What estradiol is doing in the standard protocol
The standard HRT protocol is still going to be estradiol and progesterone. Estradiol is the one that is going to be doing most of the work.
Estradiol is going to be tackling most of the symptoms we have talked about. That includes hot flashes and night sweats—the vasomotor symptoms. Brain fog, mood changes, bone pain, joint pain, and muscle pain are also areas where estradiol comes into play.
Patch and gel are transdermal forms
There are different forms of estradiol. The transdermal forms include a patch or a gel. Transdermal means that the medication goes through the skin.
The transdermal form bypasses metabolism through the liver. What that means is a decreased risk of blood clots.
If a patient has been on HRT and is over the age of 65, I switch her to a transdermal version of estradiol if she is not already using one. That decreases the risk of blood clots.
A history of blood clots, a genetic propensity toward blood clots, or tobacco use are also reasons I would go directly to the transdermal version or formulation. Those factors already carry increased blood-clot risk, so I want to choose the safest version.
Oral estradiol remains an option
There is also an oral formulation. For most patients, it is completely fine and an excellent option.
The route is part of an individual decision. HRT is not one size fits all, and the choice depends on the person, her history, and how she responds.
Why progesterone is paired with estradiol
Progesterone is required for women who have a uterus. As long as you have a uterus in place, you need to take progesterone when you are on estradiol.
When you take external estrogen, it increases cell turnover in the uterus. Long term, that can lead to a buildup of cells and potentially create a cancer risk. Progesterone eliminates that risk by causing those cells to slough off, preventing the buildup and allowing the cells to turn over.
Progesterone has its own benefits. Some people really like it. Some people do not. It depends on the person.
It can help with sleep because it is metabolized into something that acts like GABA and has a sedative effect. For some people, it helps with mood and has an anti-anxiety effect.
It can also slow gastric emptying, so some women have a difficult time with bloating and constipation.
If oral progesterone does not feel right
If you do not like how progesterone makes you feel, you can use it vaginally. Doing poorly with progesterone in the past does not eliminate your ability to use estradiol. We can change the route.
The vaginal inserts can be much more expensive and are rarely covered by insurance. I have the doctor prescribe oral progesterone and use it vaginally. If you use progesterone intravaginally, insert it at night. You may have some discharge from the gelatin dissolving when you wake up, so you may want to wear a panty liner.
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