SYMPTOMS FROM SYNTHETIC PROGESTIN
~ Headache
~ Depression
~ Weight gain and bloating
~ Moodiness
~ Lack of sexual desire
~ Potential narrowing of blood vessels, causing chest pain and lack of oxygen to the heart
ELLEN: Too Much Estrogen, Too Little Progesterone
Ellen, a potter and yoga instructor in a college town, noticed a subtle, fuzzy-minded feeling and morning dizziness during the spring of her forty-third year. One day, as she was placing a bottle of aspirin in her grocery cart, she also realized that though she’d never had headaches before, she’d gradually begun experiencing them regularly—and attributing them to tension, a weather change, or PMS. On a visit to her doctor, he drew a blood sample and tested her FSH level, which was high, convincing him she was menopausal. He told Ellen that her symptoms—the mental fuzziness, dizziness, and headaches—were consistent with menopause and that they’d improve if she took supplemental hormones. He gave her a prescription for Premarin to take daily, with some Provera for the last twelve days of every month. Within days Ellen was miserable. What previously had felt like a tension headache now was a throbbing, splitting migraine; she felt depressed; she had restless legs that were keeping her awake; and most of her other symptoms persisted.
It’s true that the symptoms Ellen experienced were consistent with the climacteric, but in light of her relative youth and the fact that she had not had these symptoms for more than a few months, it was probably early in the course of her perimenopause—which in many women is associated with low progesterone levels and a relative excess of estrogen. The blood test for FSH levels, upon which her physician based his diagnosis of menopause, is an inaccurate way to assess the big picture. It’s like looking at a single frame in a very long movie. In fact, the symptoms Ellen experienced after taking the prescribed estrogen were consistent with estrogen overdose.
Even without knowing this, Ellen did the intuitive thing: she stopped taking her estrogen. Within twenty-four hours she started feeling better, and she vowed to “tough it out” without going back to the doctor. But her original symptoms persisted, and eventually a friend referred her to another doctor, who ordered hormone tests for estrogen, progesterone, and testosterone. The results confirmed that Ellen was in an early stage of perimenopause, with her primary hormonal change being low progesterone. Now using a natural progesterone cream to gently supplement her body’s own dwindling supply, Ellen feels much better, and she understands a lot more about the transitional process. “I’m a work in progress,” she wrote. “My hormonal status is changing, and I know that what works for me now might need to be tweaked a little in six months.”
SAME DOLL, DIFFERENT DRESS
The latest wrinkle in the hormone therapy scene is prepackaged combinations. The synthetic hormones used in these preparations have been around for years; what is different is the packaging and the ways in which they are prescribed. The most commonly used, Prempro, a combination of Premarin and Provera, is the drug that was used in the WHI study. Others include Ortho-Prefest (a combination of bioidentical estradiol and the synthetic progestin norgestimate) and FemHRT (synthetic estradiol plus synthetic norethindrone). The advantage of these combinations is that they are convenient and women allegedly don’t have any monthly bleeding on them. The problem is that many get spotting and intermittent bleeding for months before their bodies get used to the drug combos, causing many to stop taking them. The biggest drawback is that all of them contain synthetic progestin, which enhances a woman’s chance of developing PMSlike side effects and also may increase her risk for heart disease and breast cancer. (To be fair, the 2006 reanalysis for the WHI and Nurses’ Health studies data did, in fact, show a decreased risk of heart disease in younger women—even in those on Prempro, which contains a synthetic progestin. But why take any risk when other forms of progesterone are available?)
Testosterone
Testosterone is produced in both the ovaries and adrenal glands. Its primary job is to provide vital assertive energy and sexual drive. Testosterone and other androgens can increase the ease with which a woman becomes sexually aroused, as well as the frequency with which she follows through by initiating sexual activity. Testosterone also increases sensitivity of the erogenous zones, frequency of orgasm, intensity of sexual fantasies, and incidence of orgasmic dreams.
Not all women’s testosterone levels drop perimenopausally—in fact, androgen levels actually increase in some. But if a woman is suffering from adrenal depletion due to chronic stress (see chapter 4), a precipitous drop in testosterone may occur, with symptoms of declining libido and overall energy depletion. Surgical removal of the ovaries, uterus, or both, as well as chemotherapy, radiation, or autoimmune disease, can also contribute to a drop in testosterone levels severe enough to cause symptoms.
For reasons that have yet to be clarified, some women experience a gradual decline in testosterone from early adulthood to old age, while other women continue to produce plenty of testosterone throughout life. The adrenals surely play a role, but whether there are other factors remains to be seen. Before you decide to try testosterone supplementation, it is essential to have laboratory confirmation of a deficiency via saliva or blood testing for free (unbound) testosterone. As with other menopause-related symptoms, there is considerable overlap among the three hormones. In many women, for example, a decline in libido is due to an estrogen deficiency, while testosterone may be normal. There is no benefit from taking supplemental testosterone if there is no deficiency to begin with. And many women with low testosterone levels have a normal sex drive! (See chapter 9.)
This bears emphasis because testosterone supplementation is now being requested by many women who think it will jump-start a flagging sex life. If there is a deficiency, the benefits may include heightened sex drive and sexual function, higher levels of energy overall, better muscle tone, and improved mood and outlook. There also is evidence that restoring normal testosterone levels can help improve bone mineral density. Incorporated into a vaginal cream, testosterone can help restore normal vaginal wall thickness and lubrication. However, if there is no deficiency, supplementation will likely lead to overdose, which can produce symptoms most women find objectionable.
Bioidentical testosterone, or DHEA (dehydroepiandrosterone), an adrenal precursor for testosterone, is available from formulary pharmacies and can be used as a skin or vaginal cream by those women who require it. (Although DHEA is available over the counter, the quality varies considerably. I recommend pharmaceutical-grade DHEA, which is available from formulary pharmacies and Emerson Ecologics [visit www.emersonecologics.com]. I recommend 5 mg sublingual DHEA manufactured by Douglas Laboratories; the suggested dose is one-half to one tablet daily, or as directed.) Testosterone is also available in a patch.
SYMPTOMS OF TESTOSTERONE DEFICIENCY
~ Decreased libido
~ Impaired sexual function
~ Decreased energy overall
~ Decreased sense of well-being
~ Thinning pubic hair
SYMPTOMS OF TESTOSTERONE OVERDOSE
~ Mood disturbances
~ Acne, particularly on the face and scalp
~ Increased facial hair growth
~ Deepened voice
HOW TO DECIDE WHETHER OR NOT
TO TAKE HORMONES
Whether you should or should not take supplemental hormones at menopause depends on a number of factors, including your overall physical health, emotional and spiritual well-being, nutritional status, lifestyle, and so forth. All these factors can influence how well your secondary hormone production sites are able to keep up with your body’s new needs. For some women, just learning that the symptoms of perimenopause are temporary is enough reassurance; they become willing to experience those symptoms without masking them with medicine. And once we relax and allow our fears and resistance to fade, the symptoms themselves may lessen. This is the “placebo effect”
in action, and it is a significant factor in menopausal treatments as well. Knowing that we can ask for and receive help creates its own healing energy.
Taking Stock Before Making the Decision
Before deciding on hormone therapy, it is important to take an honest look at yourself and at your medical history—including that of your family members—so you can draw an accurate picture of your own goals and needs. Some women need hormones to feel their best. Others don’t do well on them at all. Some women make enough hormones naturally in their own bodies to get through menopause without outside help. Others cannot make the biological conversions necessary to maintain the right hormonal balance. Still others have had their ovaries removed and need additional hormonal support, at least until they’ve reached the age when menopause would usually occur.
Despite the recent good news about HT and heart disease, I firmly believe that it is progesterone, not estrogen, that holds the biggest promise for preventing heart disease (or at the very least treating angina). I prefer a cautious, eyes-wide-open approach to long-term estrogen use to prevent chronic disease. Few would disagree, however, that hormone therapy can be very helpful for many women during the perimenopausal transition, when symptoms are at their worst. But for some women, the benefits of long-term hormone therapy may outweigh the risks—for example, when there is a strong family history of osteoporosis, or when a woman clearly feels much better on hormones than off them.
Given the nature of science, medicine, and the pharmaceutical industry, you can expect that the conventional wisdom on HT will continue to change. So stay tuned. If you have bothersome perimenopausal symptoms that aren’t relieved by other methods, give hormone therapy a try, stay with it for a year or so, and then taper your dose. See how you feel. If you feel fine, then taper some more until you’ve weaned yourself off it. If, on the other hand, you clearly feel your best on hormone therapy, then stay with it and revisit your decision yearly.
The first step you need to take in making the HT decision is to identify your risk factors and decide how much weight you intend to give them.
When I say “how much weight you intend to give them,” I mean that only you have the power to decide how much influence your cultural and family script will have on your reality. Perimenopausal discomfort is a reality for most American women, while women in some other cultures have a different experience. Studies show that while 70 to 85 percent of North American women are affected by hot flashes, only 18 percent of Chinese factory workers in Hong Kong experience them.29 I can assure you that the basic biology of the ovaries in China is not different than in North America. This speaks to the strength of expectations and how an entire culture can come to dictate what each individual will experience. Notwithstanding, each of us has the power to acknowledge this influence and then change our response to it.
Statistics predict what will happen to groups in general, not to specific individuals. Studies have shown that a woman’s faith in (or rejection of) her cultural and genetic/familial script can play a significant role in how her reality plays out. People who are known in their families as “black sheep” are the least likely to fall victim to diseases that run in the family, perhaps because it is their own personal attitude and style to reject rules and color outside the lines. Since most health care providers are trained to look at statistics when making decisions and predictions about our health, it is crucial that each of us emphasize our innate ability to become “black sheep” when and if this stance can improve our health and outlook.
Although scientific studies may change how we think about something intellectually, our behavior and what we actually do with scientific information is shaped far more by our day-to-day relationships with friends and family than by any other factor. If, for example, you’ve watched your mother, sister, or best friend come alive again after going on some form of hormone therapy, you’re apt to feel very positive about the benefits of this approach. If, on the other hand, you’ve watched a family member suffer from headaches, sore breasts, and weight gain from taking too high a dose of estrogen, you’re not going to be very eager to try it yourself. And if you are surrounded by aunts, grandmothers, or other older female role models who are vibrantly healthy, live well into their nineties in good health, and have never taken HT of any kind, your inner blueprint for what is apt to happen after you go through menopause without medication will be quite positive.
My own personal legacy includes cardiovascular disease. My mother lost both her parents to heart disease, and my beloved father collapsed and died on the tennis court at age sixty-eight, a victim of a ruptured cerebral aneurysm, when my mother was only fifty-two and perimenopausal. She finished the climacteric as a widow, during an era when women were expected to fade physically and socially after menopause. Though my mother tends to avoid conventional wisdom in general and visits to the doctor in particular, her sister and her friends were told again and again that without supplemental Premarin they would become little old ladies with fragile skeletons and weak hearts. But my mother greeted that prediction with a dismissive wave of her hand. Now eighty-four, she still climbs mountains wearing a heavy backpack and can ski rings around me on the slopes. She has an active social calendar, her mind is sharp, and no form of estrogen medication has ever entered her vibrant body. (She does use a natural progesterone skin cream, because it helps the “creakiness” in some of her joints.)
Which of my family’s medical legacies will I inherit? I firmly believe that through the physical and emotional choices I make—and the expectations and beliefs with which I live my life—I shape my own future. My daughters and future grandchildren will do the same. Would I like to have the same level of health when I’m eighty-four that my mother now enjoys? Of course I would, but I believe it will happen because I have chosen it, not because I have inherited it.
What Are Your Goals?
Too many women see the HT decision as an either/or, yes/no decision. I’d like to reframe it as a process. As a first step, it is important to define the goals you hope to achieve with hormone therapy. Contrary to the message conveyed by pharmaceutical marketing efforts, HT will not give you a means of moving backward, of denying the aging process and keeping yourself young forever. In fact, to do so would be counterproductive to your physical, emotional, and spiritual health. If you are determined to deny that you have passed middle age, HT cannot put you at peace with that fact. However, a personally tailored program—with or without supplemental hormones—can help reduce physical symptoms and health worries so that you can focus your energies on finding your creative passions, which in and of themselves can stoke the flames of your life force. Hormone therapy can help mask the heart palpitations and irritability often associated with perimenopause. And it can also promote healthy sleep (especially when natural progesterone is used). But hormones cannot resolve the underlying relationship problems (and ensuing high levels of stress hormones) that may be crying out for your attention.
Every day more and more studies are showing how effective modalities such as dietary change (in particular, a low-sugar diet), food supplements, exercise, and herbs can be in supporting a woman through her menopausal transition. Though some doctors still don’t know about these approaches and may not mention them to you, they often work as well or better than hormone therapy. They can also be used in addition to hormone therapy, to reduce dosage levels, side effects, and potential risk. In other words, you don’t necessarily have to choose between HT and alternatives. Think of your perimenopausal support as a smorgasbord. You get to choose what appeals to you at the moment and leave what doesn’t.
Becoming an Active Partner in the Decision
For our mothers and grandmothers, the decision to take HT (or not) was very often a passive one, made by their doctors (or husband or best friend), with their own involvement limited to “being good patients.” Or they decided by not deciding and simply let time go by. In those days there were very few HT preparations available, so the choices were only
two: yes or no. And until very recently, the potential benefits were too often clouded by side effects from the wrong type of medications or fear of long-term consequences. As of the late 1990s, less than 20 percent of American women used hormone therapy, and those who did often discontinued it within six months.30
Today, many women (and their doctors) are more confused than ever about hormone therapy. Part of this confusion arose because early reports on the Women’s Health Initiative study seemed to indict all hormone therapy. In fact, the women in the original 2002 WHI study were on the same dose of only one type of HT—namely, Prempro. And the 2006 analysis of the WHI data showing a decreased risk of heart disease in women who started taking it early is a silver lining in a dark cloud. But there are still a lot of unanswered questions, plus the irrefutable increased risk of breast cancer with Prempro. One thing is clear: we need far more research on the role of hormones, particularly bioidentical hormones in low dosages.
At the same time, we also need to remember that medicine will always be an art, not an exact science. In the early 1990s, science seemed to indicate that the majority of postmenopausal women would benefit from hormone therapy. Some were even dismissed from their doctor’s office if they questioned that belief. Then the pendulum swung all the way in the opposite direction. Now it’s coming back to center. In addition to the question “Do I want or need hormone therapy, at least for right now?” we also have to ask: “What kind? What strength? What route of administration? In what combination? For what reason? For how long? At what risk?”
The Wisdom of Menopause Page 22
