Is HRT Necessary in Menopause? What is Bioidentical Hormone Therapy?

Why Do Menopausal Symptoms Appear?

Menopause is a natural process in which the ovaries largely reduce their production of oestrogen and progesterone. In Turkey, the average age of menopause is between 47 and 51. This rapid drop in hormone levels can cause symptoms such as hot flushes, night sweats, sleep disturbances, mood swings, vaginal dryness, joint pain and, in the long term, a decrease in bone density (osteoporosis). The severity of these symptoms differs in every woman; some barely notice them, while others struggle to carry on with daily life.

What is HRT (Hormone Replacement Therapy)?

Hormone Replacement Therapy is the external replacement, as medication, of the oestrogen and, when needed, progesterone hormones that decline after menopause. Treatment can be applied as an oral tablet, a skin patch (transdermal patch), gel, vaginal cream or ring. The aim is to relieve the symptoms caused by hormone deficiency and to reduce long-term adverse effects.

Who is HRT Recommended For?

HRT is not mandatory for every woman; however, it should be strongly considered in the following situations:

• Moderate and severe hot flushes, night sweats
• Night sweats severe enough to disrupt sleep
• Vaginal dryness, painful intercourse (atrophic vaginitis)
• Early menopause (before age 40) or surgical menopause (removal of the ovaries)
• Patients at high risk of osteoporosis who are not suitable for other treatments

Routine HRT is not recommended in women with mild or no symptoms.

Benefits and Risks of HRT

Benefits

• Reduces hot flushes and night sweats by 75-90%
• Protects vaginal health and improves quality of sexual life
• Slows bone loss and lowers the risk of osteoporosis
• May contribute to cardiovascular protection in early menopause

Risks and Points to Consider

• It is not used in women with a history of breast cancer
• Caution is needed in those with active liver disease, uncontrolled hypertension or a history of deep vein thrombosis
• HRT started after age 60 may increase cardiovascular risk compared with earlier initiation. For this reason, it is recommended to start within the "window of opportunity" — age 60 or the first 10 years after menopause
• During treatment, annual breast examination, mammography and gynecological check-up are mandatory

The important thing is that the treatment decision is made with an individualised risk-benefit assessment.

What is Bioidentical Hormone Therapy?

Bioidentical hormones are hormones that have the same molecular structure as the hormones produced by a woman's body. They are usually synthesised from plant sources (soy, yam root) and converted into natural estradiol and progesterone in the laboratory. These molecules, which the body recognises "as if they were its own hormones", may be metabolised differently from traditional synthetic hormones.

Among the approved bioidentical products in Turkey and worldwide, the most commonly used are the transdermal estradiol patch, estradiol gel and oral micronised progesterone.

The Difference Between Classic HRT and Bioidentical HRT

• Hormone structure: Classic HRT is usually synthetic or animal-derived (conjugated oestrogen, medroxyprogesterone). Bioidentical HRT has the same molecular structure as the human hormone (estradiol, progesterone).
• Application: Classic HRT is mostly in oral tablet form. In bioidentical HRT, transdermal patch/gel and micronised oral capsule options are prominent.
• First-pass effect: Oral hormones are metabolised in the liver on first pass and can raise triglycerides. Transdermal use largely bypasses the liver.
• Thrombosis risk: The risk of thrombosis is relatively low in transdermal bioidentical forms.
• Individualisation: In bioidentical treatment, patient-specific dose adjustment can be made more flexibly.

An important distinction: Specially prepared ("compounded") bioidentical mixtures at pharmacies are different from licensed bioidentical products. The efficacy and safety of compounded products have not been proven in large-scale clinical studies; therefore, international guidelines recommend licensed bioidentical products.

How is the Treatment Process Planned?

Before starting hormone therapy:

1. A detailed medical and family history is taken (breast cancer, thrombosis, heart disease, etc.)
2. A gynecological examination and mammography are performed
3. Blood tests (lipid profile, liver function, hormone levels) are evaluated
4. Considering the patient's symptoms, preferences and risk profile, treatment is started at the lowest effective dose
5. A check-up is done in the first 3-6 months, then follow-up is performed at least once a year

How long the treatment lasts varies from person to person; it is usually reassessed every year, taking symptom control and the risk profile into account.

Frequently Asked Questions

Does HRT cause weight gain?

The weight-gaining effect of HRT has not been scientifically proven. Weight gain in menopause is mostly due to the age-related slowing of metabolism.

Do natural methods replace HRT?

For mild symptoms, herbal supplements (phytoestrogens, black cohosh) may help to a certain extent; however, they are not as effective as HRT for moderate-to-severe symptoms.

Is pregnancy possible with HRT?

No. HRT is not a fertility treatment; it aims to correct the hormone deficiency in menopause.

How long is HRT used?

It varies according to symptom control and risk profile. In most patients it is used for 3-5 years; however, in some patients it can be safely continued for longer.