Is the use of non-natural medroxyprogesterone what makes HRT bad?

Question

I don't think there is any problem with use of HRT as long as the natural estrogen (E2) is balanced with natural progesterone. What do you think? My feeling has always been that the "bad" things reported, supposedly because of HRT, even when E2 is used, are caused by the use of progestin. One can obtain progesterone easily enough, so that shouldn't be a problem.

Answer

Thanks for your comment and question.

I don't think that even the language you used, calling menopausal ovarian hormone therapy, "HRT," should be used any more. HRT is obsolete! For me the thinking--estrogen will prevent the illnesses associated with aging and menopause--is just wrong. Whether or not the estrogen is bio-identical, estradiol or E2 as you suggested, whether or not estrogen is given as a patch or gel or cream instead of as a pill, the notion that estrogen therapy will prevent anything in menopause, is wrong. It is wrong because the low estrogen levels of menopause are normal. No one has ever shown that menopause, rather than simply aging, cause illnesses (often varying like the flavour of the month) that we believe estrogen will prevent. The most commonly mentioned of these so called menopausal illnesses are heart disease, dementia and osteoporosis.

For more on concepts about ovarian hormone therapy and how our thinking should have changed in the five years since the first Women's Health Initiative trial was stopped, see WHI Five Years Later.

That I don't believe in using estrogen therapy to prevent osteoporosis in menopausal women may seem surprising because, after all, the large randomized controlled Women's Health Initiative (WHI) trials showed that fractures were something prevented by estrogen or estrogen with low dose progestin. I quite agree that WHI showed estrogen and estrogen with progestin therapy prevented fractures. But remember, those trials proved that, even with the benefits for osteoporosis taken into account, menopausal hormone therapy caused harm. My idea about preventing osteoporosis is that a healthy active childhood and adolescence, a high peak bone mass, and keeping that strong bone until irregular cycles start in perimenopause, is the best way to prevent fractures.

Now to the comment you made about progestin and progesterone as part of menopausal ovarian hormone therapy. Unfortunately, rather than looking at progesterone as an important and natural partner hormone with estrogen, the current ideas and practice are to consider estrogen important, and to add a begrudging smidge of progestin or progesterone. Repeatedly the gynecology consensus documents say the only reason for adding progestin or progesterone is to prevent endometrial (lining of the uterus) cancer. Yet progesterone prevents the estrogen-related overgrowth of cells in breasts as well as endometrium. Oral micronized progesterone (OMP, Prometrium or compounded OMP in olive oil) also improves deep sleep. And medroxyprogesterone, in a dose of 10 mg a day, it is as strong as estrogen in treating hot flushes. Most importantly, progesterone if needed for therapy, probably has effects to prevent heart disease, lowers blood pressure, and probably doesn't cause migraines, blood clots or rebound increases in hot flushes when it is stopped. In a past study we tested OMP for intense hot flushes and also determined its effects on blood vessels, blood pressure, blood clots and rebound hot flushes.

There are good reasons for Ovarian Hormone Therapy with cream/gel/patch natural estrogen and full dose daily OMP in menopausal women. They continue to be: early menopause, severe hot flushes plus osteoporosis, and finally bad hot flushes. For the hot flushes, if menopause is at a normal age, and bone density is ok, progesterone alone is good treatment. And if, because of the approximately $3.00/day cost for 300 mg of Prometrium, you can't afford progesterone, you could ask for a prescription for compounded OMP in olive oil (300 mg should cost less than $2.00 a day) or medroxyprogesterone 10 mg a day (which costs about $0.60 a day).

I hope this is useful for you,
All the best,

Jerilynn C Prior MD FRCPC