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Is Natural Hormone Replacement Therapy Better?

A pharmacist discusses its effectiveness and risks.

Medically reviewed by Femi Aremu, PharmD

Natural hormone replacement therapy (NHRT) is considered an alternative approach to conventional hormone replacement therapy (HRT). It may use natural or "bioidentical" treatments to restore hormonal balance and promote overall well-being.

The following article covers NHRT's effects, benefits, and safety considerations.

Galina Zhigalova / Getty Images

Female healthcare provider in white sweater with omega 3, vitamin D capsules in one hand and a glass of water in the other. What Is Natural Hormone Replacement Therapy?

Traditional HRT uses hormones like estrogen or progesterone to counter the sharp decline in hormone levels that occurs during perimenopause and menopause. The U.S. Food and Drug Administration (FDA) approves medications used in traditional HRT.

HRT was enormously popular throughout the 1980s and '90s. Almost half of U.S. Women over age 50 took these medications by 2001. But the prescribing and use of HRT took a nosedive the next year: research showed that taking prescription hormones was associated with the risk of heart disease, stroke, and breast cancer.

NHRT has gained traction in recent decades as traditional HRT has fallen out of favor. NHRT focuses on "natural" remedies to support hormone balance, such as:

Bioidentical hormones, often custom-made by compounding pharmacists based on hormone levels in saliva

Supplements like plant-based estrogens that may help control symptoms of menopause or other hormonal imbalances

Lifestyle modifications, such as aerobic exercise and resistance training

Dietary changes, like restricting calories, eating foods rich in calcium and vitamin D to promote bone strength, or foods with soy isoflavones, lignans (from flaxseed), and coumestan (from Pueraria mirifica) to increase estrogen levels

What Are Bioidentical Hormones?

The term "bioidentical hormones" can be confusing for a few reasons.

First, the definition itself. According to the Endocrine Society, bioidentical hormones are chemically identical to hormones made in the body. However, many people use the term "bioidentical" to refer to hormones that are compounded, derived from plants, or not synthetic (made in a lab).

Secondly, the FDA has approved several bioidentical hormones. These are available in tablets, patches, gels, creams, and sprays. Some of these prescription products include:

Estradiol products like Estrace pill, Climara patch, and Estrace vaginal cream

Progesterone products like Prometrium pill and Prochieve vaginal gel

Testosterone products like Testim gel and Androderm patch.

Compounded bioidentical hormones are custom-made in compounding pharmacies, and the FDA has not approved them. This article refers to this kind of bioidentical hormone.

What the Research Says

Despite all the hype and advertising surrounding compounded bioidentical hormones, there isn't enough evidence to determine if they're safe or effective. More research is needed to know the long-term effects of these hormones on heart health and cancer risk.

There is also limited data to recommend supplements (e.G., herbs, vitamins, etc.) instead of traditional HRT. Some plant-based products have been shown to improve symptoms like hot flashes in up to 2 out of 3 postmenopausal women, but the same effects were seen with a placebo (sugar pills).

On the other hand, physical activity (both aerobic exercise and resistance training) and eating a balanced, healthy diet have been shown to help maintain hormone levels throughout aging. Added benefits to these lifestyle changes include increased bone strength and mental function.

Balancing Your Hormones

When people talk about HRT, they are usually referring to supplementing with prescription versions of the following sex hormones:

These chemical messengers play a crucial role in various processes in the body, including:

Metabolism. The hormones insulin and estrogen metabolize (break down) food. Low levels of these hormones are associated with conditions like diabetes, heart disease, and obesity.

Reproduction.

Mood regulation. Estrogen helps regulate emotions and the body's response to stress. Testosterone helps protect against anxiety and depression.

Immune function. Estrogens act to increase the body's immune response, while progesterone decreases it. Testosterone may help protect against autoimmune disorders.

Hormone levels fluctuate throughout the life cycle and can be exaggerated by some medical conditions. Events that are associated with hormonal changes include the following:

Perimenopause, the two to five-year period before menopause that's marked by decreases in estrogen and progesterone levels in females

Menopause is when menstrual periods stop, and estrogen levels sharply decline. During this transition, many women experience hot flashes, trouble sleeping, and mood changes.

Oophorectomy (surgical removal of the ovaries) is characterized by a sudden decrease in estrogen

Cancer treatment, which can also be associated with dramatic menopause symptoms due to changes in hormone levels

Andropause, a decline in testosterone levels in men that begins around age 20 or 30

Maintaining hormone balance is crucial for overall health, vitality, and quality of life. But as with many things, finding this balance can be very tricky.

Common Hormonal Imbalances

Common hormonal imbalances that can affect both men and women include:

Signs and symptoms associated with hormonal imbalances include the following:

These can be vague and aren't always associated with hormonal issues. Your healthcare provider can help you determine if your symptoms are related to a hormonal imbalance and develop a treatment plan if so.

Benefits of Natural Hormone Replacement Therapy

Some people use NHRT to address hormonal imbalances and promote well-being. NHRT is marketed for uses like the following:

Relief from menopausal symptoms (e.G., hot flashes, night sweats, vaginal dryness).

Improvement in mood, energy levels, and cognitive function.

Support for healthy aging, bone density, and cardiovascular health.

Enhancement of libido and sexual function.

Keep in mind that while traditional HRT has proven benefits for some menopausal symptoms, NHRT has not been proven effective. This doesn't mean that NHRT can't help, but it does mean that more research is needed before these alternative treatments can be routinely recommended.

Supplements for Natural Hormone Replacement Therapy

Dietary supplements that have been studied for hormone replacement therapy include

Calcium and vitamin D: Can increase bone mineral density and prevent fractures after menopause.

DHEA: Your body uses DHEA to produce the female and male sex hormones estrogen and testosterone.

Isoflavones: Found in soybeans, these compounds act like estrogens. They've been shown to reduce hot flashes and promote bone strength.

St. John's wort: Used to relieve symptoms of menopause.

Valerian: Used for anxiety, hot flashes, and sleep problems.

Black cohosh: Used to alleviate menopausal symptoms such as hot flashes and night sweats, though it's unclear whether it is effective or not.

Dong quai: Typically used with other herbal supplements for menopausal symptoms or reproductive issues in females.

Maca root: Believed to help balance hormones and improve energy levels and libido.

Vitex (chasteberry tree): Often used to support hormone balance and relieve premenstrual syndrome (PMS) symptoms.

Vitamin E: Some research shows it can reduce the severity of hot flashes, but more evidence is needed.

Wild yam (Dioscorea villosa): Several menopause products contain wild yam, which is claimed to help reduce hot flashes due to its diosgenin content. However, your body cannot convert the diosgenin in wild yam into progesterone; this can only be done in a lab.

All supplements carry a risk of side effects and drug interactions. Discuss using these and other dietary supplements with your healthcare provider, pharmacist, or registered dietitian before adding them to your medicine cabinet.

Choosing a Supplement

In the United States, the FDA does not regulate supplements like prescription drugs. This means some supplement products may not contain what the label says.

When choosing a supplement, look for third-party tested products and consult a healthcare provider, registered dietitian nutritionist (RDN or RD), or pharmacist.

Side Effects and Risks

Many people believe that NHRT is safer or more effective than traditional HRT because it is "natural." But this is not the case.

In general, NHRT, which uses compounded hormones, is likely to have the same risks as traditional HRT. However, since these products aren't standardized, additional risks are involved. Formulations with too much or not enough estrogen or progesterone, for instance, can cause side effects or limit effectiveness.

The FDA does not approve compounded bioidentical hormones. This means these products don't have to be proven safe or effective. They also aren't required to have a black box warning about their risks, like prescription hormone products.

Other risks associated with compounded bioidentical hormones include:

Increased risk of endometrial cancer

Possible increased risk of heart disease

Risks associated with the process of compounding

Inconsistent drug levels

Side effects aren't reported

Keep in mind that people with a history of the following conditions should not use HRT of any kind:

Supportive Strategies

Regular exercise and eating a healthy, balanced diet help the body continue to produce hormones, even during aging.

Some specific findings:

Weight-bearing exercise helps build muscle mass, which is important to maintain as you age.

Both resistance training and aerobic exercise ("cardio") improve bone strength and help prevent fractures.

Achieving a healthy weight can help control symptoms of menopause, like hot flashes and urinary incontinence.

Other supportive strategies to complement traditional HRT or NHRT include:

Cognitive behavioral therapy (CBT). Recommended by the North American Menopause Society, CBT has been shown to improve symptoms of menopause like hot flashes.

Mindfulness practices like yoga and meditation. While these don't seem to benefit menopause symptoms, some research shows they can improve quality of life and sleep during this transition.

Avoiding alcohol and drugs (including tobacco). These substances can cause testosterone levels to nose-dive.

Summary

NHRT is an alternative to traditional HRT to promote hormonal balance and overall health.

Common forms of NHRT include bioidentical hormones and dietary supplements. These have a reputation for being safe because they are considered "natural."

The bottom line is that there's insufficient evidence to know whether these products are safe or effective. Risks associated with NHRT are similar to those with conventional HRT and include cancer and heart disease, plus the unknowns associated with medications that the FDA hasn't approved.

If you are experiencing signs of a hormonal imbalance, such as fatigue, mood swings, or libido changes, your healthcare provider can help determine the optimal treatment plan for you.

Read the original article on Verywell Health.

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Hormone Replacement Safe And Effective Menopause Treatment, Study Finds

Dr. Lauren Streicher:

Well, that's actually a complicated question, because we're really looking at two groups of symptoms. We're looking at the short-term issues, the hot flashes, the vaginal dryness, the brain fog, the moodiness, the insomnia.

But we're also looking at big picture, at long-term issues, not only prevention of chronic disease, such as heart disease, which is the number one thing that kills women, but things like different cancers, breast cancer, uterine cancer, cognitive function down the road, joint pain, sexual function.

So, in terms of which women would benefit, well, clearly, the group that's going to benefit at the onset of menopause are the women who are having the severe symptoms, particularly hot flashes and insomnia. And there's this idea that hot flashes aren't harmful. Dress in layers, carry a fan, you will get through it.

Well, first of all, we know that they last an average of seven to 10 years. And, in fact, hot flashes are correlated with heart disease and other serious long-term medical issues. So, clearly, women that are having these symptoms early in menopause are candidates for hormone therapy.

But the bigger question is, what about the long term? And when we look at bone health specifically, this is a big deal. Women die from osteoporosis. And so they may not have any symptoms of bone loss during perimenopause, but they are starting to lose bone. And we know from this WHI data that women who start their hormone therapy in that golden period of time between 50 and 60 have a 33 percent decreased risk of fracture.

But the minute they go off their hormone therapy, they start to lose bone again. So we're not just talking about short-term hormone therapy. We're talking about long-term hormone therapy, quite frankly, lifelong hormone therapy, to prevent those kinds of long-term problems, which cause women to not only have a significant decrease in quality of life, but also length of life.

Major Women's Health Study Supports Hormone Replacement Therapy In Early Menopause

Hormone replacement therapy can safely ease middle-aged women's symptoms during early menopause, data from a major women's health study show.

Women younger than 60 can use hormone replacement to treat symptoms like hot flashes and night sweats without significantly increasing their risk of breast cancer or other health problems, according to long-term results from the Women's Health Initiative (WHI).

"The WHI findings should never be used as a reason to deny hormone therapy to women in early menopause with bothersome menopausal symptoms," said lead researcher Dr. JoAnn Manson, chief of preventive medicine at Brigham and Women's Hospital in Boston.

"Many women are good candidates for treatment and, in shared decision-making with their clinicians, should be able to receive appropriate and personalized health care for their needs," Manson added in a hospital news release.

The WHI involved more than 160,000 postmenopausal women ages 50 to 79. The study tracked their rates of heart disease, cancer and hip fractures, and also included randomized clinical trials of more than 68,000 women to test potential aging treatments like hormone therapy or calcium and vitamin D supplementation.

Prior to the WHI, studies had reported that older women who took hormone therapy had lower risks of heart disease, stroke, dementia, chronic disease and death, researchers said in background notes.

A WHI clinical trial slammed the brakes on hormone replacement therapy in 2002, however, reporting that women taking combination (estrogen and progestin) hormone therapy had an increased risk for breast cancer, heart disease, stroke and blood clots.

But as women participating in the WHI have been followed over two more decades, a more nuanced picture of hormone therapy's risks and benefits has emerged.

Findings continue to show that hormone therapy does nothing to decrease women's risk for health problems related to aging like heart disease or hip fractures, counter to pre-WHI studies.

However, hormone therapy has been shown to not be as risky for middle-aged women nearing menopause, and helpful in dealing with symptoms related to that change in life.

"Women also have more options for treatment now, including estrogen in lower doses and delivered through the skin as a patch or gel, which may further reduce risks," Manson said. "Non-hormonal treatments are also available."

This WHI update, which was published May 1 in the Journal of the American Medical Association, also includes fresh information on the value of low-fat diets and calcium and vitamin D supplementation.

Although calcium and vitamin D supplements don't reduce risk of hip fracture in aging women, researchers noted that these supplements can help fill nutrient gaps among those not eating a balanced diet.

Meanwhile, low-fat diets now are associated with a reduced risk of death from breast cancer, researchers report. Earlier WHI findings had found that low-fat diets did not reduce risk of breast or colorectal cancer.

Researchers recommend that women talk with their doctors about whether a low-fat diet diet or calcium and vitamin D supplements would be good for them.

More information: JoAnn E. Manson et al, The Women's Health Initiative Randomized Trials and Clinical Practice, JAMA (2024). DOI: 10.1001/jama.2024.6542

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