Hormone therapy (HT) is a treatment that replaces or supplements hormones in the body, often used to address menopause, andropause, or hormone imbalances. There are two primary types of hormone therapy:

  • Hormone Replacement Therapy (HRT): This term traditionally refers to synthetic hormones or hormones derived from animal sources (e.g., conjugated equine estrogens). These are regulated and approved by health authorities such as the FDA or Health Canada.
  • Bioidentical Hormone Replacement Therapy (BHRT): These are plant-derived hormones that are chemically identical to those naturally produced by the human body. Individual bioidentical hormone ingredients (e.g., estradiol, progesterone, testosterone) are approved by regulatory authorities such as the FDA or Health Canada for use in specific commercial formulations. However, compounded BHRT (custom-mixed by a pharmacist) is not subject to the same regulatory approval process as commercially available products. Due to the wide variety of possible dosages, combinations, and delivery methods, compounded formulations cannot be standardized in the same way as mass-produced medications, making quality, consistency, and long-term safety data more variable.

While both forms of hormone therapy aim to restore hormonal balance, they carry potential risks and benefits, which can vary based on individual response, dosage, delivery method, and medical history. This FAQ will address both HRT and BHRT, including their short-term and long-term risks, as well as strategies to minimize those risks.

What Are the General Risks of Hormone Therapy?

Like all medical treatments, hormone therapy carries potential risks and side effects. These depend on dosage, duration, delivery method, and individual factors such as genetics and pre-existing conditions.

Potential risks include:

  • Short-term side effects such as bloating, breast tenderness, headaches, nausea, mood changes, and fatigue.
  • Long-term risks including blood clots, cardiovascular disease, and hormone-sensitive cancers.
  • Variability in absorption and effectiveness, especially with compounded formulations.
  • Individual differences in metabolism, meaning some people may process hormones more efficiently than others.

Are BHRT and HRT different in terms of risks?
While bioidentical hormones are chemically identical to human hormones, they still carry similar risks as conventional HRT, depending on the hormone type, dosage, and route of administration. Compounded BHRT may have additional considerations, such as variability in dosing.

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Does Hormone Therapy Increase the Risk of Cancer?

The relationship between hormone therapy and cancer risk is complex and depends on the type of hormone used, whether estrogen is used alone or with progesterone, and individual risk factors.

  • Breast Cancer: Estrogen-alone therapy (ET) does not appear to increase breast cancer risk (and may even lower it in some cases). However, estrogen plus progestin therapy (EPT) may slightly increase the risk of breast cancer over long-term use.
  • Endometrial Cancer: Taking estrogen without progesterone in individuals with a uterus significantly increases the risk of endometrial hyperplasia and cancer. This is why progestins or progesterone are required for balance.
  • Ovarian Cancer: Some studies suggest a possible slight increase in ovarian cancer risk, but findings remain inconclusive.

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What Are the Cardiovascular Risks of BHRT?

The impact of HRT and BHRT on heart health depends on timing, dosage, and individual risk factors:

  • Blood Clots & Stroke: Oral estrogen therapy has been associated with an increased risk of blood clots (deep vein thrombosis, pulmonary embolism) and stroke, particularly in those with pre-existing cardiovascular risk factors.
  • Heart Disease: The timing hypothesis suggests that starting hormone therapy before age 60 (or within 10 years of menopause onset) may have a neutral or even protective effect on heart health, while starting later in life may increase cardiovascular risks.
  • Cholesterol & Insulin Sensitivity: Estrogen may improve HDL (“good cholesterol”) and lower LDL (“bad cholesterol”), but can increase triglycerides, impacting heart disease risk.

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Does Hormone Therapy Affect Blood Sugar and Weight?

  • Insulin Sensitivity: Some studies suggest estrogen therapy may improve insulin sensitivity, potentially reducing the risk of type 2 diabetes.
  • Weight Changes: While hormones do not directly cause weight gain, they may affect fat distribution and metabolism, leading to changes in body composition, water retention, or appetite regulation.

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What Are the Risks of Different Hormone Therapy Delivery Methods?

The method of administration influences both effectiveness and risk profile:

  • Oral Estrogen: Higher clotting risk due to first-pass metabolism in the liver.
  • Transdermal (Patches, Gels, Creams): Lower clotting risk but variable absorption rates.
  • Pellets & Injections: Long-acting but may lead to supraphysiologic hormone levels, making dose adjustments difficult.
  • Vaginal Estrogen: Low systemic absorption, mainly used for genitourinary symptoms.

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What Are the Risks of Compounded BHRT?

Compounded BHRT is custom-mixed by a pharmacist and is sometimes used when commercially available options are unsuitable. However, it comes with additional considerations:

  • Inconsistent Dosing & Absorption compared to FDA/Health Canada-approved formulations.
  • Limited Large-Scale Research on safety and efficacy.
  • Lack of Standardized Regulation, as compounded products are not subject to the same approval process as commercial hormones.

Who Should Be Cautious About Hormone Therapy?

Hormone therapy, including both HRT and BHRT, may not be appropriate for everyone. Certain individuals may face higher risks of adverse effects and should approach treatment with careful consideration and medical supervision. Those who should be especially cautious include individuals with:

  • A history of hormone-sensitive cancers such as breast, ovarian, or endometrial cancer
  • Uncontrolled high blood pressure or a history of stroke
  • A personal or strong family history of blood clots (e.g., deep vein thrombosis, pulmonary embolism)
  • Severe liver disease (as some hormones are metabolized by the liver)
  • Active heart disease or a recent heart attack

For individuals in these categories, alternative treatments may be recommended, or hormone therapy may be modified to minimize risks. It is essential to discuss personal risk factors with a qualified healthcare provider before initiating any form of HRT or BHRT.

How Can I Reduce My Risk While on Hormone Therapy?

  • Start Early if Possible: Starting before age 60 or within 10 years of menopause may lower risks.
  • Use the Lowest Effective Dose: Avoid unnecessary high doses.
  • Choose Safer Delivery Methods: Transdermal estrogen (patch, gel) has lower clotting risks than oral estrogen.
  • Monitor Regularly: Mammograms, pelvic exams, bloodwork, and cardiovascular screenings are essential.
  • Prioritize a Healthy Lifestyle: Diet, exercise, and avoiding smoking reduce risks.

Final Thoughts: Is Hormone Therapy Right for Me?

HRT and BHRT have both benefits and risks, and decisions should be made with a qualified healthcare provider based on individual risk factors, symptoms, and treatment goals.