Alternatives
for Menopause – Part II
The natural changes which occur in a woman's body during menopause ultimately involve the virtual cessation of hormone production from the ovaries. Before this happens, ovulation happens less and less frequently, progesterone levels, which depend on ovulation, fall. For a while, estrogen levels may be high, or out of balance with progesterone, until they ultimately fall to a low steady state level. The production of the small amounts of estrogen and progesterone found in the fully menopausal woman is taken over by the adrenal glands, and to some extent the adipose tissue and liver. With this in mind, we can understand the rationale of adding hormones back which seem to be missing. On the other hand, women vary greatly in how they experience the menopause, so one approach is not best for all.
In Part I, we noted that the WHI seemed to show that the only benefits of hormone replacement therapy (HRT) in menopause were improvement in bone density, and alleviation of symptoms, such as hot flashes and vaginal dryness. Furthermore, the risks of breast and uterine cancer and increased incidence of clotting disorders and cardiac disease were confirmed. It is important to realize that the great majority of subjects studied used either Premarin™ or PremPro™. The estrogens were the horse-derived forms, and the progestins were mostly medroxyprogesterone, a modified stabilized progesterone molecule not found naturally in humans.
What of the effects of the bioidentical hormones natural to human women—estradiol, estrone, estriol, and unmodified progesterone? The results of these generically available hormones, when used, were not clearly separated out from the results of the foreign or semi-synthetic hormones, so we can't really say. Smaller studies on humans, animal studies, and what we know from the basic science about the differences between the cellular and body effects of the bioidentical vs. synthetic or foreign hormones, point to greater safety and efficacy and fewer side-effects with the bioidentical approach, although complete safety is not assured.
Another factor to be considered is the way the hormones are taken. The majority of women over the years have taken the hormones orally, as tablets or capsules, such as Estrace™ and Prometrium™. More recently, fixed dose estrogen patches, changed once or twice weekly, have been produced commercially, allowing slow absorption through the skin. Compounding pharmacies have been preparing compounded mixtures of estrogens, progesterone and other hormones in various cream or gel bases that allow for customized dosing and absorption patterns. Why use the skin for absorption of hormones? All hormones, natural or synthetic, produced in the body or supplied externally, are metabolized/detoxified by the liver. It is possible that some of the reported negative side-effects of hormones may have been due to the whole dose of hormone hitting the liver at once, resulting in toxic or dysfunctional chemicals produced by the overloaded metabolic machinery. Supplying the hormones via a cream or patch presents the hormone molecules slowly to the liver, closer to the natural situation. Again, the research data are not in as to whether this approach does what the theory says, and leads to greater comfort and effect with lower risk. The impressions and experience of clinicians using this method tend to support it.
How do we determine how much of each hormone is to be given, and how do we monitor therapy? Often, the best guides are the patient's history and symptoms. Blood tests can provide some guidance, as they suggest how much of each hormone is circulating in the blood stream, and can provide guidance as to where a woman is in the transition from regular cycling to menopause. These tests can also determine if a dose is excessive. Another advantage of blood tests is that the numbers themselves are very accurate, if the correct tests are done. Salivary tests have become more prevalent in the past 5-10 years. These tests are felt to better reflect the levels of hormones in the body tissues, which is really what you want to see in making clinical decisions; also, venipuncture is not required. On the downside, these tests are relatively less accurate than the blood tests (although this has greatly improved over the past few years, are often not insurance-covered, and have different, less well-established standards for various routes of hormone administration. Nevertheless, they are very useful as guides to the practitioners, myself included, who work with various forms of bioidentical hormones. They can also be quite cost-effective, with $75-100 per 4-hormone panel being the typical cost in New York.
This may sound good, but could be more than you can get your mind around just yet. How well does this approach work? I can say from my own experience, and that of other clinicians in this field, that the approach of individualized dosing of hormones, by any route, through direct monitoring of the patient, makes total sense medically, and appears to avoid many side-effects, and enhance effectiveness, at least in the symptom-control and well-being areas. The use of topical vs. oral formulations allows finer adjustment of the therapy, and avoidance of some of the potential risks and side-effects from metabolic overload. Unfortunately, this has not been borne out by large or well-controlled studies on humans, mainly because the studies haven't been done. They probably won't be done in the near future, since the money isn't there for generic products such as compounded, non-patented bio-identical hormones. In spite of these difficulties, many women opt for this type of therapy. I am happy to consult with women on this issue to help determine if BHRT is the right step for them.
There are many other aspects of the approach to menopause that I have not covered in this series. To do so would double the number of pages required, and might be far more than you want to know. It is my hope that these articles will help to educate and support women in the choices they make concerning their health and wellness, especially during the important natural transition of menopause.