Hormone Replacement Therapy in Menopause, Perimenopause and Estrogen Dominance.
By Andrea Cole-Raub, DO
WHAT IS MENOPAUSE?
Strictly speaking, menopause occurs when your menstrual cycle ceases for one year, and it’s one of the few medical conditions that can persist for a year before being diagnosed and treated.
Of course, most of us think of menopause as the stage in a woman’s life when her menstrual periods stop (and other bodily changes occur), as a result of decreasing levels of various hormones. But while most hormones are decreasing, two hormones – cortisol and insulin – may increase during the menopausal years, leading to excess abdominal fat and the slow disappearance of your waistline, among other things.
The average woman is familiar with some menopause symptoms, including hot flashes, sleep disturbance, foggy brain and depression. However, these problems may be just the tip of the iceberg.
I recently saw a new patient who was “well past” menopause, but had gained fat tissue (although her weight stayed the same), and experienced higher blood pressure, cholesterol and glucose intolerance. In addition, she was suffering a rapid decline in bone density, and had embarrassing moments of incontinence. And these were just some of her symptoms!
Once you encounter menopause, you’re stuck with it, BUT you needn’t be stuck with adverse effects to your health and appearance, as long as you restore certain all-important hormones.
Today, you have a choice about how you want to age. You can live a healthy life, filled with energy and passion, provided you maintain a balanced endocrine system.
THE 34 MOST COMMON MENOPAUSE SYMPTOMS
• Hot Flashes
• Night Sweats
• Irregular Periods
• Loss of Libido
• Vaginal Dryness
• Mood Swings
• Hair Loss
• Sleep Disorders
• Difficulty Concentrating
• Memory Lapses
• Weight Gain
• Brittle Nails
• Changes in Odor
• Irregular Heartbeat
• Panic Disorder
• Breast Pain
• Joint Pain
• Burning Tongue
• Electric Shocks
• Digestive Problems
• Gum Problems
• Muscle Tension
• Itchy Skin
• Tingling Extremities
ESTROGENS IN MENOPAUSE
There are 3 types of estrogens: estrone (E1), estradiol (E2) and estriol (E3).
Estrone is the estrogen of menopause, but because it produces a number of undesirable side effects, there is controversy over whether or not to replace estrione. One drug, Triest, is a combination of 80% estriol, 10% estradiol and 10% estrione. However, few anti-aging doctors prescribe this combination of estrogens when treating menopause.
Estradiol is the most abundant estrogen during the reproductive years. In the brain, it affects serotonin levels, pain threshold and fine motor coordination. It also affects your ability to learn and multitask. By inhibiting an enzyme called choline acetyl transferase, estradiol decreases your risk for Alzheimer’s disease. This is yet another reason why women in menopause benefit from estrogen replacement.
Estradiol also has a number of desirable affects on the heart. Transdermal estradiol reduces CRP, an inflammatory marker associated with heart disease. In many studies, it has been shown to be cardio protective, improving the elasticity of your arteries and decreasing the accumulation of plaque. Estradiol is also important for your skin and hair, your bones, energy production, and over all well-being.
Estradiol has a profound effect on a woman’s sexuality. It maintains the integrity of the vaginal wall and the cells lining the vagina. Without estradiol, the cells become thin, and the vaginal lining dries out. Obviously, this diminishes sexual pleasure by making certain activities uncomfortable and even painful.
Most important, without estradiol, the body is thrown into accelerated aging.
Some women will show symptoms of estrogen deficiency a few days before their cycle starts and into the first week of the cycle. They may suddenly feel exhausted, depressed, crying for no particular reason, have difficulty focusing, and may suffer from migraine headaches and joint pain. Often a low dose estradiol gel is beneficial. Estradiol can be best replaced as a Transdermal gel, or patch. (Oral estrogens are not recommended.)
Estriol is the weakest of all three estrogens. Found in the placenta, Estriol appears to protect against breast cancer.
The drug Biest is a combination of both estradiol and estriol, and is most often prescribed by anti-aging doctors.
BENEFITS OF TESTOSTERONE IN MENOPAUSE
Most women experience some change in sexual function during the years just before and after menopause. Usually, sexual complaints include loss of desire, painful intercourse, and diminished sexual responsiveness. Sexual arousal and function can all be influenced by ovarian hormone levels. This is why testosterone replacement often helps to restore sexual function.
Testosterone may be given as a topical cream or gel, while some physicians insert pellets. If using a cream, follow-up testing must be done by examining saliva or urine.. Blood levels may not be accurate when using a cream. If using a gel, either blood, saliva or urine may be used to follow levels.. If a level is too high, changes in doses may take months for the saliva to reflect theses changes.
Testosterone treatment has a number of other beneficial effects in women. Testosterone has been shown to increase bone density in the hip and arm bones, and also decreases fat while increasing lean muscle. In addition, testosterone helps women overcome excessive worry, since it’s been shown to improve mood and quality of life.
Judith is a 54-year-old patient who was a candidate for hormone replacement. She hadn’t had a period for five months, and was suffering from night sweats and brain fog. She also reported a history of fibroids, FCBD, very heavy bleeding during her cycle and increasing PMS toward the end of her cycle. Although she may have multiple hormone deficiencies, her history indicates estrogen dominance.
Estrogen dominance refers to a possible imbalance between estrogen and progesterone. The symptoms of estrogen dominance include:
• Weight gain
• Breast tenderness
• Fibrocystic Breast
• Dense Breast on mammograms
• History of Fibroids
• Cold hands and feet
• Dry hair
• Increased risk of female cancer
WHAT IS ESTROGEN DOMINANCE?
The causes of estrogen dominance are much more complex than the ratio between progesterone and estrogen. Estrogen dominance may be caused by a variety of environmental factors, including exposure to certain plastics, eating commercially fed animals whose diet may contain hormones, exposure to pesticides, excess caffeine, and living very stressful lifestyles. One common cause of estrogen dominance is the formation of active metabolites that have estrogen actions. Your antiaging doctor can measure how your body metabolizes estrogen and more importantly recommend ways it can be altered.
Treating estrogen dominance involves lifestyle changes, use of bio-identical hormones and certain supplements. The best way to restore hormone balance is to work with a physician to identify the causes of estrogen dominance.
Maintaining a healthy weight is also essential, as is reducing alcohol consumption and eating a low-fat diet that helps eliminate toxic estrogen metabolites.
THE FUNCTION OF PROGESTERONE
Progesterone keeps the uterus quiet by protecting a pregnancy if an egg is fertilized. It also balances the effect of estradiol on building the lining of the uterus. If estrogen goes unopposed by progesterone, the lining is thickened and the woman experiences a much heavier cycle.
Progesterone increases a chemical in the brain called GABA – the body’s natural tranquilizer. (Anti-aging doctors refer to progesterone as the “calming hormone.”)
When progesterone is absent, you may experience anxiety, irritability, insomnia and even hot flashes. Without progesterone, a woman will experience more breast tenderness, and premenstrual headaches may increase in the perimenopausal years.
PROGESTIN IS NOT PROGESTERONE
When seeking Hormone Replacement Therapy, don’t be confused by Provera or methxyprogestin. They are not progesterone. These two medications belong to a class of drugs known as progestins, and are not bio-identical to the progesterone Mother Nature produces in your body. (Designed to look similar to progesterone, progestins are molecules that trick the body into believing it is receiving actual progesterone.)
Unfortunately, progestins increase the risk of breast cancer, and decrease the protection estradiol provides for the heart. In addition, while natural progesterone increases bone formation, a number of reported cases suggest that Provera contributes to osteoporosis
BIOIDENTICAL PROGESTERONE IN MENOPAUSE
Bioidentical or Human Identical hormone progesterone decreases the risk of breast cancer and increases the heart protective properties of estrogen. It is also neuroprotective, increases hair growth, and facilitates good sleep.
REPLACING PROGESTERONE IN PERIMENOPAUSE
Replacing progesterone with bioidentical progesterone is often helpful in menstruating women, and it can be given as a gel or cream. Both will work, but it is difficult to measure the level in the blood if a cream is used. (It can be measured in the saliva or urine.) Oral progesterone can have additional benefits on calming the brain and enhancing sleep.
Using progesterone may help with irregular cycles and heavy menses, and can often prevent the migraine headaches that occur one week before the cycle.
PROGESTERONE REPLACEMENT IN MENOPAUSE
There are a number of options in progesterone replacement in the menopausal woman. For example, some women will take progesterone daily while others will use progesterone 10-15 days a month. There are benefits to either approach, and it’s best to consult your anti-aging doctor to explore the method that’s best for you.
Your hormones begin to change around age 35, with the interval from 35 until your last menstrual cycle called perimenopause. In general, PMS increases, and your cycle becomes heavier. This is caused by cycles where ovulation does not occur. If a woman does not ovulate, or has a delay in ovulation, progesterone is not released (or is released too late in the cycle), causing an imbalance between estrogen and progesterone.
The symptoms of perimenopause are often triggered by other endocrine abnormalities. For example, because stress is associated with changes in adrenal hormones, balancing out the adrenal gland can often help a woman get through the ups and downs of perimenopause.
OTHER HORMONES OF MENOPAUSE
Pregnenolone is the called the grandmother steroid. It is derived from cholesterol, and can convert into a number of hormones. It has an effect on coping, blood sugar regulation, memory and even color appreciation.
Cortisol prepares the body for battle. In acute stress situations, both cortisol and DHEA increase. The rise in cortisol shunts blood back to the brain’s more primitive areas – putting the body into a reactive mode. (After all, if you need to run through a burning room, it’s best to react quickly and not think too long about it.) Blood is also redirected from the gastrointestinal and immune systems toward the muscles, so you have enough energy to carry out the task at hand. In addition, blood sugar goes up, and adrenaline is released to provide needed energy.
In our culture, stress is the usual cause of elevated cortisol levels. Over long periods of time, too much cortisol promotes unnecessary fat in the abdomen, as if the body were preparing for a battle that never comes. Prolonged production of cortisol results in blood sugar elevation, which in turn, causes insulin levels to rise. And higher insulin levels trigger a number of chemical reactions that result in inflammation.
In addition, high cortisol levels:
• Shrink the short-term memory area of your brain.
• Depress the immune system and compromise the health of the gastrointestinal system, causing some patients to develop ulcers, constipation and other inflammatory diseases of the bowel.
• Decreases estradiol, triggering the symptoms of menopause.
DHEA IN MENOPAUSE
DHEA is another hormone made in the adrenal gland. It protects against some negative effects of cortisol, and rises during times of acute stress.
Many conditions cause lower DHEA levels, including a high-sugar diet, worry, insomnia, chronic pain, and many medications. By age 70, your body produces only 25% of the DHEA that it once made.
DHEA improves the immune system, protects against heart disease and diabetes, improves memory, and cognition. In postmenopausal women, DHEA improves mood and coping.
DHEA also lowers cholesterol, increases a hormone called adiponectin (which shifts the body into fat burning mode), and lowers the incidence of blood clots, diabetes and heart disease.
One of my patients has a story typical of adrenal exhaustion. Mary P. was a 42-year-old who first visited me shortly after her divorce. Initially, she was very anxious, and couldn’t sleep. In addition, her mood was depressed and her period had stopped, which confused her, since the rest of the women in her family didn’t go into menopause until after 50. Her cortisol and DHEA were high, indicating she was in the early stages of adrenal stress.
Unfortunately, she disappeared from my practice for a few years, and when I recently saw her again, her physical appearance spoke volumes. Her weight was up, and all her fat was located in her mid abdomen. Her skin was thin, and muscle tone was diminished. Her hair was dry and her eyes were dull and tired. Adrenal stress had caused premature menopause.
She complained of depression, changes in memory, exhaustion, joint pain, and could not lose weight – even though she was not eating very differently. Her periods still were absent. Bone loss was significant.
A saliva test now showed that her cortisol was low, as was DHEA. And since DHEA contributes to testosterone in women, her testosterone was extremely low.
I replaced a number of hormones, and recommended supplements to rejuvenate her adrenal function. Within six months her cycle returned.
Although this patient appeared like someone entering menopause, the menopause symptoms were actually those of chronic stress.
PHYTOESTROGENS IN MENOPAUSE
Found in plants, phytoestrogens are a group of chemicals that can behave like estrogen. Two very effective phytoestrogens are Genistein and Resveretrol. Resveretrol has been shown to be neuroprotective, bone and heart protective, and may be used as a breast cancer protective treatment while on estradiol.
Genistein helps to prevent bone loss, and protects the heart, as well as the brain. Often, phytoestrogens are very helpful in the perimenopausal years.
HORMONE SAFETY IN MENOPAUSE
The safety of any hormone replacement program ultimately depends on the patient’s ability to metabolize these hormones, which is why – for example – proper estrogen replacement is more complex than simply measuring levels of hormones. The presence of xenoestrogens and unique pathways of metabolism of hormones affect the safety of hormone treatment.
Many doctors put too much emphasis on your hormone levels, whether they are examining blood, saliva or urine. Frequently these levels fail to explain the clinical picture.
An evaluation of one patient (Judith) revealed a number of low hormone levels. She was started on DHEA, pregnenolone, testosterone gel, Biest and oral progesterone. Follow-up testing revealed her levels to be normal, but she was bleeding and had breast tenderness. The answer was not in the levels. A full evaluation of her metabolic pathways revealed a number of abnormal pathways, which could be modified through nutritional supplements, thus increasing the safety of her program.
YOUR PHYSICIAN AND MENOPAUSE
The job of your physician during perimenopause and menopause is to identify which hormones are contributing to your symptoms, changing your program as you continue to change. Your anti-aging doctor can assist you in learning about the proper nutrients to take, and recommending dietary and lifestyle changes.
The transition to menopause is a time to reassess your health. Partnering with a physician who understands the big picture can assist you in the realization of your most important health goals.