The number of options can be intimidating at first, but in the end you’ll feel much better about your HT decision if you’re armed with facts, know your options, and are willing to listen to your inner guidance as well as to your doctor’s advice. And although I discourage using HT as a means of numbing oneself to what is happening in body and mind during perimenopause, there is nothing to be gained from suffering. Given the range of formulations and dosages now available—as well as the many alternatives to HT—you can create an individual treatment program that supports you through the change, rather than helping you deny that it is happening.
EVIE: Brittle Diabetes, Brittle Hormones
Evie is an energetic, upbeat insurance saleswoman who steadfastly refuses to allow her diabetes—which she’s had since the age of thirteen—to dominate her life. She checks her blood glucose levels regularly and gives herself two injections of insulin each day, but she’s considered a “brittle” diabetic and still suffers at least one diabetic crisis each year.
Evie takes these episodes in stride, sometimes exasperating her friends and loved ones who wish she’d take her condition “more seriously,” but she admits that she gets “prickly” when they dote on her. She has also begun to make the connection between the state of her diabetes and the state of her emotions. When she is upset with one of her children, her boss, or her husband, her insulin and dietary needs can change dramatically and quickly. It also came as no surprise to Evie’s physician that because of her metabolic problems, her blood sugar levels went wild as she bumped and jolted through her menopausal transition. She wrote, “There’s an amusement park nearby, with a really scary roller coaster. Let’s just say I’ve got ’em beat. Estrogen, glucose, FSH—everything was bouncing all over the place.”
Jerilynn Prior, M.D., a hormone researcher and professor of endocrinology and metabolism at the University of British Columbia and founder and scientific director of the Centre for Menstrual Cycle and Ovulation Research, calls this phase “estrogen’s storm season” and has written a very helpful book with the same title (Centre for Menstrual Cycle and Ovulation Research, 2005). (For more information, see CeMCOR’s website at www.cemcor.ubc.ca.)
Because Evie’s levels were so erratic and sensitive, it was tough getting her regulated, but with trial and error Evie and her physician managed to arrive at a hormone therapy program that gently alleviated her discomfort, stabilized her metabolism (and therefore her glucose levels), and supported her body through the transition. “It was a pretty tough trip for a while there, but I noticed a difference within weeks of getting the right levels of hormones.”
Clarifying Your Needs
In order to make the best choice for you, you need to clarify your needs, then become an active partner in getting them met. This may mean consulting more than one health care provider—an herbalist or acupuncturist in addition to your OB-GYN, for instance. It may also mean asking your physician to try an approach he or she is unfamiliar with—and sharing the responsibility for the results.
To begin, review the following eight health factors and determine which, if any, apply to you. This will help you focus your thinking about which replacement regimen to use, if any, and for how long.
FACTOR 1: YOU WANT RELIEF FROM DISCOMFORT, PARTICULARLY HOT FLASHES THAT DISRUPT SLEEP. This is the most common reason why women choose hormone therapy, especially estrogen. However, discomfort is also the most common reason for women to stop taking HT—the formulation and/or the dosage prescribed may not be right for their particular metabolism, resulting in persistent medication side effects and/or symptoms of overdose.
If relief from symptoms is your sole reason for seeking treatment, treatment will probably be needed only until the perimenopausal transition is complete, which can be confirmed either by a lack of menstrual periods for at least a year or by the laboratory tests outlined in chapter 4. There might be a brief perimenopause-like adjustment when coming off hormone treatment, but if you are weaned off the hormones over a period of several months, the symptoms generally are mild. Many women come off hormone therapy once they’ve become well established on regimens that include herbs, soy, exercise, or dietary supplements. This approach often smoothes the adjustment. If you want symptomatic relief but your personal preference is to stay away from supplemental hormones, there are many nonhormonal treatments available over the counter or from health care practitioners such as naturopaths and acupuncturists. (See chapter 6.)
FACTOR 2: YOU ARE SUFFERING FROM UROGENITAL SYMPTOMS. The health of the vaginal lining and urethral tissues is highly influenced by the hormonal milieu in our bodies. Women may seek relief from stress incontinence (they leak urine when coughing, sneezing, laughing, or lifting heavy objects), urge incontinence (they have difficulty making it to the bathroom without leaking), recurrent vaginal yeast infections, vaginal dryness and/or discomfort during intercourse, recurrent bladder infections, or urinary frequency (they need to urinate more than eight times during the day, or one or more times during the night).
Taking estrogen (by mouth or applied locally) and/or androgen hormones (by mouth or applied as a skin patch or as a cream formulated for vaginal application) helps maintain healthy vaginal and urethral tissue, even when relatively small doses are used. As little as 1 to 2 mg of natural testosterone in a cream base, applied to the vagina two to three times per week, for example, is often all that is necessary. And sometimes the phytoestrogens found in herbs, soy, or flaxseed can restore vaginal tissue to its premenopausal moistness and resilience. (See chapter 6.)
Some studies from the late 1990s found that systemic oral conventional hormone therapy actually increases the risk of urinary incontinence for reasons that aren’t at all clear. What is clear is that urinary problems often clear up on their own with no treatment at all.
FACTOR 3: YOU CURRENTLY HAVE A HEALTHY HEART BUT ARE AT INCREASED RISK FOR CARDIOVASCULAR DISEASE. A woman’s increased risk of heart disease is usually related to (1) a positive family history (heart disease or stroke in father younger than age fifty-five, or in mother or other first-degree female relative at age sixty-five or younger) and all the emotions that go with it, (2) lifestyle factors, such as a high-sugar diet, smoking, or lack of exercise, or (3) a predisposing factor such as low HDL cholesterol, high LDL cholesterol, or high triglycerides. Menopause is also a time when progesterone levels fall significantly, triggering the narrowing of coronary arteries in susceptible women. Preliminary research strongly suggests that low progesterone levels are far more likely to be associated with heart disease than estrogen deficiency is. Progesterone is, unfortunately, still largely underrated and misunderstood.31
Nevertheless, beginning in the late 1980s, doctors prescribed hormone therapy liberally to women to prevent heart disease because a large number of epidemiologic studies had shown a clear benefit. Estrogen decreases LDL (the bad cholesterol) and increases HDL (the good cholesterol).32 It also has a positive effect on blood vessel walls that seems to involve nitric oxide, a chemical produced in the body that helps keep blood vessels dilated. (Viagra and other drugs for male impotence also exert their effect through nitric oxide pathways.)
But then in 2002 the Women’s Health Initiative study branch that was testing Prempro against placebo in thousands of women was abruptly halted because the drug caused an increase in strokes and heart attacks, and the medical profession quickly backed away from its original position on HT and heart disease. The WHI was the first long-term placebo-controlled trial of hormone therapy, and it clearly showed that the cardiovascular risks of Prempro outweigh the benefits. While the 2006 reanalysis of the data from both the WHI and Nurses’ Health studies showed that when women begin hormone therapy within ten years of menopause, they decrease their risk of heart disease by at least 11 percent and as much as 30 percent, a 2010 reanalysis showed that the risk didn’t drop until the women had taken HT for six years (longer than most usually take hormones) and that hormones actually increased this risk after only two years. As it
turns out, most of the women in the original WHI study didn’t start Prempro until they were in their sixties and well past the age of menopause.33 No one knows exactly what to make of these data—but clearly estrogen can be heart healthy in some women.
The problem here is that Prempro isn’t synonymous with all HT. It contains synthetic progestin, which is known to partially obliterate the beneficial effects of estrogen alone on blood vessels. In addition, all hormones in the WHI study were given orally. This increases the risk of blood clots because oral hormones must be processed in the liver, and increased clotting factors are the result—especially in older women. There are still solid data to suggest that low-dose, bioidentical estrogen, without synthetic progestin, given transdermally and at physiologic levels, could be beneficial for the cardiovascular systems of some women. Unfortunately, most of the conventionally available combination hormone therapies contain synthetic progestins, including Prempro, Combi-Patch, FemHRT, and Activella.
I feel strongly that estrogen would show a far greater potential benefit if women used individualized regimens consisting of bioidentical hormones. Because of their deleterious effect on blood vessels, I believe that synthetic progestins (especially Provera or Amen) are more dangerous than taking no hormones at all. Tried-and-true methods to decrease heart disease risk also include avoiding smoking, regular vigorous exercise, taking supplements such as vitamin E, following a diet rich in fruits and vegetables, consuming soy foods, and keeping weight normal. (See chapter 14 for my heart health program.)
FACTOR 4: YOU HAVE ALREADY BEEN DIAGNOSED WITH HEART DISEASE. It is now clear that hormone therapy, at least in the form of Prempro (Premarin and Provera), increases the risk of stroke and heart attack in older women—the ones most likely to have fullblown heart disease.
Many scientists feel that this is due to a hormone-stimulated increase in chemicals called inflammation factors, such as C-reactive protein, which was found in the bloodstream in amounts that were 85 percent higher in women taking hormone therapy. However, this is once again a case where you need to read the fine print. As I’ve said, I believe that the increased risk from conventional HT boils down mainly to the adverse effects of medroxyprogesterone acetate (trade names Provera and Amen). It is also true that estrogens at high enough doses have long been associated with increased risk of blood clots that predispose to heart attack, especially in smokers.
Here’s the bottom line: women with or without heart disease should avoid synthetic progestins and keep their estrogen doses as natural and as low as possible, and no one should take estrogen as a way to treat already-diagnosed heart disease. I would, however, consider transdermal natural progesterone.
FACTOR 5: YOU ARE AT INCREASED RISK FOR OSTEOPOROSIS OR ALREADY HAVE BEEN DIAGNOSED WITH BONE LOSS. A woman whose mother or grandmother has osteoporosis is at increased risk for this potentially disabling condition, though it is unknown whether this is because of a genetic inheritance or because we tend to “inherit” habits, lifestyle choices, and life expectations, which may predispose us to less-than-optimal bone strength. (See chapter 12 for additional risk factors, many of which are under our control.) Estrogen replacement definitely helps prevent bone loss associated with menopause, and continuous use of estrogen decreases the risk of fracture by 50 percent or more. The bone-preserving effects of estrogen are maintained only as long as a woman stays on it.
Androgens such as testosterone also play a role in preserving bone health. Those women with naturally high testosterone levels have a decreased risk for osteoporotic fractures. Low-dose testosterone supplementation has been found to help maintain bone mass.
A number of drugs—calcitonin, the bisphosphonates such as alendronate (trade name Fosamax), and SERMs such as tamoxifen (Nolvadex) and raloxifene (Evista)—have also been shown to help prevent loss of bone and decrease fracture risk. As with hormone therapy, they are effective only as long as a woman is on them.
High doses of soy protein, regular weight-bearing exercise, and vitamin D are also very effective ways of maintaining bone density and decreasing fracture risk, both at perimenopause and beyond.
FACTOR 6: YOU ARE AT INCREASED RISK FOR ALZHEIMER’S DISEASE. At this point in our limited understanding of this organic brain disorder, a positive family history is the strongest predisposing factor, although most individuals who get it don’t have any genetic predisposition. There is less consensus regarding some studies’ suggestion that high levels of aluminum intake (from using aluminum cookware or consuming food from aluminum cans) might also contribute to an individual’s risk of developing Alzheimer’s disease.
It is clear that all hormones can affect brain function—androgens and progesterone as well as estrogen—and that many women continue making enough of these throughout life to protect their brains. In fact, a 2000 British study of postmenopausal women not on hormone therapy found that those with the highest levels of endogenous estradiol were the least likely to have Alzheimer’s disease.34 But research has failed to prove that estrogen decreases the risk of dementia. Some studies even suggest that estrogen, plus or minus progestin, may actually increase a woman’s risk. There are many additional things a woman can do now to protect her mental functions in later life. (See chapter 10, “Nurturing Your Brain.”)
FACTOR 7: YOU ARE AT INCREASED RISK FOR BREAST, UTERINE, OVARIAN, OR BOWEL CANCER. A positive personal or family history for one or more of these hormone-related cancers makes the hormone therapy decision particularly anxiety-provoking for many women. Here are the facts: Recent research has suggested that the dose and formulation of hormone therapy are important factors in the cancer issue. All types of estrogen at high enough doses over a long enough period of time can potentially stimulate breast, uterine, and ovarian cancers because estrogen is a growth factor in these tissues. This includes the estrogens produced in your own body. Premarin, because of its association with DNA damage and because it has a stronger biological effect than bioidentical estrogens, may be more carcinogenic than bioidentical estrogens, especially when they are used in low doses. In other words, the increased risk of breast and uterine cancer shown by past studies may have been related to estrogen overdose or the wrong kind of estrogen, rather than estrogen per se. The addition of synthetic progestin further complicates matters. The 2002 Women’s Health Initiative study clearly demonstrated that women taking the combination drug Prempro for five or more years had a higher risk for breast cancer than those on placebo. Not all studies show an increased risk for breast cancer with HT. In fact, the most recent studies show that bioidentical hormones (including progesterone) have significantly less associated risk of breast cancer. And the estrogen-only branch of the WHI showed no increased risk. But these women had all had hysterectomies and were probably at a lower risk to begin with.
If estrogen is taken in a manner that more closely mimics the way it is produced in the body—in physiological doses calibrated to the body’s needs, in bioidentical formulation, and partnered with bioidentical, not synthetic, progesterone—it begins to lose its sinister profile. (See chapter 13.)
For the woman who is in the highest-risk category for breast, uterine, or ovarian cancer but who desires support through the symptomatic phase of perimenopause, there are two options that are unlikely to adversely affect that risk. First, she can take bioidentical hormones at the lowest possible levels during the five years or fewer when her symptoms are the most troubling. This may involve finetuning her doses with the aid of salivary or blood free hormone testing, so she takes no more than the amounts necessary to achieve physiological balance and symptomatic relief. Second, she can opt for nonhormonal, herbal treatments. (See chapter 6.)
With regard to colorectal cancer, the picture is clearer. Colorectal cancer accounts for 11.2 percent of all cancers among American women—third after breast and lung. In both prevalence and mortality it outranks endometrial, ovarian, and cervical cancers. A summary of ten studies with information on the timing of estrogen use indicates a 34 perce
nt reduced risk of colorectal cancer in current users. The 2002 WHI study confirmed this data. This protection is nearly lost within a few years of stopping hormone therapy. Though no one knows why for sure, it appears that estrogen causes a decrease in bile acids, substances manufactured in the liver that are associated with the promotion of colorectal cancer.35
FACTOR 8: YOU REACHED MENOPAUSE PREMATURELY (PRIOR TO AGE FORTY) OR ARTIFICIALLY AND ABRUPTLY (DUE TO SURGERY, ILLNESS, CHEMOTHERAPY, OR RADIATION). Women with this history are more likely to need systemic hormone therapy, a program that provides physiologically appropriate hormone levels throughout the body, rather than more locally acting products, and rather than relying solely on herbal treatments and dietary approaches. This is because the physical and mental symptoms associated with a premature or abrupt cessation of natural hormone production are usually more severe than with a gradual perimenopausal decline. With premature menopause, the woman’s body is left without endogenous hormone support for more years than if menopause had occurred later in life. I recommend using a combination of bioidentical hormones, with the dosage based on your symptoms and hormone levels.
SANDY: Surgical Menopause
Sandy had an “instant” menopause at age thirty-five, when her ovaries were removed because of severe endometriosis. This created the abrupt hormonal withdrawal characteristic of artificial menopause. Her symptoms were quite pronounced. Until her surgery, Sandy had believed that she would not take hormone therapy when she reached her natural menopause. Now, to say the least, her discomfort was intrusive. And the fact that she would be without her normal complement of hormones for approximately fifteen extra years meant that her bone density, heart health, and mental functioning might suffer in the future. As a result, Sandy felt she had no choice but to start HT. “Frankly,” she wrote, “I was so miserable I couldn’t give my full attention to the decision beyond that point.” She and her doctor decided on a skin patch that delivered bioidentical estrogen (17-beta estradiol), along with natural progesterone oral capsules. With minimal tweaking, they arrived at the optimal dose for her, and her level of comfort vastly improved.
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