Sex and the City Part 4


Thanks to my wonderful wife for providing insight into the risk/benefit discussion regarding hormone replacement. As she stated, the risks of any medical therapy need to be weighed against the benefits. That said, what are the risks of bioidentical hormone replacement therapy (BHRT)?

Men often refer to testosterone as vitamin T. It is essential to maintaining our manliness, our mojo. Testosterone peaks at age 30 in men and decreases 1-2% annually. By age 60 a man’s T is approximately ½ of normal. Does testosterone replacement in men cause any increased cancer risk?

Harvard urologist, Dr Abraham Morgentaler, discusses testosterone replacement in his book Testosterone for Life. He discovered that the “modern medicine” practice of physical castration (old school-ouch!) or chemical castration with the drug Lupron was based on a SINGLE patient. In medicine we don’t do ANYTHING based on one patient’s results. So, he started treating biopsy proven prostate cancer patients with testosterone replacement when they requested it. His average patient was followed for a minimum of 2.5 years after study enrollment. The results? His study showed stabilization of PSA (prostate specific antigen, the lab test most commonly used to follow prostate cancer). The patients felt better and the cancer didn’t progress in any of the study patients. Interestingly, 54% of the biopsies AFTER starting testosterone showed NO cancer. Is testosterone replacement a cure for prostate cancer? The data doesn’t support that assertion at present, but I haven’t heard about any young men developing prostate cancer. Prostate cancer is diagnosed well after the testosterone levels begin to drop.

HRT in women? While we know that oral estrogen DOES increase the risk of heart attack, stroke, and blood clots due to the inflammatory cascade started when the liver processes the oral estrogen, to date I am unaware of a single study that shows an increased risk from bioidentical estrogen. Likewise, we know that synthetic medroxyprogesterone DOES increase the risk of breast cancer. We don’t know whether bioidentical progesterone causes an increased risk of breast cancer, but we do know that it is protective against endometrial cancer in patients with an intact uterus. So, oral estrogen replacement and synthetic progesterone need to be avoided to decrease cancer risk. How about bioidentical estrogen and progesterone? What does the data say?

Breast cancer risk in women is less than 0.5 % at age 30 and increases an average of 1% every 10 years up to age 60. But wait! Estrogen (estradiol) levels in women don’t have a severe drop until menopause (average age 52). How can you relate decreasing natural estradiol levels to breast cancer? Estradiol is a down-stream product of testosterone. Women make the majority of their estradiol from testosterone. Testosterone is converted into estradiol by the enzyme aromatase. Testosterone levels begin to drop in women as early as age 25, and are ½ normal by age 40. Can increasing breast cancer risk be tied to decreasing testosterone levels? A 2004 study published in the journal Menopause reported a decreased breast cancer risk in women treated with testosterone in addition to “usual hormone therapy”. While we don’t have large studies looking at bioidentical hormone replacement therapy centered around testosterone replacement, the early data makes sense. We typically do not see breast cancer in young women prior to age 25.

I expect that we will see a decreased risk in both breast and prostate cancer when hormone levels are restored to natural physiologic levels. This isn’t “mainstream” medicine, but there is an increasing number of anti-aging and wellness physicians that also support this position. Will your doctor agree? This knowledge is NOT taught in medical school. If your doctor hasn’t personally looked at the data the best they can say is they don’t know. I have not seen a study showing an increased risk in ANY cancer types in patients treated with bioidentical hormone replacement therapy. There isn’t a right or wrong answer. Bioidentical hormone replacement therapy is a personal decision that each patient must make. I can personally say that I would rather face my increasing age with decreased fatigue, better sleep, better memory and concentration, and increased libido- but that’s just me.

Disclaimer: Dr Stephen Rath, MD, DABA is a board certified anesthesiologist as well as the owner and medical director of Fusion Medical Spa located in Ruidoso, NM. He isn’t an endocrinologist, but he is a local expert on bioidentical hormone replacement therapy. Comments or questions? His email address is: