Menopause, Perimenopause and Natural Hormone Replacement Therapy
Menopause is a change in life not a disease. Our focus on disease and drugs that can make quick changes led to the widespread use of unnatural synthetic hormones in a vain attempt to suppress what is mainly considered a sign of aging. It is not a sign of aging, but if the effects of menopause are severe it can appear to be so.
While the non bio identical synthetic hormones have been shown to cause cancer and heart disease the natural bio identical are far safer. In fact the types of hormones and their ratios are different; the non bio identical is primarily a synthetic altered form of estradiol which comes from cruelly stressing horses. The bio identical use estriol a far gentler and safer hormone. It may even be protective from cancer. Some women require the use of bio identical hormones some can be helped with phytoestrogens and by balancing the adrenal gland. Others do not have an estrogen issue at all, their symptoms may be due to a low thyroid. Clearly one needs to see a physician who has a broad view of your health who is not quick to use even bio identical hormones.
Symptoms of menopause include:
- Hot flashes
- Mood swings
- Night sweats
- Insomnia
- Dizziness
- Headaches
- Fatigue
- Depression and anxiety
- Palpitations
- Memory problems
- Difficulty concentrating
- Cold hands and feet
- Reduced libido
- Bladder problems
- Skin changes
- Hair loss
- Weight gain
I believe that every woman must be addressed individually. Ideally it is best to get a blood test and saliva test to measure your hormone levels. Additionally a full adrenal evaluation is necessary. Many women especially for those who complain of fatigue, I recommend a more sensitive thyroid test called the TRH stimulation test. Menopausal symptoms are related to a decline in certain hormones such as estrogen, progesterone, testosterone, and DHEA. There are two main types of estrogen, estradiol, and estriol. Additionally thyroid hormones can also be low during menopause. Restoration of the proper balance of hormones is what is needed in order for women in this period to feel like herself again.
Concerns about the dangers in non bioidentical hormones have caused many women to look for better and safer options. This is why so many women are now choosing bioidentical natural hormone replacement therapy. The Women’s Health Initiative study showed a 29% increase in breast cancer along with a higher risk of heart attack and stroke in women taking estrogen/ progestin non bioidentical drug. Another study showed an association with ovarian cancer.
Premarin and other non bioidentical hormones were never intended for the human body. Yet although the bioidentical should never be clearly the use of these hormones have a positive effect on hot flashes, depression, anxiety, and sensory libido skin. The question is can the positive effects of estrogen be obtained without increasing the risk of cancer and heart disease, the answer is yes.
Use of Phytoestrogens or Soy:
Soy phytoestrogens can reduce menopausal symptoms according to some studies. However not all studies support the positive effects of soy. Most studies are in agreement that the soy intake at levels of greater than 50mg per day will lower cholesterol and increase bones but will have clinically no estrogenic effect on the vaginal and uterine epithelium. Clinical studies have also not shown consistently supported the benefits of soy for hot flashes over a long period of time.
Some women who either experience such severe menopausal symptoms or intuitively feel they are just not themselves and need some boost in estrogen and progesterone can take the natural bioidentical estrogen and progesterone. This should only be the case if they had an adrenal evaluation and TRH stimulation test to evaluate the thyroid and ascertained with certainty that their symptoms are not due to either a low functioning adrenal or a low thyroid.
While estradiol is the hormone used as a non bioidentical drug, estriol in the natural form is used by those who prescribe bioidentical natural hormone replacement. Estriol is used extensively in Europe for estrogen replacement therapy. The primary forms of estrogen synthesized by the body include estrone, estradiol and estriol. Estrone in the form found in Premarin while 17- estradiol is the form in the drugs Estrace and Estraderm. Estrone and estradiol may significantly increase the perk of breast and ovarian cancer. According to the Merck manual these estrogens have been listed as known carcinogens. To make matter worse the estrogens come from horses under stress so the estrogen is different chemically than the estrogen found in the human body. No wonder they cause cancer.
Estriol the form used in bioidentical hormone replacement therapy is a weaker form of estrogen yet apparently provides the benefits without the risk of cancer. Estriol is less stimulating to treat ovarian and uterine cells. It is such a safe form that during pregnancy huge amounts of estriol are secreted by the placenta to protect the fetus. The cream form is also safer for a variety of reasons. It does not immediately go to the liver which can alter detoxification pathways and change the production of various biochemicals making one more susceptible to heart disease and clot formation.
Dosages Commonly Used:
Estriol is used in doses of 2-8 mg per day. Estriol even at 8mg per day does not cause endometrial hyperplasia, a condition that can lead to cancer. The non bioidentical hormones do cause endometrial hyperplasia. A large long term study of estriol therapy for re symptoms of menopause was conducted by Lauritzen in Germany at the University of ULM. The researchers concluded “estriol therapy was successful in 92% of cases. In 71% hot flashes and sweating were completely eliminated in 21%. They were ameliorated becoming weaker and occurring more seldom. Depressive moods were abolished in 24% of cases, and in 33% they were ameliorated so that an overall improvement occurred in 57%.” The study also found that forgetfulness, poor concentration, irritability, and palpitations were significantly improved. Migraine headaches also vaginal dryness and atrophy improved and the quality of the skin improved.
A study conducted in the Chinese Great Wall Hospital showed that a derivative of estriol was also beneficial for osteoporosis. (Cheng et al 1992) animal studies show that estriol can prevent breast cancer. Lemon and associates at the University of Nebraska Medical Center induced tumors of the breast in female rats. One group received estriol and while 75% of those rats who did not receive estriol developed breast cancer, only 48% developed cancer in the estriol protected group. Lemon also found that women with breast cancer have low levels of estriol relative to the other forms of estrogen. In many women estriol alone is insufficient to control all the symptoms of menopause. Therefore frequently a low dose estradiol is added. However what is most important is the concept of hormonal balance. When using hormones one must address all the hormones in the endocrine system. Frequently estrogen and progesterone deficiency is not the only issue that needs to be addressed. Frequently DHEA, thyroid hormone, testosterone, and other adrenal hormones need to be balanced.
It is not uncommon that for some women their problem is not estrogen or progesterone deficiency a low dose estradiol is added. However what is most important is the concept of hormonal balance. When using hormones one must address all the hormones in the endocrine system. Frequently estrogen and progesterone deficiency is not the only issue that needs to be addressed. Frequently DHEA, thyroid hormone, testosterone, and other adrenal hormones need to be balanced.
It is not uncommon that for some women their problem is not estrogen or progesterone deficiency at all but thyroid or adrenal hormone deficiency or an imbalance of adrenal hormones such as DHEA or testosterone. Many women have an imbalance of estrogen and progesterone as well. This is especially true during the perimenopausal time when an imbalance is likely to develop. During perimenopause progesterone declines more rapidly than estrogen resulting in a phenomenon called estrogen dominance. Estrogen dominance causes fatigue, depression, fluid retention, weight gain, fat storage, and thyroid dysfunction. Estrogen dominance is exacerbated by environmental pesticides and obesity. Estrogen dominance can continue in menopause itself. Estrogen dominance is another cause of thyroid disease which can easily be overlooked. Fatigue, weight gain, depression, poor memory, and low libido can all be due to a low functioning thyroid. Additionally one can have an imbalance between the three estrogens; estradiol, estriol, and estrange. It is best to test one’s hormone levels both in the saliva and the blood. Both have advantages and disadvantages. Evaluate the results and the chemical presentation and decide on a personalized program for each patient. If I decide to use bioidentical hormones the form I use is called Biest. This consists of 80- 85% estriol, the safer estrogen and 15- 20% estradiol. I also use progesterone in the natural form. Both are usually prescribed in the cream form as this is safer.
Why is this progressive natural approach better and safer than conventional drug therapy? 1- The natural hormones are biologically identical to the hormones made in a women’s body, as opposed to estrogen the drug which comes from a horse under stress. This hormone is chemically different that the hormones found in a women’s body. 2- The doses are titrated to each woman’s particular need as opposed to estrogen and progesterone. The drug which is typically one size fits all. 3- The natural bioidentical hormone is given in a cream form. The drug estrogen and progesterone are usually given in a pill form. The cream bypasses the liver and thus considered safer. 4- Other hormones are considered as well in a natural, holistic approach to menopause. 5- The natural bioidentical hormone uses estriol as the main hormone a far safer hormone. The drug approach uses estradiol.
Progesterone Deficiency:
Most women develop a progesterone deficiency even before they develop an estrogen deficiency. This can occur even before perimenopause but certainly the decline becomes significant as women get closer to menopause. Symptoms of progesterone deficiency include premenstrual discomfort, hot flashes, night sweats, decreased sense of well being and depression, and a decreased ability to concentrate and focus. Progesterone in general could help women feel better physically and mentally.
Progesterone may also help prevent mental decline that can occur with aging. Progesterone has been shown to increase neuronal energy production and to protect brain cells. Additionally progesterone has been shown to stimulate new bone formation. Therefore it can prevent and reverse osteoporosis. (Heersche et al 1998) Progesterone may help prevent breast cancer. A large body of evidence suggests that progesterone is protective against breast cancer. A study by Chang et al (995) showed transdermal progesterone decreased breast cell proliferation rate by over 400%. According to studies women undergoing breast cancer surgery during the luteal phase of the menstrual cycle when progesterone was highest, they have much longer survival times. (Cooper et al 1999) Angiogenesis or new blood supply formation is essential for tumor growth. Vascular endothelial growth factor (VEGF) is one of the most potent angiogenesis factors. Progesterone lowers VEGF expression and thus decreases the potential for tumor spread. Mohr et al (1996) showed that women with a progesterone level of 4ng/ml or more at the time of breast cancer. Surgery had a significantly better survival rate at 18 years than those with lower progesterone levels. 65% were surviving 18 years later compared to 35%. A study at Cowan showed that the incidence of breast cancer was 5.4 times greater in women with low progesterone compared to favorable progesterone levels. The common form of “progesterone” prescribed as a drug in the unnatural, non bioidentical form is called medroxyprogesterone and sold under the name Provera. What is the difference between medroxyprogesterone or Provera and natural progesterone? The most outstanding difference between the two is that Provera is an analog- a look alike- of progesterone, not truly progesterone at all, but rather a progestin. Even a slight difference in the molecular configuration of a compound can produce a totally different response from its natural counterpart. The unnatural progesterone Provera can actually lower a patient’s level of true progesterone. Provera can cause headaches, mood swings, and fluid retention. The natural progesterone or the other hand diminishes mood swings, improves mood, helps with migraine headaches and helps alleviate fluid retention.
The problem of loss of sexual desire is far more common in women of all ages than is appreciated. While psychosocial issues can be a cause, hormonal imbalances can play a significant and often overlooked role. Low thyroid is a very common and frequently overlooked cause. Routine tests often miss the diagnosis. A more sensitive test called the TRH stimulation test from my experience is much more likely to pick up the problem. Estrogen and progesterone deficiencies and imbalances can also play a role. Deficiency in estrogen has been showing to cause decreased libido and estrogen supplementation has been shoen to enhance sex drive. Progesterone can also improve sex drive.
Declining levels of testosterone in women throughout the reproductive years but accentuated around menopause is a common cause of low libido. It has been shown that levels of testosterone play an important role in psychological and sexual changes that occur in menopause. The use of testosterone with post menopause women successfully increases their sexual desire. Clinical studies show that although estrogen as well improves libido the confirmation of estrogen and testosterone provided greater improvement in energy, focus, mood and sexual desire and function than estrogen alone. (Bachmann 1999, Geflan 1999).
For younger women with declining testosterone and other androgens treatment with testosterone at low levels coupled with progesterone is safe and effective. Many women lose sexual desire after giving birth. This also can be due to a low thyroid frequently mistaken as post partum depression. For all women young or old evaluating all hormones and establishing balance is the key to feeling well, youthful and vibrant.
