Hormones: One of the driving forces of femininity

Estrogen hormone, especially estradiol (E2), affects femininity in every cell of the body. When it is lacking, it causes rapid aging and degeneration. Conversely, having enough can slow down degeneration at the cellular level for all women.

Principles for choosing hormone replacement therapy currently (MHT OPTIONS on 2020) Time/ Window of opportunity

The appropriate timing is important for hormone replacement therapy because estrogen helps prevent vascular degeneration (anti-atherosclerosis) and prevents plaque formation on the blood vessel walls by increasing HDL, reducing LDL, and having vasodilatory effects by stimulating the secretion of NO2 & prostacyclin and reducing the secretion of endothelin-1 which causes vasoconstriction. As women age and reach the postmenopausal period for a long time, it means a lack of estrogen protecting the blood vessels for a long time. Blood vessels may degenerate and atherosclerotic plaques may have already formed. Administering estrogen at this stage risks causing unstable plaques, meaning plaques may shift, rupture, and detach to block various blood vessels.

Therefore, for maximum benefit and minimal risk, hormone replacement should be given to those who are in the early postmenopausal period (< 10 years), aged no more than 60 years, and have no vascular degeneration with existing atherosclerotic plaques. Physicians should consider individual risk factors case by case.

MHT Agents

The estrogen we should choose is estradiol (E2), which is the most abundant type in women before menopause and has the most natural effect on the body. This is because we want menopausal women to regain strength as before menopause without complications like those from older hormone therapies such as Premarin, which contains more than 20 mixed components and only 0.9% estradiol (E2), while the main component is estrone (E1) at 49.3%, which is not the estrogen type the body needs and also increases the risk of cancer. Therefore, currently, the type of estrogen used for hormone replacement should be estradiol (E2).

Routes

Innovations in drug administration via transdermal application allow hormones to be absorbed directly into the bloodstream and act on target organs. The advantage is avoiding liver metabolism, reducing the production of proteins that bind hormones, and decreasing clotting factors, thus reducing the risk of blood clots in common sites such as legs, groin, and arms (DVT). Overall, this reduces the incidence of venous thromboembolism (VTE) and stroke. Applying estradiol (E2) through the skin is therefore the best option, especially for those at risk of cardiovascular disease.

Progesterone / Progestin

Menopausal women need estrogen but do not want endometrial cancer. Therefore, they must receive progesterone as well because progesterone is a natural hormone produced by the body with many benefits, including protecting against endometrial cancer. Currently, Utrogestan (micronized progesterone) is a natural hormone type that can be safely used for replacement.

Progestin is a synthetic hormone that acts like progesterone. Among several classes, the safest is dydrogesterone, which is closest to natural progesterone. Studies using it with estradiol for 5 years show no increased risk of breast cancer.

Benefits of hormone replacement

Vasomotor symptoms : It is the most effective option for treating hot flashes in menopausal women. However, if contraindicated, other options such as the herb black cohosh or SSRI or SNRI drugs may be used instead.

Bone health : Improves bone quality and density, reducing fractures. Large studies have found that the benefits of hormones on bones last up to 2 years even after stopping use.

Diabetes : Benefits blood sugar balance by lowering blood sugar levels, increasing muscle sugar utilization, increasing insulin secretion from the pancreas, and enhancing insulin sensitivity, thus reducing the risk of diabetes.

Moods : Both estrogen and progesterone are neurosteroids, acting on the central and peripheral nervous systems. Estrogen protects against nerve cell injury and degeneration, stimulates cell division, and enhances nerve signal transmission. It significantly affects mood by stimulating the production and release of neurotransmitters such as dopamine, serotonin, and norepinephrine. Additionally, progesterone, especially its derivative allopregnanolone, stimulates GABA release, helping reduce anxiety, promote calmness, and improve mood. Therefore, hormone replacement helps reduce anxiety and depression.

Sleep : Improves sleep quality by reducing hot flashes and producing neurotransmitters that calm the brain, helping better sleep. Quality sleep also supports the production and secretion of other important hormones such as growth hormone, thyroid hormone, and adrenal hormones.

Breast cancer : Meta-analyses of studies using estradiol (E2) alone or combined with natural progesterone for 5 years show no evidence of increased breast cancer risk.

Indications for hormone replacement therapy

1. Hot flashes (Vasomotor symptoms)
2. Vaginal dryness, burning, frequent urinary tract infections (Genitourinary symptoms of Menopause)
3. Prevention of osteoporosis
4. Women with premature menopause before age 40 (Premature Ovarian Insufficiency)

In summary, if menopausal women have indications for hormone replacement therapy, they must have no contraindications, be within the window of opportunity age range, and have no vascular degeneration with existing atherosclerotic plaques. Using hormone replacement based on current principles, focusing on the most natural forms, menopausal women affected by hormone deficiency will gain maximum benefits in all aspects when receiving the correct hormone replacement.