Menopause & Natural (Bio-identical) Hormone Replacement Therapy
by J.P. Saleeby, MD
Hormones and their Functions
Hormones are chemical messengers, produced by the endocrine system (produced by one organ), that circulate in your bloodstream giving instructions to your cells (another organ/system). For example, the thyroid gland's hormone, thyroxine (T4), governs and monitors your body's rate of metabolism and energy production.
The hormones that are most vulnerable to the aging female are called sex steroid hormones produced by a woman's ovaries.
Sex (Gonadal) Steroid Hormones
Estrone (E1), Estradiol (E2), and Estriol (E3): Categorized as 'the estrogens', each of these ovarian hormones has its particular functions. Estradiol, the most potent estrogen, primarily aids in the cyclic release of eggs from the ovaries for potential fertilization and preparation of the uterus for pregnancy. In addition to its role in cycling and pregnancy, estradiol also has powerful beneficial effects on heart, bone, brain and colon. It is the reduction in the level of estradiol that causes common menopausal symptoms such as hot flashes and night sweats. Estriol is produced in large quantities during pregnancy and is considered by some to be the 'gentle' estrogen providing some of the protection without exposure to the risks associated with stronger estrogens. Estrone, which can be converted to estradiol in some women, is the primary estrogen in postmenopausal women and is generated in fat cells.
Progesterone: Produced cyclically by the ovaries, progesterone maintains the uterine endometrium to nurture a fertilized egg and allows for fetal development throughout a pregnancy. Progesterone has been labeled the body's anti-estrogen, partnering with estradiol to maintain the delicate balance required between a woman's reproductive hormones. A woman's progesterone level diminishes, along with that of estradiol, as she approaches and enters menopause and, in most women, drops to low postmenopausal values.
As a woman ages (in her 40’s or 50’s)there is the slow decline of ovarian hormone production beginning with the irregular cycling of perimenopause which can last several years followed by menopause which is defined as not having cycled for twelve consecutive months. Though menopause brings with it a variety of desirable changes in a woman's life such as no more menstrual cycles, contraception or PMS, there can be many undesirable symptoms. These include:
- Hot flashes, night sweats
- Vaginal dryness
- Dryness and thinning of skin, nails, hair
- Bone loss
- Mood swings
- Decrease in libido (sex drive)
- Memory problems
- In addition to the decline in estradiol and progesterone levels, a woman's testosterone and DHEA levels continue to drop throughout her lifetime and are responsible for some menopausal symptoms.
Surgically Induced Menopause
Removal of a woman's ovaries will result in immediate menopause creating a series of rapid and intense symptoms that can be debilitating and can be addressed successful0ly with the appropriate form of hormonal intervention.
Diseases Associated with Hormones and the Aging Process
- Heart disease is the number one killer in America and the leading cause of death in women over age 65. As a woman's estradiol level decreases, her risk of heart disease increases. Older women are 10 times more likely to die from heart disease than breast cancer.
- Osteoporosis, a disease that occurs when bone is breaking down faster than it is being rebuilt, makes bones more fragile and susceptible to fracture. Testosterone has also been shown to help protect against osteoporosis.
- Alzheimer's Disease affects more than four million Americans a year with women at greater risk than men. Women taking estrogen therapy have a significantly lower risk of the dementia. In addition, recent animal studies indicate that testosterone may also have a protective effect against Alzheimer's Disease.
- Colon cancer is the second leading cause of cancer death in the United States with women at greater risk than men. Estradiol is now being studied as providing protection against this disease though the mechanism is still unclear.
What is Hormone Replacement Therapy?
HRT is the administration of steroid hormones (either natural, synthetic or animal-derived) to make up for the decline in those hormones (that drop naturally with age). Natural HRT or bio-identical HRT refers to a regimen of hormones that is bio-identical in structure and physiological activity to what the body produces. Importantly it also refers to the correct ratios of hormones. For example the correct ratio of E1:E2:E3 and E2:P. Natural progesterone is derived from Mexican Wild Yam, but must be manipulated in the lab. The wild yam is only active in humans once pharmaceutical conversion has taken place. Natural HRT brings with it the following benefits:
- Better tolerance (less unwanted side effects) such as blood clots, gallbladder disease.
- Better therapeutic profile, since the ratios are correct for humans.
- Improved long term patient acceptance.
Currently, more and more women and men are opting for natural HRT. Given both the short and long term health benefits, HRT is now considered by many healthcare providers as the preventive medicine of the 21st century for women and men in the second half of life. On the average, a female HRT user can expect to live up to 3 years longer than a non-user.
Replacing the body's declining hormones with natural, bio-identical hormone replacement is quite different from what might be considered 'natural' menopausal choices that can include:
- Maintenance of a healthy lifestyle such as frequent exercise, no smoking and minimal stress
- Dietary intervention with plant estrogens (such as those in soy products)
- Herbal intervention such as with dong quai, black cohosh or licorice (see below)
While there are scientific studies showing that some of these solutions do address short-term symptoms such as hot flashes, research is on going as to the long-term benefits of natural, non-hormonal solutions. This topic is evoking much interest especially with breast cancer patients and survivors who are experiencing severe menopausal symptoms and hesitate to intervene with hormones. While there is some concern about the estrogenic effects of these phytoestrogens they are weak at best and do not come close to the potency of E2. It is said that about 25% of postmenopausal women with breast cancer and 15% of postmenopausal women without breast cancer use these products. This is the conclusion by researchers at the Univ. of Pittsburgh studying the effects of Dong quai, vitex, Chinese ginseng, American ginseng, black cohosh, red raspberry leaf, licorice root, wild yam root.
Soy based compounds such as tofu, soy milk, roasted soy nuts, (and in one study 60 grams of soy protein daily caused a 33% decrease in not flashes after 4 weeks and 45% reduction after 12 weeks) are useful in reducing menopausal symptoms.
Vitamin E (800 IU per day) has been shown in studies as far back as the late 1940’s to alleviate menopausal symptoms. A trial period of no less than 3 months is recommended.
Vitamin C (1200 mg daily) was studied in the mid 1960’s and reports concluded that in combination with the bioflavonoid hesperidin ameliorate menopausal symptoms.
Herbals with weak estrogen-like actions have similar effects they include Licorice, Alfalfa, Red clover, Black cohosh, Vitex, Dong quai, Ginseng and Sage (useful in profuse sweating) have been tested by Germany’s Commission E. It is recommended that before starting any herbal patients should consult with their physician especially a nutritionally minded physician. While herbal preparations are somewhat effected the compounded NHRT creams and prescriptions are the most potent form of replacing low hormone levels.
Women who lead sedentary lifestyles are more likely to have menopausal symptoms. In one trial menopausal symptoms were reduced immediately after aerobic exercise. Aerobic exercise is certainly recommended for other health benefits as well.