Bioidentical Hormone Replacement Therapy (BHRT)

Hormone Replacement Therapy: A Functional Perspective (educational)

As a health care provider who has followed both men and women for more than 18 years, I can confidently say that many of my healthiest and most active patients benefit from bioidentical hormone replacement therapy (HRT) as they age.  I remain disappointed that HRT continues to be viewed as controversial within the conventional medical system. Women, in particular, have suffered for decades from the misunderstanding and confusion created by the inaccurate interpretation of the Women’s Health Initiative (WHI) study.

Hormones are vital at every stage of life, and we are all healthier when they are in balance. The benefits of HRT include relief from hot flashes, night sweats, fatigue, weight gain, and irritability.  It also supports bone health, lowers the risk of colon cancer, improves mood and sleep, and decreases the risk of Alzheimer’s disease and cognitive decline. Unfortunately, these significant benefits have been overshadowed by outdated concerns and caution.

The Women’s Health Initiative (WHI), conducted in the early 2000s, was a huge study done as a follow-up to the Harvard’s Nurses’ Health Study (which showed significant improvement in perimenopausal symptoms for women taking HRT).  The WHI however, was flawed for many reasons.  The average age of participants was 63; more than 70% were obese, and over half smoked and had hypertension.  The study was discontinued when data leaked by JAMA suggested a possible increased risk of breast cancer and stroke/heart disease.

Subsequent analyses have provided much-needed clarity.  The alleged increase in breast cancer risk was not statistically significant and was only seen in women receiving both estrogen and synthetic progesterone (progestin).  Women in the estrogen-only arm had no increased breast cancer risk.

It’s worth noting that women who were already on estrogen replacement therapy prior to the WHI had a lower overall incidence of breast cancer, and those diagnosed while on HRT tended to have better prognoses than women who were not using it at the time of diagnosis.  We now understand that the synthetic progestin—not estrogen—was responsible for this slight elevation in breast cancer risk.  Most clinicians today prescribe bioidentical progesterone in combination with estrogen, eliminating this concern.

Regarding clotting and cardiovascular risk, research shows that women without preexisting atherosclerosis who begin HRT within 12 months of their last menstrual period face no increased clotting risk.  Starting HRT within 10 years of menopause carries a very low risk, but initiating therapy more than 10 years after menopause—particularly in women with vascular disease—can increase the likelihood of dislodging existing plaque during the first year of treatment.  Estrogen helps blood vessels maintain elasticity, and when initiated decades after plaque has developed, there is a risk of dislodging it.  This explains why HRT is generally not recommended for that population.  Remember, the WHI participants were, on average, 63 years old with multiple comorbidities, already placing them at higher cardiovascular risk.

The New York Times summarized many of these issues in a February 2023 article:
https://www.nytimes.com/2023/02/01/magazine/menopause-hot-flashes-hormone-therapy.html

Significantly, an NIH analysis of more than 7 million postmenopausal women, published in May 2022, found that women on HRT lived 20% longer and had lower rates of neurodegenerative disease, as well as statistically lower risks of breast, ovarian, uterine, lung, and colorectal cancers.  The key, however, lies in using the right formulations: transdermal (not oral) estrogen and bioidentical progesterone.
https://www.medrxiv.org/content/10.1101/2022.05.25.22275595v1

When optimizing hormones, it’s essential to also consider gut health and stress response. The estrobolome—the collection of gut bacteria capable of metabolizing and modulating circulating estrogen—plays a critical role in hormonal balance.  A healthy estrobolome helps regulate estrogen levels, influencing weight, mood, and libido.  This is why the functional medicine approach often begins with the gut.

Stress management is equally important.  Estrogen, progesterone, and testosterone are all derived from cholesterol—the same precursor used to produce cortisol.  During times of acute stress, hormone production is shunted toward cortisol, which is adaptive short term but detrimental when chronic. Prolonged high cortisol output suppresses progesterone production, contributing to hormonal imbalance and related symptoms.

HRT is not for everyone, and anyone considering it should discuss their individual case with a knowledgeable provider.  A comprehensive approach—one that evaluates stress hormones, gut health, and personal risk factors—is essential. If you are not already working with someone you trust, I’d love to help support you on your path.  Education and awareness are powerful tools in navigating your own health journey.

In health,


Lindsay Wojciechowski, FNP-C

  • Bioidentical hormone replacement therapy (BHRT) refers to hormone therapy that uses compounds structurally identical to human hormones. It’s used to treat men and women who have experienced a drop or imbalance in their hormone levels. Symptoms related to hormonal imbalance can happen for a variety of reasons, and are most commonly seen in women during the menopausal transition. Hormone replacement therapy supports healthy aging, particularly in the context of improving bone strength and preventing osteoporosis, supporting brain health and thus lessening cognitive decline, improving sleep, and lowering the risk of cardiovascular disease in women. Bioidentical hormones are identical in makeup to the ones our bodies produce naturally. BHRT is not right for every patient, and the benefits and risks must be discussed with each patient.

  • Yes. I prescribe hormone replacement therapy when clinically appropriate and individualized to the patient. This may include estrogen, progesterone, testosterone, or other hormone support needed. Sometimes the patient needs replacement of the actual hormones themselves, and sometimes they just need support to enhance what they can make on their own.

  • My approach to hormone therapy is thoughtful and comprehensive. Hormones are never prescribed in isolation. I consider things that can impact hormones first; inflammation, metabolic health, gut health, detox pathways, stress physiology, nutrient status, and overall risk profile to ensure once started, HRT therapy is optimal and effective.

  • Many women experiencing symptoms such as hot flashes, sleep disruption, mood changes, brain fog, joint pain or changes in body composition may benefit from HRT. Many women without symptoms but are newly postmenopausal will often opt to start hormones to optimize health and longevity.

    That said, HRT is not for everyone. Determining candidacy requires a thoughtful review of symptoms, medical history, family history, and individual risk factors and personal goals. This decision is always personalized.

  • The most commonly prescribed hormones include estrogen and progesterone. Estrogen supports brain, bone, cardiovascular and metabolic health, while progesterone protects the uterine lining and supports sleep and the nervous system. In some cases, testosterone is included for energy, muscle mass, libido and cognitive support. Not every patient needs every hormone replaced.

  • Hormones can be delivered in several ways, including transdermal patches, oral capsules, topical creams and gels and pellets. I personally do not administer pellets in clinic. Each method has different advantages and considerations related to absorption, metabolism and safety.

  • Yes! For most women, HRT is very safe and very beneficial when prescribed appropriately and monitored carefully, especially when started less than 10 years post menopaus. Much of the fear around HRT comes from old studies that were not interpreted correctly. Older studies also used synthetic hormones rather than the bioidentical forms most clinicians use now.

  • A comprehensive evaluation typically includes a detailed symptom review, medical and family history, and appropriate lab testing. Labs help guide decision making, but are only part of the picture. Symptoms and clinical context matter greatly. In addition, for some patients, we dive into adrenal health and detox pathways, as well as gut health. These can impact hormones significantly if impaired. I listen to patients and we create a plan that meets their needs.

The information provided on this page is for educational purposes only and is not intended to diagnose, treat, or replace individualized medical care.

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