Dr. Amy’s Wellness Tip for October 2016
Contributed by Dr. Amy Whittington, Trilogy’s Naturopathic Physician
Few medical treatments have waxed and waned the way the use of estrogen for menopausal women has. Prior to 2002, hormones like estrogen were prescribed frequently, almost routinely, for menopausal women, especially those suffering from hot flashes, low libido, poor mood, and sleep disturbance. In 2002, however, the release of a large-scale study on hormone use in women, the Women’s Health Initiative (WHI), caused a sudden halt in the use of estrogen and other hormones for both men and women.
With limited alternate treatment options, this left many women to suffer through disturbing sweats, sleepless nights, and emotional roller coasters. Nearly 15 years later, however, we are prescribing estrogen once again. Leafing through popular magazines, it is not uncommon to find ads promoting the safe and beneficial use of estradiol, the most prominent type of estrogen. We have reversed our stance on hormone therapy to the relief of many sufferers benefitting from hormone therapy.
The ripple effect of the WHI in 2002 caused nearly all types of physicians to completely abandon hormones, whether synthetic or compounded bio-identicals, because at the time, we were unsure what component was increasing risks (and significantly so) for breast cancer and cardiovascular disease. With further review and study, it was determined that the most causative agent was the inclusion of a synthetic type of progesterone called progestin, which alone carries all of the risk factors seen with the combination used in the WHI. Use of estrogen alone, or better yet, a combination of estrogen and progesterone (not the synthetic progestin), eliminates these risk factors for most women. Multiple studies since 2002 indicate benefits for hormone use even beyond the obvious relief of menopausal symptoms.
I would be remiss if I did not point out that hormones of any kind hold some risk for women. Certain types of breast and ovarian cancer can have what are called estrogen receptors. These receptors responds to estrogen, and in the case of a cancerous cell or tumor, exposure to any estrogen, whether endogenous, synthetic, or bio-identical, can cause cancer cell or tumor growth. Women who have had hormone-sensitive cancers, who have first-degree relatives with hormone-sensitive cancers, or those with a positive genotype, are more likely to have these receptors, and so hormone therapy is often avoided for these groups. It is possible for any woman to have these receptors, so use of hormones is not completely risk-free for anyone.
However, you may be considered lower risk if you are within approximately a five-year window of having had estrogen in your system. For example, it is desired that you be within five years of menopause (which begins one year after the cessation of your cycle) or that you are within five years of using any kind of estrogen (i.e. if you have been menopausal 10 years but had an estrogen patch that you stopped using three years ago, you are still within the five-year window). It is thought that within this five-year span, your likeliness for aberrant receptors is lower. If you are outside of the high-risk group and within the five-year window, benefits of hormones, especially bio-identical ones, might make consideration worthwhile.
While menopause symptoms may be subtle for some and seem trivial to others who have not experienced them, some women, have debilitating symptoms and the use of hormones becomes an obvious choice to improve their quality of life. Further evidence suggests that benefits of hormone therapy may go well beyond relief of symptoms. A study published in the Journal of American Medical Association (JAMA) showed a decrease in cardiovascular risk by 46% for those who initiated estrogen use in their 50s. Hormone therapy has also been shown to improve bone health and decrease bone loss. A small study also showed a neuroprotective effect that could decrease risk for dementia. To the delight of many, we also see improvements in skin and tissue health with the use of hormones.
Although commercial pharmaceutical estrogen most commonly used now is much better than the version used prior to 2002’s WHI, don’t rush to your doctor with that magazine ad just yet. There are great benefits in the use of bio-identical hormones (BHRT) versus estradiol alone. It used to be that integrative physicians and naturopaths were the primary prescribers for this version of hormone therapy, but now many general practitioners and traditional gynecologists also choose to prescribe bio-identicals, which are compounded for patients individually at a compounding pharmacy. One advantage of BHRT is the inclusion of a weaker estrogen, called estriol, in the compound with the stronger estradiol (a combination typically referred to as bi-est). This weaker estrogen is thought to act as a buffer against the more powerful estradiol, lessening the risks of therapy for women who may have estrogen-sensitive receptors that we don’t know about. Progesterone is also typically compounded with the bi-est and guards against the over-proliferation of the lining of the uterus.
It used to be thought that if a woman no longer had a uterus, she no longer needed progesterone; we now know that progesterone affects not only on the uterus, but also in the breast tissue, brain, and perhaps even other places systemically for women. Furthermore, studies which combine the use of both progesterone and estrogen show an even further reduced risk for breast cancer than those using estrogen alone. Compounded BHRT is commonly given via a transdermal application (i.e. a cream on the skin), a sublingual (lozenge), or a pellet (placed under the skin), all of which carry less cardiovascular risk than an oral application. Finally, other hormones including testosterone and various hormone precursors can be included as necessary to a compounded form of BHRT to properly balance all of the sex hormones.
It goes without saying that if you decide you want to proceed with bio-identicals, or any kind of hormone therapy, you should talk to your physician about the risks and benefits specific to you. Proper hormone care should include screening and monitoring of hormones levels, usually every 6-12 months, to ensure that you are falling within a normal range.
It is not 2002 anymore, and estrogen is back. Thank goodness, especially for those women who suffer with menopausal symptoms, but also thankfully for all women, as studies are likely to show further decreases in morbidity and deteriorating bone strength with the proper balance of hormones. Talk with your physician about what options are right for you.
Stay healthy and be well!
Amy Whittington, NMD