has drained me.

April 20, 2022 at 1:25pm

Richard Martin replies

Hi Gayle. Margaret cannot provide you with advice regarding your situation. This is best discussed with your physician. Thank you.