NAMASTE AND WELCOME TO THIS MONTH'S WAY UP NEWSLETTER
WE ARE GOING TO DELVE INTO THE VAST SUBJECT OF MENOPAUSE
This is another example of trying to squeeze the complex into a short
Millions of women (& indirectly, their families) suffer the consequences of declining hormones. Many suffer needlessly because of fear & confusion about what to do. Some undergo abrupt & severe menopausal symptoms when there is a total hysterectomy.
The transitional phase of "perimenopause" can last 5-10 years before actual menopause & can be an insidious beginning of sometimes problematic changes in quality of life. Symptoms of hormone decline also tend to begin earlier in those with a history of hormone imbalances, such as with PMS, ovarian cysts, uterine fibroids, endometriosis, & fibrocystic breasts.
The average age of actual cessation of menses (Menopause) is 50-51 yrs.
Menopausal symptoms are brought about by declines in progesterone, estrogen, testosterone, DHEA, & pregnenolone. All of the sex hormones are related to each other & derived from cholesterol via pregnenolone. The hormones are produced by the ovaries & the adrenal glands.
Even when the ovaries have decreased functioning, some women make enough estrogen , progesterone & testosterone from the adrenal sources which are the hormones, pregnenolone & DHEA. These women may have adequate hormone levels with minimal or no deficiency symptoms. Though , with advancing age this adrenal source may ultimately decline as well.
WHAT ARE THE AREAS OF CONFUSION?
The greatest misunderstanding exists about whether or not to use hormone replacement therapy (HRT) & what hormones to use at what doses.
First let me say that stopping menstruation alone is not a reason for HRT. Only those with discomfiting symptoms, low serum hormone levels, osteoporosis, or high risk for osteoporosis need HRT.
Unfortunately "cook-book" dosages of synthetic estrogens & progestins are handed to many women without taking a careful history or doing blood tests to see what & how much they need. On the other hand, if you really need HRT it is important to proceed with treatment unless there are contra- indications. But I am not talking about the usual synthetic hormones!
Proceed with the minimum dose needed to ameliorate symptoms, to maintain appropriate blood levels, & promote bone density. HRT reduces the incidence of osteoporotic fractures by at least 50%. Osteoporosis causes more illness & mortality than any other disease in women.
WHAT ARE THE SYMPTOMS OF MENOPAUSE?
When deciding about the need for HRT, we are looking for some constellation of the following complaints: sleep problems, mood problems, depression, anxiety, irritablity, increased emotional volatility, memory problems, difficulty focusing & concentrating, hot flashes, night sweats, palpitations, increased urinary frequency, incontinence, or other urinary symptoms (from thinning &/or inflammation of the urethra), vaginal dryness, itching & inflammation of the vagina, painful intercourse, decreased libido & sexual responsiveness, dryness of eyes, mouth, skin & hair, more rapid skin wrinkling & general acceleration of aging, increase in facial hair, fatigue, muscle soreness & joint stiffness, osteoporosis.
We are also looking for these symptoms to have begun & increased up to & past menopause.
HOW ARE THE HORMONES MEASURED?
Generally if one is still having periods, there may not be absolute hormone decreases, but imbalances & more subtle changes. At this time I prefer to use any of the various Female Hormone Profiles available which involve the collection of saliva throughout the cycle to see the cyclic pattern of estrogen & progesterone production. We can then see which times of the month the hormones are depleted or out of balance & correct accordingly. A number of labs offer these tests. See the laboratory section in the health related links to see what the labs offer.
When the periods have stopped, I prefer to do blood tests for absolute decreases of hormones. The blood tests I order are serum estradiol, FSH, serum progesterone, serum free & total testosterone, serum DHEA sulfate, & sometimes, serum pregnenolone. This helps me to know which hormones are how low so the dose can be individualized. We then do follow up testing several months later to make sure we have achieved the desired blood levels & are not too high or still too low & adjust the dose accordingly, if necessary. Then blood testing is generally done at yearly intervals, ideally.
Different labs report different normal values for these hormones depending upon their testing methods, so it is difficult to give you precise information about this. Here are some guidelines.
The lab I use (Unilab) has a normal serum estradiol range for the menstruating years from 27-48 depending upon the time of the cycle. Post menopausally, we aim to keep the levels between 75-100 which is 15-21% of maximal levels & usually enough to ameliorate symptoms, yet to be conservative. I see many miserable patients with serum estradiol levels of 10-30!
Unilabs' normal premenopausal serum progesterone is from 0.2-25.9 depending upon the time in the cycle. Post menopausally I prefer to keep it between 4-10 which is 16-39% of maximal premenopausal levels.
Unilabs' serum DHEA levels for premenopausal women is approx. between 1300-4900 so we try to keep in the middle of this range. DHEA dosage needs generally range from 5 mg daily to 100 mg daily depending on the woman & her response. If the pregnenolone is low (when I measure it) or if the DHEA is low I also add pregnenolone in doses of 10-100mg. These are available over the counter.
If the testosterone is low, I prescibe a compounded testosterone skin gel, usually a low dose of 2-5 mg daily. Often this will need to be decreased after the levels are brought up as the testosterone levels seem to readily bounce up with treatment. Signs of low testosterone are loss of libido, low energy & motivation, depression, breast tenderness, & an increase in allergies. Testosterone helps to prevent & to treat osteoporosis. .
SHOULD ESTROGEN EVER BE TAKEN WITHOUT NATURAL PROGESTERONE?
This brings us to another of my major annoyances with how HRT is often practiced. When taking estrogen it should always be taken with natural progesterone EVEN WHEN THERE HAS BEEN A HYSTERECTOMY!!!
Many Drs see progesterones' only function as the protection of the uterus from cancer & if no uterus, no progesterone. Furthermore, they don't know the difference between the synthetic progestins which the drug companies have done a great job of selling, & natural progesterone. The synthetics have a different chemical structure than the natural, which is the same chemical structure as that produced in the body. The synthetics won't even show up on the blood tests for progesterone, so besides being potentially harmful they cannot be measured with this test. The synthetics have side effects not found with the natural progesterone & do not have most of the benefits of the natural molecule. Sometimes progestins actually aggravate menopausal symptoms. The confusing recent presentation in the media of an even greater increased risk of breast cancer in women on both estrogen & progestins over that of women on estrogen alone was in women using the synthetic progestins, not the natural form.
Categorically, I & holistically oriented Dr.'s prescribe no synthetic progestins for HRT. Some of the names of these are: Provera, Aygestin, Depo-provera, Cycrin, Micronor, Amen Tabs, Ovrette, Nor Q D.
Previously, natural progesterones were only available from compounding pharmacies, or as over the counter skin creams derived from soy & yam. Fortunately, demand won out & 2 different natural progesterone products are now available from any pharmacy; Prometrium, a capsule in 2 strengths, & Crinone Gel for vaginal application. Altogether it is available as oral micronized capsules, sublingual tabs, rectal suppositories, as well as the creams & gels.
Natural progesterones are the building blocks for other steroid hormones. Progestins are incapable of performing this function. There are natural evolutionary metabolic pathways for handling progesterone, while progestins are foreign drugs. The main similiarity of the Progestins & natural progesterone are that they both promote secretory functions of the lining of the uterus, to help thin the uterine lining. But natural progesterone does much much more & is critical in balancing the effects of estrogen.
By the way, many birth control pills contain higher doses of estrogen than the doses used in post menopausal HRT. Also birth control pills contain the synthetic progestins. For these reasons birth control pills are associated with higher side effect risks than appropriate HRT.
HOW DO ESTROGEN & PROGESTERONE BALANCE EACH OTHER?
both interact with neurotransmitters to affect brain function, both regulate menstrual cycles & sexual behavior.
BOTH REQUIRE THE PRESENCE OF EACH OTHER FOR MANY OF THEIR ACTIONS BECAUSE EACH HELPS SENSITIZE THE RECEPTOR SITES FOR THE OTHER.
WHAT IS THE BEST FORM OF ESTROGEN FOR HRT?
When you are making your own estrogen you make 3 forms: E1 (estrone) , E2 (estradiol), E3 (estriol) which exist in a certain balance with each other.
Some Dr's such as Dr Jonathan Wright have found that maintaining the appropriate ratio between these 3 hormones helps to protect against breast, uterine, or ovarian cancer risk. Some labs have tests which measure this ratio. Meridian Valley Lab at 800-234-6825 or 253-859-8700 includes this in their Comprehensive Hormone Profile which is done by using urine.
The usual prescription estrogens are for E2 ( estradiol) only. Most oral estrogens are given as "conjugated estrogens" which must be converted in the body to the active compound 17-beta-estradiol. Since 17-beta- estradiol is well absorbed through the skin, it is the form of estrogen used with the patch. One patch maintains a relatively constant serum level for 3.5 days, so it is ideal to use 1 patch twice weekly. Alternative physicians usually prescribe compounded estrogens containing the E1, 2 &3 or E2 & E3 together in varying proportions, Generally the E3 is present in highest concentration being 50-80% of the formulation. Or if a patch is used, the Dr might add some separate E3. These compounded formulations are available as oral capsules, skin creams, vaginal creams, & sublingual drops.
Some women at higher risk for breast cancer, but with severe menopausal symptoms may want to use the Estriol (E3) alone. It is weaker in effect & a higher dose is needed to control symptoms. It has been used in doses from 2-15 mg. The higher doses may give nausea. What I prefer to do is to still give some estradiol, but a relatively low dose, so we don't need so much E3 for symptom control. Since E3 does not cause thickening of the uterus as do E1 & E2, there is usually no bleeding in the women put on these combination products. For the first several months of HRT we may cycle the hormones to see if there is any period & will continue to do this as long as there is any need to bleed, which is usually not long. After that we maintain the hormones continously.
Since many have not heard of estriol, let's go into more detail. It isn't clear why estriol hasn't been more extensively studied, when it has looked so promising. Specifically: Estriol inhibited the breast cancer promoting effect of Estradiol in mice. Estriol inhibited the development of breast cancer in rats induced by 2 different chemical carcinogens. Dr H.M. Lemon investigated estriol's relationship to breast cancer in humans. He found that women with breast cancer had a low level of estriol relative to other forms of estrogen & that healthy females had a higher ratio of E3 / E1 & E2.
Seventeen women with fibrocystic breast were given 600 units Vitamin E for 2 months. Vitamin E has been reported to relieve fibrocystic breasts & to inhibit chemically induced breast cancer in rats. It was found that the Vitamin E produced an 18% increase in the ratio of Estriol to Estradiol.
In a preliminary study done some time ago, Estriol in doses of 2.5-15 mg was given to a group of women with metastatic breast cancer. In 37% of those receiving Estriol there was either a remission or no further progression of metastatic lesions. These results were far better than expected considering the usual outcome of metastatic breast cancer. Estriol may lower the blood clot risk induced by other estrogens. It is not clear whether Estriol helps with osteoporosis.
CAN PROGESTERONE BE TAKEN WITHOUT ESTROGEN?
In the perimenopausal years progesterone often starts decreasing before estrogen & is often used alone during that time to help with the early symptoms. It is the hormone I most often find decreased on the saliva tests ordered for perimenopausal women, most often in the second 2 weeks of the cycle & most frequently supplemented during that time. Proper usage of progesterone can minimize the needed doses of estrogen.
WILL THIS EVER END?
This short newsletter by now seems interminable & we've barely scratched the surface, yet managed to address what I consider the most critical issues. For more in depth info look at the Hormone Section in the book list. I particularly refer you to books by Dr John Lee & Dr Julian Whitaker.
If you know anyone who would find this info to be of interest, please forward to them. If the formatiing isn't as you want when you print this news, it will be in the archives on the web site in a few weeks where it will copy better for printing.
WE'LL GET TO THE MEN & A DISCUSSION OF TESTOSTERONE IN THE FUTURE!
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