The transition though perimenopause into menopause can bring many unpleasant symptoms. There are many products marketed to women searching for relief, including over-the-counter hormones.
While convenient, they put powerful products in the hands of women who likely have no expertise in using them. As a doctor of pharmacy who has worked with many women, I know there is a mindset that over-the-counter availability translates as safe. But that is not necessarily true, and there’s a real possibility of creating a potentially dangerous situation when bioidentical hormones are used incorrectly. Let’s take a look at commonly available hormone supplements.
Your body produces three types of the hormone estrogen: estriol, estradiol, and estrone. Estriol is the weakest form of estrogen in the body. It is usually abundant in women who are pregnant. Although estriol is relatively weak, it has been reported to produce beneficial effects with few side effects and health risks. Estriol is not FDA approved as a prescription drug. However, it is available over the counter in different forms.
It has been reported to improve vaginal dryness and aging skin. While systemic absorption is said to be low, my personal experience with estriol is that it greatly increases breast tenderness — which means that it was absorbed into my body.
There is conflicting information about whether a woman needs to add progesterone if she uses estriol. It is not necessary if the product is used vaginally.
Bi-Est is a combination of estradiol and estriol. In over-the-counter products, it is 80 percent estriol and 20 percent estradiol. This cream is used to help with symptoms of low estrogen, which can include hot flashes, night sweats, insomnia, brain fog, and depression.
I never recommend using Bi-Est without the guidance of a professional. If you have a uterus, you will need to add progesterone to reduce the risk of uterine cancer that increases with use of unopposed estrogen.
Side effects, which are mainly related to overdose of estrogen, include weight gain, breast tenderness, anxiety, bloating, return of periods after menopause, and headaches. Although estrogen does not cause cancer, these products should not be used by women who have a personal history of hormone-sensitive cancers.
Progesterone supplementation is a go-to for many perimenopausal women who are deficient in the hormone because of lack of ovulation. It can greatly improve anxiety, breast tenderness, heavy periods, and fatigue, and also helps with countering weight gain. Progesterone can be used topically or orally. Only the topical form is available over the counter. It comes in a number of strengths (typically 3, 10, or 20 percent) and forms.
Dosing can vary widely. Some experts recommend as little as 20 milligrams per day (what the body would normally produce on its own before menopause), but some recommend doses in the hundreds of milligrams to overcome estrogen dominance. I suggest starting low and increasing as needed.
Use of topical progesterone is a low-risk option in perimenopause, but be aware that symptoms may worsen before they get better. Also, if you suspect you have low cortisol, use of progesterone may worsen anxiety and weight gain if the body needs the progesterone to make cortisol.
I am often asked if progesterone is linked to breast cancer risk. There is no evidence that suggests this is the case.
DHEA is the precursor to testosterone and estrogen, and it’s the most abundant hormone in the body. DHEA declines with age, beginning around our mid-20s; maintaining proper levels of DHEA has been shown to increase energy and reduce the risk of various diseases. It can also be used as a “back door” way to increase testosterone, since it tends to convert to testosterone in women.
DHEA, one of your androgenic (male) hormones, is available orally, topically, or as vaginal inserts. It is typically used for adrenal support, to increase energy and overall sense of well-being. There is an increasing body of data that shows positive outcomes for vaginal dryness with inserts. DHEA is often combined into one product with estriol, vitamin E, and cocoa butter into vaginal inserts. These can be ordered online. Little of the active ingredient is absorbed systemically from the vagina, so side effects are rare.
Oral DHEA is available online and in many health food stores. It is commonly found in 25- or 50-milligram strengths on store shelves. However, this dose is much too high for women! I once had a client who didn’t mention to me that she was taking DHEA. She was having significant hair loss, so I tested her hormone levels. They were sky high — she was taking 50 mg of DHEA! I rarely recommend more than 10 milligrams for women. Side effects of DHEA (all from excess dosing) are oily skin, acne, hair loss, and irritability.
Topical DHEA cream is also available. Some studies suggest that it is better absorbed through the skin, since much of an oral dose will be sulfated in the liver. Avoiding sulfation leaves more of the parent compound available.
DHEA should not be used if you’ve had a hormone-sensitive cancer like breast or ovarian cancer, since there is the possibility that it can convert to estrogen.
A do-it-yourself approach to hormone replacement is tempting given the easy access to over-the-counter products. My opinion is that this is generally a bad idea, especially if you’ve had no testing to guide decision making. Better to work with a professional who can suggest proper testing and guide you on a safe approach to symptom relief.
Dr. Anna Garrett is a leader in the testing and treatment of hormonal imbalances and the author of Perimenopause: The Savvy Sister’s Guide to Hormone Harmony. Learn more about Dr. Garrett at drannagarrett.com and order her book at perimenopausebook.com.