“At that point,” Sandy wrote, “I could start applying myself to decisions that would affect my future. I really had not wanted to take HT after menopause, but I didn’t want to increase my chance of osteoporosis, so it felt right to take HT under the circumstances. Then it hit me: I can have the best of both worlds! I decided I’ll take these hormones until I’m fifty-five, when I’d probably have completed my menopausal transition naturally, and then I’ll wean myself off the hormones and sail through my menopausal years au naturel. I feel much happier about this plan. I feel like the idea was a thank-you gift from my body for bending the ‘rules’ and providing it with hormones during these extra fifteen years of menopause.”
When to Start HT
Over the years I’ve watched scores of women left to “tough it out” during their stormy perimenopausal years because their doctors didn’t want to prescribe hormones until they were definitely past menopause. There’s no need for this. You should feel free to start what you need when you need it—and that includes hormones, herbs, foods, lifestyle changes, or a combination of all these. Because menopause is really a retrospective diagnosis, you won’t know you’re there until you’re there! And symptoms are generally at their peak during perimenopause, not later.
For the woman who wants help with perimenopausal symptoms and finds that a nonhormonal approach does not provide sufficient relief but who is afraid that supplemental estrogen might increase her risk for breast or uterine cancer, HT is not necessarily out of the question. (See chapters 8 and 13.) As I’ve said above, I’m not convinced that there is any significant risk from taking bioidentical estrogen at a low dose only during the five years or fewer that menopausal symptoms are likely to be the most intrusive. After that, she can wean herself off some or all of the hormones or replace them with other alternatives. And if you feel your best on hormones, any increased risk might well be worth the benefits!
PRINCIPLES OF HT
~ Establish your natural hormonal levels by getting a baseline test in your late thirties or early perimenopause.
~ Replace only those hormones that need replacing.
~ Use the lowest dose that does the job. Reevaluate your HT decision yearly and plan to use alternatives when possible.
~ Use bioidentical hormones that are an exact molecular match to those naturally occurring in your body.
~ Support your HT regimen with a healthy diet, the right nutritional supplements, and exercise.
~ Be realistic. The goal is not to turn back the clock. Rather, the goal is to optimize your comfort and overall health so you can live the second half of your life with maximal vitality and mental clarity.
WITH HORMONE THERAPY, TIMING MAY BE EVERYTHING
One of the hot topics at the moment for hormone researchers has to do with figuring out why hormone therapy might be beneficial for a woman who begins taking it early on (before about age sixty) but harmful to the same woman if she starts it later. Why those differences exist is part of what researchers are calling the “timing hypothesis,” which involves both heart health and brain health, as well as relative risk for various cancers, osteoporosis, and mood disorders. This concept was even the focus of a January 2010 symposium called “Window of Opportunity of Estrogen Therapy for Neuroprotection,” presented by the Stanford Center for Neuroscience in Women’s Health and the Stanford Center for Longevity.
Here, in a nutshell, is why cutting-edge scientists now suspect age matters with HT. When estrogen is added to a healthy brain, its molecules act like tiny keys fitting into all sorts of locks that open the doors to a host of positive effects. It increases levels of HDL (the “good” cholesterol), protecting the heart. It regulates levels of the feel-good hormones serotonin and dopamine. And it assists brain cell growth and plasticity (the ability to adapt to various stimuli), which both strengthens and repairs brain tissue, protecting it from diseases such as Alzheimer’s.
But when estrogen is added either to a brain that has already begun the natural aging process or to a brain in the early stages of Alzheimer’s, some or all of the locks no longer open. Estrogen, then, either has no effect or, worse, it actually harms brain cells and hastens their death. So the timing hypothesis suggests that the degree to which HT helps or harms a woman depends on how healthy her brain is at the time she starts taking it.
Making that determination, however, isn’t easy. So at the moment, women facing the HT decision are still left trying to balance unknowable factors (what they do know about what they may be at risk for in the future versus what they don’t know about what is already happening inside their bodies). Stay tuned for more developments—and, hopefully, more answers—in this pioneering area of research.
RENÉE: Losing Control, Finding Compassion
Though many of us have fixed ideas about how we will negotiate menopause and what we will and won’t do, we need to be willing to let go of all our preconceptions once we actually begin going through the experience. Renée’s story is a beautiful example of this.
I’d decided a long time ago that I wasn’t going to color my hair when it went gray and I wasn’t going to take supplemental hormones when I hit menopause. Menopause for me was going to be a beautiful thing. I had it all figured out.
Then on my forty-seventh birthday my father died, without warning, of a massive heart attack. My mother, confused and scared and in need of support, moved in with us. Then my husband, David, lost his funding and suddenly was faced with the prospect of being unemployed by the end of the year. And I was practically blindsided one week later with my first hot flash, which was so powerful it actually steamed up my glasses. Emotionally, financially, hormonally, and in terms of my overall sense of security, it felt like the proverbial rug was being pulled out from under my feet. My hot flashes became increasingly bothersome, particularly when they happened in the middle of the night and interrupted my sleep. I was feeling short-tempered with my mom and with David, and the house felt claustrophobic—I guess I just couldn’t handle all the unexpected stresses that came up at what felt like the worst possible time in my biology. When my gynecologist suggested that I needed a little hormonal support, I sighed with relief and accepted it, and I feel much better now. In fact, just making the decision to accept help made a big difference in the way I felt right away.
The lesson I learned from all this applies to more than just menopause: you can’t control everything. I’ve always been a big control freak, but now I understand that in some ways we’re all just along for the ride, and we need to be compassionate with ourselves and willing to change direction once in a while, in order to adjust to and accommodate what life throws our way, no matter what stage of life we’re in at the time.
A DUSTING OF HORMONES
Okay, let’s say that you’ve decided that you may want to try hormone therapy. You are still having periods, but you’re getting hot flashes before they start. You also have occasional night sweats. I’d recommend that at this point you get your hormone levels tested. The ideal time is about a week before your period is due, because you’ll be able to see what your peak progesterone level is at that time, and it will also give you an idea of how much estrogen and testosterone is normally circulating in your system. These measurements will also give you a baseline to work toward once you start hormones.
The next thing you do, depending upon your hormone levels, is to start supplementing the hormone that is lowest. In most cases, this will be progesterone, and maybe estrogen. Increasingly we’re finding that many perimenopausal women also have an androgen deficiency. As already mentioned, natural progesterone in the form of a 2 percent skin cream has been shown to give good blood levels and is available over the counter. This alone may be all you need. Try it for two weeks before your period, then take two weeks off after your period starts. You can also use it for three weeks on and one week off. Most women notice a reduction of their symptoms within a month of starting this cream. Continue with this as long as you’re getting good results.
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sp; If your estrogen level is too low or you’re having lots of hot flashes, you’ll want to start with the lowest level of estrogen available. Estrogen is available by prescription only, so you’ll need to work with a health care practitioner to get the right dose and blood levels for you. Many women like the convenience of the estrogen patch, which comes in many different strengths and can be left on the skin for several days. Others prefer to take a pill.
A relatively new natural estrogen gel called Divigel offers a convenient alternative and comes in three dosage strengths—including the lowest approved dose of estradiol available, 0.25 mg—so you can take only as much as you need. Studies show the lowest dose significantly reduced the number of hot flashes after five weeks, and the highest dose significantly reduced symptoms after two weeks; further improvements were reported over eight to twelve weeks of treatment.36 This clear, quick-drying gel is invisible and odorless when dry, and it leaves no sticky residue. In fact, it’s similar in look and feel to hand sanitizer. (For more information, call 800-654-2299 or visit www.divigelus.com.)
If you’re taking estrogen, you have to be sure that you have enough progesterone to prevent excessive buildup of your uterine lining. This can be accomplished in some women with 2 percent progesterone skin cream. Others may need a higher amount of progesterone, available only by prescription. I recommend Crinone vaginal gel, Prometrium capsules orally, one of the formulations I mentioned earlier, or another one from a formulary pharmacy.
The good news is this: many health care providers are now familiar with bioidentical natural hormones and work closely with pharmacists who specialize in compounding individualized prescriptions to fit a woman’s unique needs. Look for a pharmacy that is accredited by the Pharmacy Compounding Accreditation Board; see www.pcab.org. At the very least, be sure that the pharmacy you use sends samples of its products to an outside testing lab to check their strength and purity. Some health plans cover prescriptions for formulary pharmacies and others don’t. If your plan doesn’t, I’d recommend that you advocate coverage if your plan covers conventional hormone therapy. Your doctor may be able to assist you.
It’s always best to call ahead and make sure that your doctor is open to discussing an individualized natural hormone approach before spending the time and money on an appointment. If your doctor doesn’t know about this approach, either educate him or her or find someone who already knows about it. Many nurse practitioners are familiar with individualized hormone therapy and will work with you to find the right solution.
CLEARING UP THE CONFUSION ABOUT
COMPOUNDING PHARMACIES
Compounding (or formulary) pharmacies specialize in creating hormone prescriptions that are tailored to a patient’s individual needs. These formulas are prescribed for patients by their physicians and compounded by state-licensed pharmacists using FDA-approved bioidentical hormones—the same hormones that drug companies use—procured by suppliers that are registered and inspected by the FDA. (Foreign suppliers also must be FDA-registered.) It is not true, as the American College of Obstetricians and Gynecologists and the North American Menopause Society would have people believe, that compounding pharmacies are not regulated. All pharmacies, including compounding pharmacies, are required to meet standards set by their respective state pharmacy boards (there is no such thing as an “FDA-approved pharmacy”). In addition, the Pharmacy Compounding Accreditation Board (PCAB) has developed national standards to accredit pharmacies that perform a significant amount of compounding (see www.pcab.org for more information).
HOW LONG SHOULD YOU STAY ON HORMONES?
The length of time you continue to take hormones depends entirely on why you are taking hormones and what other things you are doing to achieve the same benefit. For example, if you originally started estrogen to maintain bone health but have since incorporated regular weight training into your lifestyle, you can probably taper off the estrogen and still maintain your bone density. If on the other hand, you are a confirmed couch potato, have been on steroids, or smoke and you know you are at risk for osteoporosis, then you’ll want to do everything you can to maintain your bone density. Follow a low-acid diet and make sure your vitamin D levels are optimal. (I am very concerned about the long-term effects of bisphosphonate drugs, such as Fosamax. See chapter 12 for a discussion of this.)
With bioidentical hormones at low levels, the benefits of HT may far outweigh any risks—especially if you feel good on them, have risk factors that HT is known to ameliorate, or have a health history that doesn’t include a lot of healthy ninety-year-old relatives! The vast majority of women start taking hormones, herbs, or both for immediate relief of menopausal symptoms such as hot flashes or vaginal dryness and will need them for only a few years. Others are far more concerned about osteoporosis or sexual function. Taking hormones for short-term symptom relief is very different from taking hormones for long-term disease prevention. The majority of women experience most of their menopausal symptoms during a five-to-ten-year period, after which the symptoms abate naturally.
An increasing number of women have now been on bioidentical hormones for well over ten years, and they feel great when taking them and not so good when they stop. Here’s an example from a sixty-two-year-old woman who just consulted me on this issue: “I’ve been on oral capsules of estrogen plus 100 mg of progesterone daily ever since I did some research after the WHI study stopped. I had already had my uterus removed as well as most of my ovaries when I was in my late thirties because of endometriosis, but I did not take hormones until I went through menopause and suffered from heart palpitations, fuzzy thinking, and awful hot flashes. Once I got on hormones, I felt reborn. When I’m not on them, I feel spacey and get urinary incontinence. I exercise and do yoga regularly, don’t drink alcohol, and am happy with my life. Is it unusual to be taking hormones for this length of time?”
Given that this woman, and thousands like her, do not have normal ovarian function and feel great on small amounts of bioidentical hormones, I recommend staying on them. Yes, there is a potential risk. But why ruin one’s quality of life right now to prevent a very unlikely event in the future? As with everything, this decision must be individualized.
IF YOU’VE BEEN TAKING HT AND
WANT TO STOP ALL HORMONES
Don’t stop cold turkey. Wean yourself gradually and slowly, giving your body time to adjust. Here’s a sample weaning schedule:
Week one: Skip Sunday’s pill
Week two: Skip Sunday and Tuesday
Week three: Skip Sunday, Tuesday, and Thursday
Week four: Skip Sunday, Tuesday, Thursday, and Saturday
Week five: Skip Sunday, Tuesday, Thursday, Friday, and Saturday
Week six: Off hormones altogether
During and after this tapering-off period, support your body by making sure you’re getting enough plant hormones. Eat a wide variety of fruits and vegetables, plus ground flaxseed and soy. (See chapter 6.) You’ll also need a good multivitamin/mineral to help your adrenals and ovaries keep your hormones balanced.
Not Carved in Stone
Many women went into a panic after the initial Women’s Health Initiative study results were announced, and stopped their HT cold turkey. Many also worried that they’d done irreparable damage to themselves by being on HT. This simply is not true. To put matters into perspective, the vast majority of women in the WHI study did not experience any adverse outcomes from being on Prempro, and their risk of death was no greater than that for women taking placebo. The data indicate that if 10,000 women take Prempro for a year, eight more will develop invasive breast cancer than would develop it if they didn’t take Prempro. An additional seven will have a heart attack, eight will have a stroke, and eighteen will have blood clots. But they will also suffer six fewer colorectal cancers and five fewer hip fractures.37 Unfortunately, we now face a situation in which many women who could truly benefit from HT are so frightened by the risk of cancer that they are refusing it and suffering needlessly. Instead
, every woman should know that she can decrease her risk of side effects from HT by switching from synthetics such as Prempro to low-dose bioidentical hormone therapy. Or, if she chooses, she can wean herself gradually off HT to avoid rebound symptoms.
Because every woman’s body is a work in progress, your hormonal status—and your need for a particular type of support program—may well change. If you elect to take supplemental hormones, it is wise to have your hormone levels checked every six months during the first year of hormone use. Compare the results to how you’re feeling. This can help indicate if, and where, your prescription needs fine-tuning. After you have reached a comfortable level, you only need to test every year or so.
If you’ve been taking Prempro or another type of synthetic HT, feel good on it, but want to decrease any possibility of adverse side effects: I suggest that you switch to bioidentical hormones at the lowest possible dose. Your doctor can give you a prescription for bioidentical hormones, which include oral Estrace and some of the patches (Estraderm, Vivelle, and Climara). If you have a uterus, you’ll also need progesterone. Prometrium is available in all pharmacies. The usual dose is 100 mg a day, at least twelve days of the month. If you don’t want to get a period, you may need to take it daily. These brands of bioidentical hormones are covered by most health plans that have prescription coverage.
The Wisdom of Menopause Page 24
