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What to Do About Hormone Replacement Therapy (HRT)
By M. Sara Rosenthal, PhD
WebMD Medical Reference from "The Gynecological Sourcebook"
IN JULY 2001 a study by the U.S. National Heart, Lung, and Blood Institute, part of a huge research program called the Women's Health Initiative, suggested that hormone replacement therapy should not be recommended for long-term use; in fact, the results were so alarming, the study was halted before its completion date. It was found that Prempro, a combination of estrogen and progestin, which was a "standard issue" HRT formulation for postmenopausal women, increased the risk of invasive breast cancer, heart disease, stroke, and pulmonary embolisms (blood clots). However, Prempro did reduce the incidence of bone fractures from osteoporosis and colon cancer. Nevertheless, the idea that HRT is a long-term "fountain of youth" is slowly dissolving. The study participants were informed in a letter that they should stop taking their pills. HRT in the short term to relieve menopausal symptoms is still considered a good option, and there was no evidence to suggest that short-term use of HRT was harmful. The study only has implications for women on HRT for long-term use—something that was recommended to millions of women over the past twenty years because of perceived protection against heart disease.
In 1998 an earlier trial, known as the Heart and Estrogen/Progestin Replacement Study, looked at whether HRT was reduced in women who already had heart disease. HRT was not found to have any beneficial effect. Women who were at risk for breast cancer were never advised to go on HRT; similarly, women who had suffered a stroke or who were considered at risk for blood clots were also never considered good candidates for Hormone Replacement Therapy (HRT). It had long been known that breast cancer was a risk of long-term HRT, as well as stroke and blood clots. However, many women made the HRT decision based on the fact that it was long believed to protect women from heart disease. Millions of women are now questioning whether they should be on HRT in light of what many experts are calling the "9-11 of HRT." This discussion provides you with the new rules about HRT.
What Is Hormone Replacement Therapy (HRT)?
Hormone replacement therapy (HRT) refers to estrogen and progestin, which is a factory-made progesterone, given to women after menopause who still have their uterus to prevent the lining from overgrowing and becoming cancerous (known as endometrial hyperplasia). Estrogen replacement therapy (ERT) refers to estrogen only, which is given to women who no longer have a uterus after surgical menopause. Both HRT and ERT are designed to replace the estrogen lost after menopause and hence:
Prevent or even reverse the long-term consequences of estrogen loss. The only proven long-term benefit of HRT is that it can help to preserve bone loss and reduce the incidence of fractures. Until July 2001 it was believed that HRT protected women from cardiovascular disease, but this is no longer considered true. In women who are at higher risk of breast cancer, HRT was always believed to be risky; now it is believed that it may trigger breast cancer in low-risk women.
Treat the short-term discomforts of menopause, such as hot flashes and vaginal dryness. This is all still true, and you can discuss with your doctor how long he or she recommends that you stay on HRT before it becomes risky.
Once you weigh the benefits and risks, if you decide to be treated with conventional HRT or ERT, you have the choice of using it as either a short-term therapy or a long-term therapy.
Being a Slave to the Medical System
An obvious but underreported risk of HRT is that it forces you into another continuous cycle: one of constant doctor visits and tests. And each time you go to your doctor, you risk some sort of invasive procedure or referral for invasive tests. For example, women on HRT are more likely to be prescribed the following tests or medications:
-blood tests for hormone levels
-diuretics for fluid retention
-Ponstan, aspirin, or other analgesics for uterine cramps
-endometrial biopsies to check the endometrium
-D & C for bleeding
-blood pressure tests
-blood tests for cholesterol levels
-baseline mammograms before starting therapy and regular mammograms thereafter
-visits for repeat prescriptions of hormones at least every six months
Women who are not on HRT are not burdened by as many tests, visits, and other procedures. Do these increased doctor visits save lives because they offer early detection of many serious diseases? Critics of HRT argue that women are paying a higher price for their dependency on the medical system and are burdened with too much monitoring and early detection.
The Forms of HRT and ERT
You can take estrogen in a number of ways. The most common estrogen product uses a synthesis of various estrogens that are derived from the urine of pregnant horses. That way the estrogen mimics nature more accurately. Estrogen replacement comes in either pills, patches (transdermal), or vaginal creams. Other common, synthetic forms of estrogen include micronized estradiol, ethinyl estradiol, esterified estrogen, and quinestrol.
As a short-term therapy, you may only need the vaginal cream to help with vaginal dryness or bladder problems. Estrogen can also be "worn." In this case, it's placed in a small plastic patch about the size of a silver dollar, worn on the abdomen, thighs, or buttocks, and changed twice weekly.
When estrogen is in patch or cream form, it goes directly to the bloodstream, bypassing the liver; this form of estrogen was previously discouraged for some women because it was not considered to have any protection against heart disease. But in light of the recent risk of heart disease with conventional formulations of HRT, the patch may pose no long-term harm, and you may want to discuss whether this is an option for more long-term use. Some women also have an allergic reaction to the skin patch and get a rash. If you're one of them, you can investigate taking the estrogen in other forms.
Finally, you can also have estrogen injected. Each shot lasts between three and six weeks, but this is expensive and inconvenient. Estrogen gel containing estradiol is now being used in some parts of the world, though it is not yet available in North America. The gel is spread over a wide area of the abdomen every second day. The problem women have encountered with this method is a variation in levels of absorption each time the gel is applied.
Even more controversial are the pellets or implants containing estradiol inserted under the skin of the abdomen or buttocks under local anesthetic. Subcutaneous implants are also not yet available in North America, primarily because they are difficult to remove or halt if a woman experiences complications.
What About Progestin?
This is the synthetic version of progesterone that is found in all combination oral contraceptives and the injectable contraceptive Depo-Provera. Progesterone receptors do not recognize progestin and will not transport it to the cells. This may account for many of the progestin-related side effects that mimic PMS. The most common progestins include Provera, Amen, Curretab, and Cycrin (all brand names of medroxyprogesterone acetate); Duralutin, Gesterol L.A., Hylutin, and Hyprogest 250 (all brand names of hydroxyprogesterone caproate); Norlutate, Norgestrel, and Aygestin (all brand names of norethindrone acetate); Norlutin (norethindrone); and Magace (megestrol acetate). Micronor, Nor-Q.D., and Ovrette are other brand-name progestins on the market.
Progestins are taken in separate tablets along with estrogen. Together, the estrogen and progestin you take is called Hormone Replacement Therapy (HRT). HRT can be administered two ways: cyclically or continuously. Taking HRT cyclically is very similar to taking an oral contraceptive because the hormones more closely mirror a natural cycle. The first day you start is considered day 1 of your mock cycle. You take estrogen from day 1 to day 25; you then add the progesterone from day 14 to day 25. Then you stop all pills and bleed for two or three days—just as you would on a combination oral contraceptive. This vaginal bleeding is called withdrawal bleeding, which is lighter and shorter than a normal menstrual period, lasting only two or three days—just like a period on a combination oral contraceptive. In fact, if the bleeding is heavy or prolonged for some reason, this is a warning that something's not right, and you should get it checked.
In addition, you may experience breakthrough bleeding, or spotting, during the first three weeks after you begin Hormone Replacement Therapy (HRT). This kind of bleeding is, again, similar to what happens on a combination oral contraceptive. This bleeding usually goes away after a few months, but report it anyway. You may need to switch to a lower dose of estrogen or take a higher dose of your progestin. Once your miniperiod of withdrawal bleeding is finished, you simply start the cycle again. Many women can't tolerate cyclical HRT because they feel as though they should be rid of their periods by now and not have to deal with pads and tampons ever again. However, it is believed that cyclical HRT offers slightly better heart protection.
When HRT is taken continuously, you simply take one estrogen pill and one progestin pill each day. When you do it this way, the progesterone counteracts the estrogen; no uterine lining is built up, so there's no withdrawal bleeding that needs to happen.
The Appropriate Dosages
Every woman requires a different dosage of estrogen and progestin. But initially you will always be placed on the lowest possible dosage of either one and may have the dosage increased gradually if necessary. If your estrogen dosage is too high, you'll experience side effects similar to those seen with oral contraceptives: headaches, bloating, and so on.
So before you or your doctor determines how much estrogen you'll need, it's crucial to first determine how much your body is still producing; this really depends on your weight, estrogen loss discomforts, and a hundred other things.
Common Side Effects
If you're taking cyclical progestins with your estrogen because you still have your uterus, bleeding is not a side effect! The whole point of adding progestin to your estrogen is to trigger withdrawal bleeding and get your uterine lining routinely shed. However, if you're taking continuous progestins with your estrogen, bleeding is not the norm and should be checked into.
A common side effect of estrogen is fluid retention, because estrogen will decrease the amount of salt and water excreted by kidneys, which is retained by legs, breasts, and feet, which can swell. Because of the fluid retention, you may weigh more, but you will not necessarily be fatter.
Nausea is another common side effect, also seen with oral contraceptives. This happens during the first two or three months of your therapy and should just disappear on its own. Some women find that taking their dosages at night (for pills) may remedy this. Decreasing the dosage is also an option.
Some other side effects reported include headaches, skin color changes (called melasma) on the face, more cervical mucus secretion, liquid secretion from the breasts, change in curvature of the cornea, jaundice, loss of scalp hair, and itchiness. Again, these side effects vary and depend on the brand you're taking, the dosage, your medical history, and so on.
Are You an HRT or ERT Candidate?
In light of the recent shadow cast over HRT, clearly it is not for everyone. If you answer yes to any of the following questions, you might consider short-term or long-term use of HRT or ERT:
-Do you suffer from severe hot flashes that don't respond to the natural remedies in the section "Flower Power"?
-Are your vaginal changes causing urinary tract infections, vaginitis, or painful intercourse, which does not respond to such remedies as more stimulation of the clitoris during sex or sexual lubricants?
-Are you concerned about developing osteoporosis? Studies still support that using HRT or ERT in the long term may lower your risk of developing osteoporosis. (But so will exercise and a high-calcium diet.) There are now bone-building drugs that are alternatives to HRT and ERT, which you can discuss with your doctor.
-Women Who Shouldn't Be on HRT or ERT
Women who suffer from certain medical conditions should not be on HRT or ERT as discussed in the following list:
-Women with a history of endometrial cancer should not be on unopposed estrogen ERT. Again, if you still have a uterus, you'll be placed on HRT (estrogen and progesterone), which lowers your cancer risk anyway.
-Women with breast cancer or a history of breast cancer or who are considered at high risk for breast cancer should not be on either HRT or ERT.
-Women who have had a stroke should not be on either HRT or ERT.
-Women who have a blood-clotting disorder should not be on either HRT or ERT.
-Women with undiagnosed vaginal bleeding should not be on HRT or ERT.
-Women with liver dysfunction may be on the estrogen patch or use vaginal cream to relieve menopausal discomforts but shouldn't take any pills orally.
-Women Who May Benefit More from HRT or ERT
-Discuss with your doctor whether you're a candidate for HRT or ERT, given the protective effects each has against osteoporosis and colon cancer.
However, you may need to think twice if you have any of the following other conditions:
-sickle cell disease
-high blood pressure
-migraines
-uterine fibroids
-a history of benign breast conditions such as cysts or fibroadenomas
-endometriosis
-seizures
-gallbladder disease
-a family history of breast cancer
-a past or current history of smoking
-Natural Hormone Replacement Therapy (NHRT)
Many of you may have heard the media hype surrounding natural hormone replacement therapy (NHRT), which includes natural progesterone, versus conventional hormone replacement therapy (HRT). The difference is akin to the difference between breast milk and formula for a baby. NHRT is a combination of human estrogens and natural human progesterone. HRT, on the other hand, is a factory-made estrogen, much of which is derived from horse estrogen, and a factory-made progesterone, called progestin. Now many reports and studies show that the symptoms of menopause are better controlled with NHRT, and with fewer side effects.
What NHRT Contains
When you go on NHRT, you're getting about 60 to 80 percent estriol, 10 to 20 percent estrone, and 10 to 20 percent estradiol, as well as natural human progesterone plus DHEA (dehydroepiandrosterone), a "natural androgen," if you will, that turns into a "natural testosterone" in the body, something all women need to maintain sex drives. On HRT you're getting 75 to 80 percent estrone, 6 to 15 percent equilin (a horse-derived estrogen), and about 5 to 19 percent estradiol, as well as progestin, a factory-made progesterone, and sometimes anabolic steroids, if your libido needs a boost.
The bottom line is that human women do better with human hormones rather than animal-derived hormones, just like human infants do better on human milk than cow's milk. However, as you can see from the range of concentrations of various natural estrogens, it may take a while for you to find just the right dose of each kind of natural estrogen and progesterone, so you have to work with your doctor and experiment until you get it right. There is a perception out there that NHRT is perfect the first time you take it, but many women have to tinker with their "triple estrogens" before they find the right combination: a typical prescription for NHRT is often 10 percent estrone, 10 percent estradiol, and 80 percent estriol, mixed with about 25 to 30 mg natural progesterone after menopause and 10 to 30 mg DHEA, which should, but doesn't always, convert into necessary amounts of testosterone. (If it doesn't, you may need to add a steroid to the mix of natural hormones if your libido is very low, which can be debilitating.)
Where Do You Find NHRT?
All the books and articles about NHRT can mislead you into thinking that NHRT is just available everywhere. This is not so. You can't simply walk into a health food store and buy natural estrogens or progesterones. They need to be prescribed by a doctor (although the doctor need not be an M.D.; several naturopathic doctors are prescribing them, too). A pharmacist, known as a compounding pharmacist, has to prepare a doctor's prescription for NHRT from scratch. Not all pharmacies are compounding pharmacies, so ask your doctor or current pharmacist about where to go to get such a prescription prepared. You can also call the International Academy of Compounding Pharmacists (IACP) or the Professional Compounding Centers of America (PCCA) for the nearest compounding pharmacist in your area. Most compounding pharmacists are members of either or both organizations. You can reach the IACP at 800-927-4227 or go to iacprx.org and the PCCA at 800-331-2498 or pccarx.com.
Phytoestrogens: The HRT Alternative
If you are uncomfortable with the idea of taking any kind of hormone replacement therapy, you may wish to consider the therapeutic benefits of phytoestrogens, or plant estrogens. Many women treat their discomforts with herbs, as outlined in the "Flower Power" section later in this chapter.
Phytoestrogens contain a multitude of chemicals, including estrogenic substances. Although phytoestrogens have been used in Asian cultures for centuries to treat hot flashes, they're just beginning to catch on in the West. The first controlled trial began in 1996 at Columbia-Presbyterian Medical Center in New York.
Many food sources, such as soy, contain such high concentrations of phytoestrogens that scientists believe it may account for the incredible lack of menopausal discomforts in Japan, which has a soy-heavy diet. Blood levels of phytoestrogens are ten to forty times higher in Japanese women than in their Western counterparts, but Japanese women report hot flashes about one-sixth as often as Western women. Even the average vegetarian would not consume nearly as much soy as the average Japanese woman.
More interesting, plant hormones not only help prevent menopausal discomforts but also may protect you from breast cancer. Breast cancer rates are dramatically lower in Japan than in the United States, but there may be other factors involved, such as childbearing habits and fat intake. After menopause, high-fat diets can increase your risk of heart attack or stroke no matter how much estrogen you take. Meanwhile, bad habits, such as drinking coffee or alcohol or smoking, can all increase your risk of osteoporosis. Right now, most doctors will tell you to go ahead and add as much soy as you want to your diet. It may well help—and it certainly can't hurt! Soy has most recently been declared a "heart-healthy" food.
What Are the Drawbacks?
The problem with phytoestrogens is that they are plant hormones and not human hormones, which means that they will not solve the problem of rising FSH and LH levels (the gonadotropins, which "kick-start" the ovaries). However, some plants do encourage estrogen production, and some do contain flavonoids, which are estrogen-like.
Plant hormones can be converted to human hormones in a laboratory. What plant hormones do is to provide you with hormonal building blocks rather than hormones themselves, which in theory can allow you to create the amounts (and combinations) of hormones you need for your unique menopausal journey.
It is possible to have allergic reactions to a variety of herbs. It's also important to note that because herbal products are not regulated, there is a danger of misuse, overuse, or using poor quality merchandise.
Phytoestrogens can be taken orally or even in creams, which can be applied to your body parts. Creams are "quasi-natural," however, because the plant hormones they contain are modified in a lab. One good question many women are asking is whether phytoestrogens carry the same risks as Hormone Replacement Therapy (HRT). The answer is that because plant-based hormones contain chemicals that are similar but not identical to your natural estrogen, the risks of plant hormones are that you may still suffer from discomfort associated with estrogen loss in spite of your dedication to ingesting plant hormones.
John Lee's Estrogen Dominance Theory
Dr. John Lee is the next big name in the natural progesterone story. In the mid-1990s he began to publish his theory that many women are progesterone deficient due to estrogen dominance, which can be caused by synthetic estrogens in oral contraceptives or other hormone therapies; by obesity, which results in too much estrogen because fat cells make estrogen; by estrogen pollution, caused by the flushed urine of women on all these synthetic estrogens, which gets into our sewage systems and water supply; as well as by another form of pollution known as environmental estrogens, also called xenoestrogens, which are beyond our control. Hormones in meat are other sources of estrogen. Estrogen dominance can cause a myriad of women's health problems. Unless there is an equal ratio of progesterone to estrogen, estrogen dominance can mean a progesterone deficiency. And for some women, that translates into more severe menopausal symptoms as well as more severe PMS symptoms.
Where to Find Natural Progesterone
As discussed earlier, you must go to a compounding pharmacist to find natural progesterone. What you can get over the counter in some health food stores and natural pharmacies are creams containing botanical progesterone, which is progesterone that comes from plants such as wild yam. This is not harmful, but it will not be as pure as the progesterone your doctor prescribes, which often comes from soy and wild yam, too, but is a very pure extraction. The term natural does not mean "human"—instead, it means that it is not synthetic. Natural progesterone is recognized by our progesterone receptors as if it were progesterone we made in our bodies.
Creams
Progesterone works very well in cream form. There are a few kinds:
-creams that contain only progesterone in a carrier such as aloe vera or vitamin E
-creams with progesterone and other essential oils or herbs
-creams that contain progesterone and phytoestrogens (plant estrogens)
-creams that contain progesterone and three kinds of natural estrogen
Creams that contain estrogen are not for you; these creams are for menopausal women who are using natural hormone therapy to relieve estrogen loss and other menopausal discomforts.
Natural progesterone can also be found in an oil form (which is taken under the tongue), as tablets, as capsules, as vaginal suppositories, as a vaginal gel, and in an injectable form.
By M. Sara Rosenthal, PhD
WebMD Medical Reference from "The Gynecological Sourcebook"
IN JULY 2001 a study by the U.S. National Heart, Lung, and Blood Institute, part of a huge research program called the Women's Health Initiative, suggested that hormone replacement therapy should not be recommended for long-term use; in fact, the results were so alarming, the study was halted before its completion date. It was found that Prempro, a combination of estrogen and progestin, which was a "standard issue" HRT formulation for postmenopausal women, increased the risk of invasive breast cancer, heart disease, stroke, and pulmonary embolisms (blood clots). However, Prempro did reduce the incidence of bone fractures from osteoporosis and colon cancer. Nevertheless, the idea that HRT is a long-term "fountain of youth" is slowly dissolving. The study participants were informed in a letter that they should stop taking their pills. HRT in the short term to relieve menopausal symptoms is still considered a good option, and there was no evidence to suggest that short-term use of HRT was harmful. The study only has implications for women on HRT for long-term use—something that was recommended to millions of women over the past twenty years because of perceived protection against heart disease.
In 1998 an earlier trial, known as the Heart and Estrogen/Progestin Replacement Study, looked at whether HRT was reduced in women who already had heart disease. HRT was not found to have any beneficial effect. Women who were at risk for breast cancer were never advised to go on HRT; similarly, women who had suffered a stroke or who were considered at risk for blood clots were also never considered good candidates for Hormone Replacement Therapy (HRT). It had long been known that breast cancer was a risk of long-term HRT, as well as stroke and blood clots. However, many women made the HRT decision based on the fact that it was long believed to protect women from heart disease. Millions of women are now questioning whether they should be on HRT in light of what many experts are calling the "9-11 of HRT." This discussion provides you with the new rules about HRT.
What Is Hormone Replacement Therapy (HRT)?
Hormone replacement therapy (HRT) refers to estrogen and progestin, which is a factory-made progesterone, given to women after menopause who still have their uterus to prevent the lining from overgrowing and becoming cancerous (known as endometrial hyperplasia). Estrogen replacement therapy (ERT) refers to estrogen only, which is given to women who no longer have a uterus after surgical menopause. Both HRT and ERT are designed to replace the estrogen lost after menopause and hence:
Prevent or even reverse the long-term consequences of estrogen loss. The only proven long-term benefit of HRT is that it can help to preserve bone loss and reduce the incidence of fractures. Until July 2001 it was believed that HRT protected women from cardiovascular disease, but this is no longer considered true. In women who are at higher risk of breast cancer, HRT was always believed to be risky; now it is believed that it may trigger breast cancer in low-risk women.
Treat the short-term discomforts of menopause, such as hot flashes and vaginal dryness. This is all still true, and you can discuss with your doctor how long he or she recommends that you stay on HRT before it becomes risky.
Once you weigh the benefits and risks, if you decide to be treated with conventional HRT or ERT, you have the choice of using it as either a short-term therapy or a long-term therapy.
Being a Slave to the Medical System
An obvious but underreported risk of HRT is that it forces you into another continuous cycle: one of constant doctor visits and tests. And each time you go to your doctor, you risk some sort of invasive procedure or referral for invasive tests. For example, women on HRT are more likely to be prescribed the following tests or medications:
-blood tests for hormone levels
-diuretics for fluid retention
-Ponstan, aspirin, or other analgesics for uterine cramps
-endometrial biopsies to check the endometrium
-D & C for bleeding
-blood pressure tests
-blood tests for cholesterol levels
-baseline mammograms before starting therapy and regular mammograms thereafter
-visits for repeat prescriptions of hormones at least every six months
Women who are not on HRT are not burdened by as many tests, visits, and other procedures. Do these increased doctor visits save lives because they offer early detection of many serious diseases? Critics of HRT argue that women are paying a higher price for their dependency on the medical system and are burdened with too much monitoring and early detection.
The Forms of HRT and ERT
You can take estrogen in a number of ways. The most common estrogen product uses a synthesis of various estrogens that are derived from the urine of pregnant horses. That way the estrogen mimics nature more accurately. Estrogen replacement comes in either pills, patches (transdermal), or vaginal creams. Other common, synthetic forms of estrogen include micronized estradiol, ethinyl estradiol, esterified estrogen, and quinestrol.
As a short-term therapy, you may only need the vaginal cream to help with vaginal dryness or bladder problems. Estrogen can also be "worn." In this case, it's placed in a small plastic patch about the size of a silver dollar, worn on the abdomen, thighs, or buttocks, and changed twice weekly.
When estrogen is in patch or cream form, it goes directly to the bloodstream, bypassing the liver; this form of estrogen was previously discouraged for some women because it was not considered to have any protection against heart disease. But in light of the recent risk of heart disease with conventional formulations of HRT, the patch may pose no long-term harm, and you may want to discuss whether this is an option for more long-term use. Some women also have an allergic reaction to the skin patch and get a rash. If you're one of them, you can investigate taking the estrogen in other forms.
Finally, you can also have estrogen injected. Each shot lasts between three and six weeks, but this is expensive and inconvenient. Estrogen gel containing estradiol is now being used in some parts of the world, though it is not yet available in North America. The gel is spread over a wide area of the abdomen every second day. The problem women have encountered with this method is a variation in levels of absorption each time the gel is applied.
Even more controversial are the pellets or implants containing estradiol inserted under the skin of the abdomen or buttocks under local anesthetic. Subcutaneous implants are also not yet available in North America, primarily because they are difficult to remove or halt if a woman experiences complications.
What About Progestin?
This is the synthetic version of progesterone that is found in all combination oral contraceptives and the injectable contraceptive Depo-Provera. Progesterone receptors do not recognize progestin and will not transport it to the cells. This may account for many of the progestin-related side effects that mimic PMS. The most common progestins include Provera, Amen, Curretab, and Cycrin (all brand names of medroxyprogesterone acetate); Duralutin, Gesterol L.A., Hylutin, and Hyprogest 250 (all brand names of hydroxyprogesterone caproate); Norlutate, Norgestrel, and Aygestin (all brand names of norethindrone acetate); Norlutin (norethindrone); and Magace (megestrol acetate). Micronor, Nor-Q.D., and Ovrette are other brand-name progestins on the market.
Progestins are taken in separate tablets along with estrogen. Together, the estrogen and progestin you take is called Hormone Replacement Therapy (HRT). HRT can be administered two ways: cyclically or continuously. Taking HRT cyclically is very similar to taking an oral contraceptive because the hormones more closely mirror a natural cycle. The first day you start is considered day 1 of your mock cycle. You take estrogen from day 1 to day 25; you then add the progesterone from day 14 to day 25. Then you stop all pills and bleed for two or three days—just as you would on a combination oral contraceptive. This vaginal bleeding is called withdrawal bleeding, which is lighter and shorter than a normal menstrual period, lasting only two or three days—just like a period on a combination oral contraceptive. In fact, if the bleeding is heavy or prolonged for some reason, this is a warning that something's not right, and you should get it checked.
In addition, you may experience breakthrough bleeding, or spotting, during the first three weeks after you begin Hormone Replacement Therapy (HRT). This kind of bleeding is, again, similar to what happens on a combination oral contraceptive. This bleeding usually goes away after a few months, but report it anyway. You may need to switch to a lower dose of estrogen or take a higher dose of your progestin. Once your miniperiod of withdrawal bleeding is finished, you simply start the cycle again. Many women can't tolerate cyclical HRT because they feel as though they should be rid of their periods by now and not have to deal with pads and tampons ever again. However, it is believed that cyclical HRT offers slightly better heart protection.
When HRT is taken continuously, you simply take one estrogen pill and one progestin pill each day. When you do it this way, the progesterone counteracts the estrogen; no uterine lining is built up, so there's no withdrawal bleeding that needs to happen.
The Appropriate Dosages
Every woman requires a different dosage of estrogen and progestin. But initially you will always be placed on the lowest possible dosage of either one and may have the dosage increased gradually if necessary. If your estrogen dosage is too high, you'll experience side effects similar to those seen with oral contraceptives: headaches, bloating, and so on.
So before you or your doctor determines how much estrogen you'll need, it's crucial to first determine how much your body is still producing; this really depends on your weight, estrogen loss discomforts, and a hundred other things.
Common Side Effects
If you're taking cyclical progestins with your estrogen because you still have your uterus, bleeding is not a side effect! The whole point of adding progestin to your estrogen is to trigger withdrawal bleeding and get your uterine lining routinely shed. However, if you're taking continuous progestins with your estrogen, bleeding is not the norm and should be checked into.
A common side effect of estrogen is fluid retention, because estrogen will decrease the amount of salt and water excreted by kidneys, which is retained by legs, breasts, and feet, which can swell. Because of the fluid retention, you may weigh more, but you will not necessarily be fatter.
Nausea is another common side effect, also seen with oral contraceptives. This happens during the first two or three months of your therapy and should just disappear on its own. Some women find that taking their dosages at night (for pills) may remedy this. Decreasing the dosage is also an option.
Some other side effects reported include headaches, skin color changes (called melasma) on the face, more cervical mucus secretion, liquid secretion from the breasts, change in curvature of the cornea, jaundice, loss of scalp hair, and itchiness. Again, these side effects vary and depend on the brand you're taking, the dosage, your medical history, and so on.
Are You an HRT or ERT Candidate?
In light of the recent shadow cast over HRT, clearly it is not for everyone. If you answer yes to any of the following questions, you might consider short-term or long-term use of HRT or ERT:
-Do you suffer from severe hot flashes that don't respond to the natural remedies in the section "Flower Power"?
-Are your vaginal changes causing urinary tract infections, vaginitis, or painful intercourse, which does not respond to such remedies as more stimulation of the clitoris during sex or sexual lubricants?
-Are you concerned about developing osteoporosis? Studies still support that using HRT or ERT in the long term may lower your risk of developing osteoporosis. (But so will exercise and a high-calcium diet.) There are now bone-building drugs that are alternatives to HRT and ERT, which you can discuss with your doctor.
-Women Who Shouldn't Be on HRT or ERT
Women who suffer from certain medical conditions should not be on HRT or ERT as discussed in the following list:
-Women with a history of endometrial cancer should not be on unopposed estrogen ERT. Again, if you still have a uterus, you'll be placed on HRT (estrogen and progesterone), which lowers your cancer risk anyway.
-Women with breast cancer or a history of breast cancer or who are considered at high risk for breast cancer should not be on either HRT or ERT.
-Women who have had a stroke should not be on either HRT or ERT.
-Women who have a blood-clotting disorder should not be on either HRT or ERT.
-Women with undiagnosed vaginal bleeding should not be on HRT or ERT.
-Women with liver dysfunction may be on the estrogen patch or use vaginal cream to relieve menopausal discomforts but shouldn't take any pills orally.
-Women Who May Benefit More from HRT or ERT
-Discuss with your doctor whether you're a candidate for HRT or ERT, given the protective effects each has against osteoporosis and colon cancer.
However, you may need to think twice if you have any of the following other conditions:
-sickle cell disease
-high blood pressure
-migraines
-uterine fibroids
-a history of benign breast conditions such as cysts or fibroadenomas
-endometriosis
-seizures
-gallbladder disease
-a family history of breast cancer
-a past or current history of smoking
-Natural Hormone Replacement Therapy (NHRT)
Many of you may have heard the media hype surrounding natural hormone replacement therapy (NHRT), which includes natural progesterone, versus conventional hormone replacement therapy (HRT). The difference is akin to the difference between breast milk and formula for a baby. NHRT is a combination of human estrogens and natural human progesterone. HRT, on the other hand, is a factory-made estrogen, much of which is derived from horse estrogen, and a factory-made progesterone, called progestin. Now many reports and studies show that the symptoms of menopause are better controlled with NHRT, and with fewer side effects.
What NHRT Contains
When you go on NHRT, you're getting about 60 to 80 percent estriol, 10 to 20 percent estrone, and 10 to 20 percent estradiol, as well as natural human progesterone plus DHEA (dehydroepiandrosterone), a "natural androgen," if you will, that turns into a "natural testosterone" in the body, something all women need to maintain sex drives. On HRT you're getting 75 to 80 percent estrone, 6 to 15 percent equilin (a horse-derived estrogen), and about 5 to 19 percent estradiol, as well as progestin, a factory-made progesterone, and sometimes anabolic steroids, if your libido needs a boost.
The bottom line is that human women do better with human hormones rather than animal-derived hormones, just like human infants do better on human milk than cow's milk. However, as you can see from the range of concentrations of various natural estrogens, it may take a while for you to find just the right dose of each kind of natural estrogen and progesterone, so you have to work with your doctor and experiment until you get it right. There is a perception out there that NHRT is perfect the first time you take it, but many women have to tinker with their "triple estrogens" before they find the right combination: a typical prescription for NHRT is often 10 percent estrone, 10 percent estradiol, and 80 percent estriol, mixed with about 25 to 30 mg natural progesterone after menopause and 10 to 30 mg DHEA, which should, but doesn't always, convert into necessary amounts of testosterone. (If it doesn't, you may need to add a steroid to the mix of natural hormones if your libido is very low, which can be debilitating.)
Where Do You Find NHRT?
All the books and articles about NHRT can mislead you into thinking that NHRT is just available everywhere. This is not so. You can't simply walk into a health food store and buy natural estrogens or progesterones. They need to be prescribed by a doctor (although the doctor need not be an M.D.; several naturopathic doctors are prescribing them, too). A pharmacist, known as a compounding pharmacist, has to prepare a doctor's prescription for NHRT from scratch. Not all pharmacies are compounding pharmacies, so ask your doctor or current pharmacist about where to go to get such a prescription prepared. You can also call the International Academy of Compounding Pharmacists (IACP) or the Professional Compounding Centers of America (PCCA) for the nearest compounding pharmacist in your area. Most compounding pharmacists are members of either or both organizations. You can reach the IACP at 800-927-4227 or go to iacprx.org and the PCCA at 800-331-2498 or pccarx.com.
Phytoestrogens: The HRT Alternative
If you are uncomfortable with the idea of taking any kind of hormone replacement therapy, you may wish to consider the therapeutic benefits of phytoestrogens, or plant estrogens. Many women treat their discomforts with herbs, as outlined in the "Flower Power" section later in this chapter.
Phytoestrogens contain a multitude of chemicals, including estrogenic substances. Although phytoestrogens have been used in Asian cultures for centuries to treat hot flashes, they're just beginning to catch on in the West. The first controlled trial began in 1996 at Columbia-Presbyterian Medical Center in New York.
Many food sources, such as soy, contain such high concentrations of phytoestrogens that scientists believe it may account for the incredible lack of menopausal discomforts in Japan, which has a soy-heavy diet. Blood levels of phytoestrogens are ten to forty times higher in Japanese women than in their Western counterparts, but Japanese women report hot flashes about one-sixth as often as Western women. Even the average vegetarian would not consume nearly as much soy as the average Japanese woman.
More interesting, plant hormones not only help prevent menopausal discomforts but also may protect you from breast cancer. Breast cancer rates are dramatically lower in Japan than in the United States, but there may be other factors involved, such as childbearing habits and fat intake. After menopause, high-fat diets can increase your risk of heart attack or stroke no matter how much estrogen you take. Meanwhile, bad habits, such as drinking coffee or alcohol or smoking, can all increase your risk of osteoporosis. Right now, most doctors will tell you to go ahead and add as much soy as you want to your diet. It may well help—and it certainly can't hurt! Soy has most recently been declared a "heart-healthy" food.
What Are the Drawbacks?
The problem with phytoestrogens is that they are plant hormones and not human hormones, which means that they will not solve the problem of rising FSH and LH levels (the gonadotropins, which "kick-start" the ovaries). However, some plants do encourage estrogen production, and some do contain flavonoids, which are estrogen-like.
Plant hormones can be converted to human hormones in a laboratory. What plant hormones do is to provide you with hormonal building blocks rather than hormones themselves, which in theory can allow you to create the amounts (and combinations) of hormones you need for your unique menopausal journey.
It is possible to have allergic reactions to a variety of herbs. It's also important to note that because herbal products are not regulated, there is a danger of misuse, overuse, or using poor quality merchandise.
Phytoestrogens can be taken orally or even in creams, which can be applied to your body parts. Creams are "quasi-natural," however, because the plant hormones they contain are modified in a lab. One good question many women are asking is whether phytoestrogens carry the same risks as Hormone Replacement Therapy (HRT). The answer is that because plant-based hormones contain chemicals that are similar but not identical to your natural estrogen, the risks of plant hormones are that you may still suffer from discomfort associated with estrogen loss in spite of your dedication to ingesting plant hormones.
John Lee's Estrogen Dominance Theory
Dr. John Lee is the next big name in the natural progesterone story. In the mid-1990s he began to publish his theory that many women are progesterone deficient due to estrogen dominance, which can be caused by synthetic estrogens in oral contraceptives or other hormone therapies; by obesity, which results in too much estrogen because fat cells make estrogen; by estrogen pollution, caused by the flushed urine of women on all these synthetic estrogens, which gets into our sewage systems and water supply; as well as by another form of pollution known as environmental estrogens, also called xenoestrogens, which are beyond our control. Hormones in meat are other sources of estrogen. Estrogen dominance can cause a myriad of women's health problems. Unless there is an equal ratio of progesterone to estrogen, estrogen dominance can mean a progesterone deficiency. And for some women, that translates into more severe menopausal symptoms as well as more severe PMS symptoms.
Where to Find Natural Progesterone
As discussed earlier, you must go to a compounding pharmacist to find natural progesterone. What you can get over the counter in some health food stores and natural pharmacies are creams containing botanical progesterone, which is progesterone that comes from plants such as wild yam. This is not harmful, but it will not be as pure as the progesterone your doctor prescribes, which often comes from soy and wild yam, too, but is a very pure extraction. The term natural does not mean "human"—instead, it means that it is not synthetic. Natural progesterone is recognized by our progesterone receptors as if it were progesterone we made in our bodies.
Creams
Progesterone works very well in cream form. There are a few kinds:
-creams that contain only progesterone in a carrier such as aloe vera or vitamin E
-creams with progesterone and other essential oils or herbs
-creams that contain progesterone and phytoestrogens (plant estrogens)
-creams that contain progesterone and three kinds of natural estrogen
Creams that contain estrogen are not for you; these creams are for menopausal women who are using natural hormone therapy to relieve estrogen loss and other menopausal discomforts.
Natural progesterone can also be found in an oil form (which is taken under the tongue), as tablets, as capsules, as vaginal suppositories, as a vaginal gel, and in an injectable form.
