” Today’s truth is this: There is no magic hormone or combination of hormones that can be indiscriminately used by all women. Each woman is an individual and hormonal balance must be the ultimate goal for all women”Joseph Collins, MD
I am oftentimes asked about hormone replacement therapy and specifically bio-identical hormone replacement therapy. In fact, many of my patients come to see me for relief with their natural hormonal decline.
I thought it a good idea to put together some of the most frequently asked questions about hormone replacement therapy that I get asked.
What do we know about the non-bioidentical synthetic hormone replacements?
The government sponsored women’s health initiative program halted its study on estrogen plus progestin (synthetic progestin plus conjugated horse estrogen) on July 9, 2002. This was three years early because of an increased risk of breast cancer in women taking these hormones. Analysis of the study also revealed that heart attack risk began increasing in the progestin group early in the study which was conducted on 16000 women who had not had a hysterectomy. Participants in the study were either given conjugated horse estrogens plus a synthetic progestin or a placebo.
Findings of the Study
The study revealed the following results:
- The stroke rate was 41% higher.
- The rate of blood clots doubled.
- Breast cancer risk increased by 26%.
- Risk of heart disease went up by 22%.
- There was a 37% decrease in colorectal cancer.
- A decrease in fracture rate of the hip of 33%
- A decrease in total fracture rate of 24%
Additional studies, such as Heart and Estrogen/Progestin Replacement Study (HERS II) agree with the findings of the women’s health initiative trial. Several other studies have shown recently that progestins (synthetic progesterone) have an unfavorable effect on lipid levels and may promote cardiovascular disease.
Women taking progestins show an increase in cardiovascular disease risk
In defense of the pharmaceutical company manufacturing the product used in this trial, low dose oral estrogen has been suggested instead of the much higher doses used in the studies.
Other problems with non bio-identical synthetic hormones include:
- Lot of women (estimated at 1/2) stop taking their hormones after 1 year due to being unable to tolerate their side effects
- Incomplete messages are given to cells resulting in wastage of energy and failing to produce a balanced hormonal response
What do we know about bio-identical natural hormone replenishment?
These are some of the reasons you should consider natural hormone replenishment/replacement:
- Relief of menopausal or hormone deficiency symptoms.
- Prevention of memory loss. May delay the beginning and decrease the risk of Alzheimer dementia.
- Heart health (transdermal bioequivalent hormone replenishment DOES NOT increase your cardiovascular risk at all.
- Bone production (prevention of osteoporosis).
- Growth and repair.
Natural hormone replacement means using hormones that are biologically identical to what your body makes. Customized natural hormone replacement is the safest way to replace hormones. Hormone replacement shouldn’t be considered without a thorough understanding of how all your body’s hormones interact with each other.
“It is impossible to achieve optimum health without a properly functioning hormonal system”
– David Brownstein, MD -The miracle of natural hormones
Transdermal delivery of estrogen is safer than oral delivery.
Oral estrogen can
- increase blood pressure
- increase triglycerides
- increase estrone (a dangerous type of estrogen)
- cause gallstones
- elevate liver enzymes
- decrease growth hormone (the hormone that keeps you youthful)
- interrupt tryptophan metabolism and consequently serotonin metabolism (serotonin keeps you happy and calm)
- increase sex hormone binding globulin (can decrease testosterone)
- increase carbohydrate cravings
- increase weight gain
- Estrogen has more than 400 crucial functions in your body, you need estrogen for optimal health.
- The amount of estrogen you have is important, too little or too much can cause symptoms.
- Synthetic estrogen is not the same chemical structure of estrogen that your own body makes.
- Synthetic estrogen takes longer to be eliminated from your body.
- Synthetic estrogens have coatings and additives which may cause problems.
- Mentioned earlier was the cardiac risk associated with progestins.
Effects seen with natural progesterone, but not with progestins:
- helps balance estrogen.
- leaves your body quickly.
- helps you sleep.
- natural calming effect.
- lowers high blood pressure.
- helps your body use and eliminate fats.
- lowers cholesterol.
- may protect against breast cancer.
- increases scalp hair.
- normalizes libido.
- helps balance fluid in the cells.
- increases the beneficial effects of estrogens on blood vessel dilation in atherosclerotic plaques.
- has an anti-proliferative effect (decreases the rate of cancer) on all progesterone receptors.
- does not change the beneficial effect estrogen has on blood flow.
- increases metabolic rate.
- natural diuretic.
- natural antidepressant.
It is clear that natural progesterone offers a safer approach to HRT than progestins
Do you need progesterone if you have had a complete hysterectomy?
The answer is simply yes, since progesterone has many positive effects on your body listed above.
Are there cancer issues with HRT?
Non bio-identical progesterone and non-bioidentical estrogen may increase the risk of endometrial and breast cancer.
Bio-identical Hormones vs Non-bioidentical Hormones
Contrary to non bio-identical progesterone and non-bioidentical estrogen, bio-identical progesterone and bio-identical estriol are considered protective against breast cancer:
- Bio-identical progesterone is protective (Campagnoli C. Pregnancy, progesterone and progestins)
- Estriol(E3), a bio-identical estrogen, binds to the second estrogen receptor ER beta which is a tumor suppressing receptor (Barden A, Boulle N, Lazannec; loss of ER beta expression as a common step in estrogen dependent tumor progression
- Estriol has been found to improve menopausal symptoms
- Estriol has been shown not to promote breast cancer and considerable evidence exists to show that it protects against it, and in Europe, estriol has been used for many years [14,15,16,17]
- Estriol has even been used to treat breast cancer
- A leading estriol researcher Henry Lemmon postulates:
- in vitro when estriol is given with estradiol, estriol accelerates removal of estradiol bound to protein receptors
- very little carcinogenesis is initiated with estriol in animal studies
- animal studies confirm that estriol helps to prevent carcinogen-induced mammary tumors
- estriol metabolism does not result in carcinogenic substances
Due to the possible protective effects of estriol, a combination cream such as bi-est (estradiol and estriol) or tri-est (estrone and estradiol and estriol) together with natural progesterone replenishment seems to be the safest way to replenish sex-hormonal deficiencies.
How do the metabolites of estrogen help in establishing your cancer risk?
- Increased 16-OH estrone production is proposed to have significant estrogenic activity and an increased risk of breast cancer
- Increased 4-OH estrones also may enhance cancer development studies have shown that 4-OH estrone from equine (horse) estrogen, causes mutagenic damage 5 times more rapidly than normal 4-OH estrones.
- Equine estrogens, increase metabolism to 4-OH estrone
- The 2-OH estrone pathway is the pathway to metabolize estrogen to have a low cancer risk
What can raise your 2-OH estrone (good) levels?
- moderate exercise
- cruciferous vegetables
- high protein diet
- omega 3 fatty acids
- vitamins b6, b12, folic acid
- indole 3 carbinol supplements
After all, the Hippocratic Oath that all doctors sign states “first do no harm”
Concerns Over the Effects of Transdermal Bio-equivalent Hormone Replenishment
There is no evidence that transdermal bio-equivalent hormone replenishment does any harm whatsoever. Is there evidence that oral HRT can be dangerous if used AFTER the initial period when oral HRT is mostly used to relieve symptoms? YES (Particularly for the older group of women who are at increased risk for cardiovascular disease)
It seems also from subgroup analysis of WHI that initially in the first few years of taking oral estrogen synthetics, that there is an improvement in cardiovascular risk (a decrease in coronary calcium score). However, the longer you use the oral synthetics the more likely your cardiovascular risk might increase for reasons stated previously.
“The problem with popular thinking is that it doesn’t require you to think at all.”Kevin Myers
What should every woman know about her hormones?
Maintaining a healthy hormone balance, which includes natural estrogen, is absolutely vital for any woman. What successful hormone treatment depends on is the careful monitoring of all hormone levels and making sure that the replacement hormones are not foreign to the body. For femore than a decade, integrative and preventive medicine specialists have been advocating this view, but still it seems as though it hasn’t quite filtered into conventional practice yet.
What are the key hormones that affect women’s health and wellbeing?
Key hormones that affect women’s health and wellbeing include estrogen, progesterone, testosterone, Dehydroepiandrosterone (DHEA), pregnenolone, melatonin, and cortisol.
Benefits of Estrogen
- Improves memory
- Lowers Alzheimer’s risk
- Lowers the risk of seizures
- Boosts dopamine levels, which controls energy, motivation, drive and mood
- Makes acetylcholine more available in the brain, a chemical needed for memory
- Makes serotonin more available, which affects mood and relieves anxiety
- Improves blood flow to the brain
- Boosts norepinephrine levels, needed for energy and dealing with stress.
Benefits of Progesterone
- Keeps estrogen levels balanced, without interfering with blood flow to the brain, as synthetic “progestins” do
- Improves sleep
- A natural antidepressant
- Improves libido
- Prevents migraines and headaches
- Helps protect nerve cells.
Benefits of Testosterone
- Boosts norepinephrine levels, a brain chemical needed for energy and dealing with stress
- Improves memory
- Improves emotional well-being, self-confidence, and motivation
- Boosts libido.
Benefits of Dehydroepiandrosterone (DHEA)
- Better sleep
- Boosts growth hormone levels in the brain
- Improves your body’s response to sugar
- Improves mood.
Benefits of Pregnenolone
- Improves the way your nerve cells work
- Boosts your memory
- Helps repair nerve damage
- Better energy levels, both mentally and physically
- Better sleep
- Improves your ability to deal with stress
- Reduces pain and improves your ability to deal with it
- Quicker learning
- Increases alertness
- Better mood.
Benefits of Melatonin
- Improves mood and sleep
- Boosts levels of the “sex hormones”, testosterone, estrogen and progesterone
- Protects the brain
- Lowers cortisol levels to help you cope with stress.
Benefits of Cortisol
- Influences the immune system
- Affects how all of the other hormones work in the body
- Affects how your body reacts to stress
- Plays a role in improving sleep, mood and thought processes.
Comments on hormones
The body makes three main estrogens:
- Estrone E1: Many researchers believe it may be related to an increase in breast and uterine cancer
- Estradiol E2: The most potent estrogen maintaining memory, bone health, and aids in protecting you from heart disease
- Estriol E3: Considerable evidence suggests that estriol protects against breast cancer
Estradiol is 12 times stronger than estrone and 80 times stronger than estriol.
There are over 400 functions of oestrogen in your body.
These are the main functions of estradiol:
- increases hdl, lowers ldl, decreases total cholesterol, decreases triglycerides
- decreases platelet stickiness
- increases growth hormone
- increases serotonin
- increases endorphins
- improves sleep
- helps maintain memory
- helps absorption of mg,ca,zn
What problems can arise from estrogen imbalance?
Too high levels of estradiol are associated with breast and uterine cancer.
Low levels of estrogen can cause the following symptoms:
- Dry skin/hair
- Hot flushes
- Night sweats
- Vaginal dryness
- Sleep disturbances
- Memory loss
- Bladder symptoms
- Difficulty in reaching climax
How can we get estrogen back in balance (what are the treatment options)?
In anti-aging medicine, we never replenish estrogen without replenishing progesterone first.
Bio-identical transdermal estrogen is much safer than oral estrogen due to:
- no elevation of blood clotting factors as seen with oral estrogen
- no elevation of blood pressure as seen with oral estrogen
- no elevation of highly sensitive CRP and triglycerides as seen with oral estrogen
- no elevation in incidence of gallstones as seen with oral estrogen
- no lowering of IgF1 as seen with oral estrogen
- no interference with tryptophan metabolism as seen with oral estrogen
When using hormones like estrogen it is highly recommended to assist the body to metabolise oestrogen to the healthy 2-hydroxy-estrone rather than the potentially dangerous 16- or 4-hydroxy-estrone. This can be done by supplementing with:
- indole-3-carbinol or DIM. Daily dose recommended is 200 to 300mg
- moderate exercise
- cruciferous vegetables
- flax, soy, kudzu, high protein diet, omega 3, B6, B12 and folate
Androgens are often called “male hormones”. They are testosterone, DHEA and androstenedione. Testosterone is made in the adrenal glands and ovaries. It is important to measure both free and bound testosterone since only about 1% is freely available, the rest is bound to SHBG (sex hormone binding globulin) which carries the testosterone in your blood.
Testosterone has a myriad of functions in the human body:
- motivation, emotional well-being, self-confidence
- increases muscle mass and strength
- increases sexual interest
- helps maintain memory
- helps maintain bone strength
- decreases excessive body fat
- increases muscle tone so your skin does not sag
What problems may arise from testosterone imbalance?
Low levels of testosterone result in a decrease in motivation, loss of muscle mass, decreased libido, excessive body fat, loss of muscle tone.
Excessive testosterone can cause masculinising effects such as male pattern hair loss, acne and excessive hair growth.
How can we get testosterone back in balance (what are the treatment options)?
Natural testosterone is the preferred method to supplement. Methyltestosterone (synthetic) has been suggested to be carcinogenic to the liver. Natural testosterone is effective as a pill or a cream however, rotation of the site of application is important to prevent hair growth. Also remember the skin has an enzyme, aromatase, which can change the applied testosterone to estradiol. Natural aromatase inhibitors include zinc, progesterone and chrysin. There are natural treatments like nettle root that also increase the free testosterone from SHBG (mentioned earlier). Injectable testosterone is also available but is mostly used in andropause.
Importance of Progesterone
- Natural progesterone helps balance estrogen
- Leaves your body quickly (unlike progestins)
- Helps you sleep
- Natural calming effect
- Lowers high blood pressure
- Helps your body use and eliminate fats
- Lowers cholesterol
- Protects against breast cancer
- Increases scalp hair
- Normalises libido
- Helps balance fluids in the cells
- Blood vessel dilation
- Antiproliferative effect
- Increases metabolic rate
- Natural diuretic, natural antidepressant
- Builds bone
- Helps thyroid hormone function
- Protects against fibrocystic breast disease
- Protects against endometrial cancer
- Normalises zinc and copper levels
What problems may arise from progesterone imbalance?
Progesterone deficiency occurs before estrogen deficiency in the perimenopause, and the risk for breast cancer goes up as the progesterone level goes down. Progesterone has antiproliferative effects on the breast and uterus. In antiaging medicine we never replenish estrogen without replenishing progesterone first. Progesterone is protective against breast cancer, unlike progestins which potentially increase your risk for breast cancer. It is also recommended by anti-aging physicians to supplement progesterone even in hysterectomized women.
How can we get progesterone back in balance (what are the treatment options)?
Bio-identical progesterone in transdermal or oral micronized form.
How do our hormones change as we age? How do hormonal shifts affect the way we age (what physical changes can be attributed to hormonal flux?)?
Osteoporosis is a debilitating, crippling disease that’s preventable. As you grow older, you burn up, swell up and dry out, due to inflammation, dehydration, and calcium seeping out of your bones and settling in your brain and blood vessels.
Growth and repair
Without sufficient hormones, the body’s ability to renew itself, heal and repair damage slows down, which speeds up aging.
Estrogen protects your heart. This benefit is lost when estrogen levels are low. The safest way to replace estrogen is through bio-identical hormones, absorbed either through the skin or the vagina. This way, there’s no risk of blood clotting as happens with estrogen taken orally. There’s also no risk of inflammation, no blood pressure problems, no effect on the mood-stabilising brain chemical, tryptophan, and no weight gain.
Prevention of memory loss and Alzheimer’s
The brain is especially dependent on the hormone pregnenolone to replenish brain cells and for clear, quick thinking.
A longer life
Women who replace their hormones live longer than those who don’t.
HRT is somewhat controversial. How do you know if you are a suitable candidate?
One of the most widely publicised investigations of the health effects of synthetic estrogen and progestin, called the Women’s Health Initiative Randomized Controlled Trial, was stopped in 2002 due to a sharp spike in the number of breast cancer cases among the otherwise healthy participants receiving these hormones. The study also found an increase in the incidence of coronary heart disease, stroke and pulmonary embolism, and established that the use of synthetic synthetic estrogen and progestin caused more harm than benefit
Since then, it’s almost become an accepted fact that HRT with synthetic hormones is risky business, because it significantly ups a woman’s chances of developing breast cancer. But that might be due to one (or both) of two possible reasons. Firstly, the hormone levels might not be monitored and balanced carefully enough, which means that the level of estrogen goes up so high that cancer does become a risk. Secondly, neither the replacement estrogen nor the replacement progesterone used in conventional HRT is bio-identical. They are synthetic molecules, which are foreign and unnatural to the body, which may trigger unwanted responses that could lead to cancer.
Alternatives to Hormone Replacement Therapy
When it comes to hormone replacement therapy, one size doesn’t fit all. You need to do what is right for your body, which is why customised natural hormone therapy is the best way to replace your hormones safely. This is because your hormone response is as unique as your fingerprints.
How you respond to hormone restoration therapy depends on your genes, stress levels, health condition, your environment and lifestyle, the nutritional supplements you use and your diet. Since no two women are the same, or share the same lifestyle, no two women should follow identical treatment plans.
“Bio-identical” hormone replacement therapy (BHRT) is a modification of conventional hormone replacement therapy that involves use of supplemental doses of hormones, with three important criteria:
- BHRT has the identical chemical structure to the hormones that exist naturally in the human body, and
- BHRT is used to replenish levels to physiologically normal concentrations, never exceeding physiological levels, and
- BHRT is administered via a mode/route of administration that most mimics the body’s natural production (e.g. given transdermally) to avoid metabolic byproducts produced by first pass metabolism to the liver, which occurs only with oral dosage routes, which for example increases the risk of blood clotting
A good approach to the safe use of hormones includes the following:
- Correct only deficiencies (avoiding unnecessary treatments)
- Carefully adjust the doses, personalising them to each individual
- Doing regular follow-ups (with cancer screening)
- Using small physiological doses (avoiding overdoses)
- Correctly balancing the hormone system (rarely using one hormone on its own, because of the risk of unbalancing the system)
- Use bio-identical hormones (avoid synthetic derivatives of natural human hormones)
- Lifestyle changes to lower the risk of cancer are also important, for example: regular exercise; dietary adjustments (eating excessively or cooking at too high temperatures, altering diets high in saturated fat); focusing on positive emotions; nutritional supplementation, e.g. I3C, DIM, soy, flax and Omega-3.
Resources and other information sources:
- Depression. University of Maryland-Medical Centre: www.umm.edu/altmed/ articles/depression-000047.htm
- La Valle JB, et al. Cracking the metabolic code. Basic Health Publications, Laguna Beach: 2004
- Lichten EM. Textbook of Bio-identical Hormones. Foundation for anti-aging research LLC: 2007
- Miller PL, et al. Life Extension Revolution. Bantam Books, New York: 2005
- Wartian Smith P. HRT: The answers. Healthy Living Books, Traverse City: 2003
- Wartian Smith P. What you must know about women’s hormones. Square One, New York; 2010:159
- Wright E. Neuroendocrinology in Clinical Practice: The link between Neurotransmitters and Hormones. Neuroscience. www.neurorelief.com/index.php?option=com=content&task
- Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative Randomized Controlled Trial. JAMA. 2002;288(3):321-33Frequently asked questions about hormones