Hormone replacement therapy - An Anti-Aging Physician’s Perspective
"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, M.D
Occasionally we share a technical article. Of course, the information contained in them is important to us. Generally, people find the idea of safe hormone replacement therapy quite overwhelming.
For this reason, I have decided to write about the scientific evidence that we have available today. To begin with, is it possible to do HRT in a safe and controlled way? Indeed, many of my female patients thrive on their therapy.
Before we go further, it is important to note that we look at two different types of hormone therapy. Firstly, there are non-bioidentical hormones which have a similar structure to the hormones in your body. Secondly, there are bioidentical hormones that are exactly the same structure to those found naturally in your body.
What do we know about the non-bioidentical synthetic hormone replacements?
To begin with, 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 government-sponsored 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 hormone study were either given conjugated horse estrogens plus a synthetic progestin or a placebo.
The study revealed the following results:
- 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.
Furthermore, several other hormone studies have shown recently that progestins (synthetic progesterone) have an unfavourable effect on lipid levels and may promote cardiovascular disease.
We need to be fair in this review. In defence of the pharmaceutical company manufacturing the product used in this trial, low dose oral estrogen has been suggested instead of the much higher hormone doses used in the studies.
Additional problems with non-bio-identical synthetic hormones include:
- Many 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. This results in wastage of energy and failing to produce a balanced hormonal response
What do we know about bio-identical natural hormone replenishment in hormone replacement therapy?
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 therapy is the safest way to replace hormones. It is important to know that your body’s hormones interact with each other. When you understand these interactions, you start seeing the beautiful hormonal symphony.
"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 estrone (a dangerous type of estrogen)
- cause gallstones
- elevate liver enzymes
- increase weight gain
- decrease growth hormone (the hormone that keeps you youthful)
- increase triglycerides
- interrupt tryptophan metabolism and consequently serotonin metabolism (serotonin keeps you happy and calm)
- increase sex hormone-binding globulin (can decrease testosterone)
- increase carbohydrate cravings
It is important to note that:
- Estrogen has more than 400 crucial functions in your body, you need estrogen for optimal health.
- Elimination of synthetic estrogen takes longer from your body.
- 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 estrogens have coatings and additives which may cause problems.
- Mentioned earlier was that progestins carry a cardiac risk.
On the other hand, progesterone shows the following benefits:
- 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 hormone replacement therapy than progestins
Do you need progesterone if you have had a complete hysterectomy?
The answer is simply yes since the hormone progesterone has many positive effects on your body listed above.
Are there cancer issues with hormone replacement therapy?
Non-bioidentical progesterone and non-bioidentical estrogen may increase the risk of endometrial and breast cancer in hormone replacement therapy.
In contrast, bioidentical progesterone and bioidentical 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 tumour suppressing receptor (Barden A, Boulle N, Lazannec; loss of ER-beta expression as a common step in estrogen-dependent tumour 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
- Finally, 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 tumours
- 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.
The metabolites of estrogen are also important 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".
There is no evidence that transdermal bio-equivalent hormone replenishment does any harm whatsoever.
Is there evidence that oral hormone replacement therapy (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