Hormone Deficiency

Having reached menopause by definition you are hormone deficient.

How will this effect me?

There are hormone-dependent tissues in every organ system in your body. As hormone levels fall these tissues loose their ability to function optimally. When the duration of hormone loss is prolonged or acute, as is the case of a premature menopause or removal of the ovaries, the effect is magnified. Hormonally dependent tissues cannot and do not function optimally or maintain their integrity when the required hormone is absent.

Hormone deficiency causes an increase in the incidence of coronary artery disease, strokes, osteoporosis and possibly Alzheimer's disease. Fortunately the increase in frequency of these problems can be prevented by appropriate use of HRT.

DOES THAT MEAN I WILL DEFINITELY HAVE PROBLEMS IF I DON'T TAKE HRT?

It is impossible to predict if a specific woman will experience problems, however there are a number of factors that significantly increase the risk:
•Heredity: A family history of Osteoporosis, Cardiovascular Disease or Alzheimer's.
•Surgical removal of the ovaries: Unlike a natural menopause where the fall is more gradual, the decline in ovarian sex hormone production is sudden and complete and so women in this category tend to be at greater risk.
•Early menopause: Early menopause can be due to premature menopause, surgery or ovarian injury. The risks begin once the hormone levels decrease, and the they increases with each passing month that the problem is not corrected..
•Lifestyle: Smoking, excess alcohol intake, sedentary lifestyle, high fat diet and low intake of calcium and other important nutrients all affect the risk factor.
•Concurrent medical problems: There are a number of medical conditions that increase risk, either as an effect of the disease itself or the medication necessary to treat it. 

WHAT TYPES OF MEDICAL PROBLEMS INCREASE RISK?

Here are a few examples. Elevated levels of lipids (fats) in the blood, hypertension, obesity and diabetes increase the risk of coronary artery disease and stroke.

There are also a number of medical conditions that risk of osteoporosis including diseases of kidney function and calcium metabolism, of stomach and intestinal absorption, chronic lung disease, hyperthyroidism and Cushings disease - a disorder of the adrenal gland.

Medications can also cause problems. Medications called glucocorticoids, such as prednisone given in high doses over a period of time as short as a few months can cause significant mineral loss from bone as can heparin an anticoagulant. Also, thyroid hormone in excess of replacement requirements taken over an extended period of time results in significant bone loss as well.

WILL MENOPAUSE CHANGE THE WAY I FEEL?

The majority of women experience symptoms which range from mild to debilitating, including hot flushes, sweats, insomnia, problems with memory and/or concentration, headaches, loss of sex drive, mood changes, and muscle aches. A woman may experience some of these symptoms, all of them, or none of them.

WILL MENOPAUSE CHANGE MY BODY? 

Almost all women will experience alterations in sex hormone dependent "target tissues" and "organ systems". This includes atrophy of the vagina, urethra, labia and clitoris, loss of skin thickness and collagen content, loss of bone mineral content from the skeleton as well as effects on the brain and cardiovascular system. Again, these changes are preventable by appropriate use of HRT.

WHAT HAPPENED TO THAT "YOU'RE NOT GETTING OLDER, YOU'RE GETTING BETTER" STUFF?

I know Aunt Sadie lived to 94, was sharp as a tack, had a younger boyfriend she nearly killed with her sexual demands, drove a car, mowed her lawn and was active until the day she died. Everybody thinks it's great. Hormonally deficient people can function, of course they can. Aunt Sadie did. But that's not issue. The point is that no one, regardless of gender can function optimally, if they are hormonally deficient.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Breast Cancer and HRT

Does Hormone Replacement Therapy increase the risk of breast cancer?  

Well ... Does hormone therapy increase the risk of breast cancer?

It doesn't seem so.

The belief that HRT increases the risk of breast cancer is without merit.  It is primarily based on misinformation communicated to the media and health professionals by a seemingly reliable source, the National Institutes of Health (NIH) sponsored Women’s Health Initiative (WHI).  The results of the WHI  Estrogen Plus Progestin (E Plus P) Trial was published in the July, 17, 2002 issue of the Journal of the American Medical Association (JAMA) The article stated that there was a substantial increase in the risk of breast cancer associated with the hormones used in the study.

It is clear that the writers group of the NIH-sponsored project misrepresented their study findings as the data collected in the study did not support this conclusion.   What their agenda was remains unknown.

If this is true why does my doctor tell me estrogen causes breast cancer?

Unfortunately, very few physicians actually bothered to read the WHI article and most received their information from the media or from colleagues who didn’t read it.  As a result how they advised and treated their patients was often sub optimal.  The WHI article including the conclusions and recommendations was written by twelve individuals, eight non-physicians and four physicians, known as The Writing Group for the Women’s Health Initiative Investigators.  Only two of the four physicians were practicing and none of them were known to have expertise in menopausal medicine.  Incredibly the conclusions of the writers group were accepted by most physicians and the media with a complete absence of professional skepticism.  Physicians who had prescribed HRT for years with good patient results without independent thought or analysis simply stopped writing prescriptions for HRT and told their patients they could no longer use it.

Dr. Jacque Rossouw, the physician who heads the WHI and was in charge of the study, did not believe the WHI study provided evidence that the hormones used in the study increased the risk of breast cancer.  He said the WHI E Plus P study lasted only a little over five years and that during that time a breast cancer initiated by the hormones could not have grown to a size large enough to have been detected by mammography or a physician examination.  Dr. Rossoux was clear in saying that the breast cancers discovered were there before the study began.   How would I know that Dr. Rossoux said this?  I have spoken to Dr. Rossoux several times, face to face and on the phone. He told me this directly and the wording he used was that the breast cancers pre-existed the study.  I would presume that if an investigative reporter took the time to call him at the NIH he would tell them the same thing.

Consider some comments from recognized authorities in menopausal medicine:

A recent article in the Journal of the International Menopause Society, Climacteric, The Journal of Adult Women’s Health and Medicine in June 2014 concluded:

“Over-interpretation and misrepresentation of the WHI findings have damaged the health and well-being of menopausal women by convincing them and their health professionals that the risks of HT outweigh the benefits.” 

An excerpt from an editorial published in a prior issue of the Climacteric, and was endorsed by seven members of the Board of the International Menopause Society concluded:

“On current assessment, the WHI trial the most important and the most ambitious project in menopause medicine, has done a great disservice to the well-being and health of adult women.”

In an issue in the Journal Menopause Management, James Simon, MD, clinical professor at George Washington University, President and Medical Director of Woman’s Health & Research Consultants, Washington, DC, and a Past president of the North American Menopause Society, wrote in a “Letter to the Editor:

“While I applaud those WHI investigators who are finally emerging to voice their concern and frustration with being excluded from the July 2002 media- grabbing media-distorting WHI publication, they now must find their own absolution and path to redemption.

An entire generation of women, their partners and their families suffer unnecessarily for their collective sins.”

Summary

The events that transpired following the WHI publication were and continue to be a tragedy for menopausal women.  The media did their job which is primarily to sell advertising by sensationalizing anything that is remotely possible to sensationalize. Physicians failed in their responsibility to their patients by responding to the WHI’s publication without independent thought or compassion for their patients. 

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Sex & Libido With HRT

Libido & HRT

This section addresses the role of sex hormones in maintaining libido and sexual function. It discusses the manner in which a natural, or surgical menopause, or medications may affect the sexual experience and provides treatment options to restore sexual desire and function.

There just doesn’t seem to be any way of getting around it. If you’re menopausal and want to be at your optimum sexually, you need to replace your hormones. Menopausal women, without the benefit of hormone replacement, may be capable of enjoyable and satisfying sex. They may be capable of great sex. But ultimately they loose the potential, as least as far as sex is concerned, to be the best they can be.

A healthy lifestyle, a positive attitude, exercise, a loving, giving, patient and understanding partner …all are important. But, they can not substitute for adequate hormone levels. It is clear and unequivocal; the integrity of the sexual experience is dependent on sex hormones.

WHAT IS DESIRE PHASE DISORDER?

Diminished hormone levels interfere with optimum sexual function by their affect on sexual desire and hormonally sensitive tissues.

Sexual desire, or libido, consists of thinking about sex, fantasizing about sex, the development of "sexual tension" and the awareness of a need for sexual release. Some people may call feeling this way as being "horny". It motivates us to initiate and participate in sex and if circumstances require, search for a sexual partner.

Lack of, or diminished sexual desire and loss of sexual motivation is sometimes referred to as a "desire phase" disorder.

ARE THERE DIFFERENCES IN HOW WOMEN ARE AFFECTED?

A postmenopausal woman’s decrease in libido can range widely, from a barely noticeable fall in sexual interest to a "sexual aversion" where the very thought of being touched in a sexual context is repulsive. A number of patients have told me, " I feel dead from the waist down", to describe their lack of sexual interest. Several who were affected to a lesser extent have shared, that although they really had no interest in sex or in initiating sexual contact, once they were aroused by sexual direct stimulation, the sexual activity was enjoyable and orgasm was possible. I have found that some women evidence little concern over their loss of libido and have no interest in restoring it. And this is the very essence of not having a libido. Other women are devastated by the loss and are interested in pursuing any reasonable treatment that will allow them to regain their previous sexuality.

Unfortunately, many women who express a concern about a lowered sex drive are referred to a psychiatrist, counselor or psychologist, before even a cursory analysis of their hormonal status and/or Hormone replacement therapy program is considered. Certainly, stressful life events, health, psychological or relationship problems influence libido, but these factors should only be considered along with the menopausal woman’s hormonal status.

WHAT CAUSES A DECLINE IN SEXUAL DESIRE?

The decline in sexual desire is likely a direct result of diminished sex hormone levels on the brain itself. Although estrogen plays a part, the hormone that has been shown to be most closely associated with sex-drive is testosterone.

The ovary, although incapable of producing estrogen after a "natural" menopause, may continue to produce significant amounts of testosterone for several years. This is the reason why many women maintain a good sex-drive for a considerable length of time. These testosterone levels provide additional benefits to the naturally menopausal woman. Tissues of the body are able to convert some of this circulating testosterone to estrogen. This is the mechanism by which naturally menopausal women have fewer and less severe symptoms and health problems usually attributed to sex hormone deficiency. If a postmenopausal woman were to undergo removal of her ovaries, this benefit would be lost.

WHAT ABOUT PREMENOPAUSAL WOMEN WHO HAVE HAD A HYSTERECTOMY?

If the surgery is performed prior to menopause and the ovaries are preserved and their hormone secretion is unaffected, there may be no change in libido following the post-operative healing period. In fact, some women experience a post-surgical increase in sexual desire if prior to the surgery they had been distracted by heavy bleeding or significant pelvic pain. There is evidence, however that in this group of patients, ovarian failure occurs up to 50% of the time within 3 years following the surgery. If this happens, a diminished libido and other menopausal symptoms would reflect the decline in hormone levels. Unfortunately, some physicians are not aware of the frequency of ovarian failure following hysterectomy. I have seen many patients who were in this category, who found it necessary to come to my office because their physicians did not believe their symptoms were possible or related to the surgery.

If the surgery is performed prior to menopause and the ovaries are removed, the fall in estrogen and testosterone levels is abrupt and severe. As would be expected this type of surgically induced menopause almost always, results in a dramatic fall in sexual desire.

IS THERE ANYTHING ELSE THAT CAN CAUSE PROBLEMS WITH MY SEX DRIVE AFTER MENOPAUSE?

Significant health problems, depressive illnesses, relationship problems and certain medications can affect libido.

WHAT ARE SOME OF THE MEDICATIONS THAT CAN CAUSE A PROBLEM?

A class of anti-depressants, SSRI’s frequently depress both libido and potential for orgasm. SSRI’s can do this so effectively in some patients that it is used as a treatment for obsessive sexual preoccupation and premature ejaculation.

I have had several patients express a concern over a fall in their libido who had recently begun treatment with an SSRI, not realizing that this was the cause. Occasionally, delayed ejaculation or inability to ejaculate develops in men who are not aware of this side effect and can lead to conflict in a relationship if the couple doesn’t realize the medication is responsible.

Orally administered estrogen replacement medications and oral contraceptives are absorbed by the gastrointestinal tract and reach the liver in a "bolus". This so called "bolus effect", induces the liver to increase its production of a substance, "sex hormone binding globulin" (SHGB) which binds to circulating testosterone, leaving less "unbound" or "free" testosterone available to maintain libido. This is not well known and is often not recognized as a cause for a diminished libido.


HOW EFFECTIVE IS HORMONE REPLACEMENT THERAPY IN MAINTAINING LIBIDO?

It is very effective. Most of the frequently used regimens of hormone replacement therapy will maintain or restore libido. This will often take 4-6 weeks of treatment and it helps if you are aware of this ahead of time.

Many women, especially those, who have had a surgical menopause, will need a regimen that includes testosterone replacement. This may include some women who choose an oral regimen due its effect on SHBG levels as described above. Testosterone can be given by most of the routes of administration, including injections, gels and subcutaneous implants. When nothing else seems to work, subcutaneous implants rarely fail to reestablish libido.

In the late 1980’s, a television journalist who had interviewed me for some news segments, which dealt with menopausal issues, called me with a request. He shall remain unnamed for his own protection and journalistic credibility. He wanted to know if I could find a woman for an on-air news segment interview, "over 50", and "still having sex". After a brief period, during which I was recovering from having been rendered speechless, I told him that I was sure I could find someone. We made arrangements for the interview to be shot at my office the following week.

The television journalist and his camera crew appeared at the appointed time. I introduced them to June, an attractive, very sexual, woman of 80, who had been on hormone replacement therapy for over 30 years. The interview was broadcast on the evening news the following day to a potential audience of several million. June was an educated and sophisticated woman who was anything but shy. She informed the journalist and the viewing public, that she enjoyed sex, had intercourse on average twice a week …and was orgasmic.

I was chuckling for days. On the way out she told me that she probably would have had sex more often had she been getting along better with her husband. I was pretty impressed with her. I was pretty impressed with both of them.

Yes …appropriate hormone replacement therapy is very effective in maintaining libido.

Part 1: Sex and Menopause

Loss of sexual desire and ability to participate in and enjoy sex is not a normal part of aging. Dr Nosanchuk explains why a menopausal woman's desire to have sex and her capacity to physically participate in sex are both affected by her menopause...

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Regimens of HRT

This page discusses regimens of hrt, progesterone intolerance, cyclic therapy, continuous combined therapy, premarin, aygestin and prometrium.  

The defining difference between HRT programs for women with and without a uterus is the need to give progesterone (progestin) when the uterus is present. For this reason HRT programs for women who have had a hysterectomy are less complex and avoid the symptoms of progesterone intolerance experienced by many women.

PROGESTERONE INTOLERANCE

Approximately 30-40% of women who take progesterone experience unpleasant PMS-like symptoms which can range from mild to severe such as moodiness, irritably, breast tenderness and muscle aches. Individuals who had significant premenstrual symptoms while they were premenopausal are more likely to be affected. Progestins produce moodiness and irritability by effecting specific sites in the brain. Changing the type of progesterone, the dose, the route of administration and the length of treatment can lessen this effect. Forms of natural progesterone given by either the oral or vaginal route may be less of a problem than synthetic progestins. But some patients are so sensitive to the effects of progesterone they continue to have significant problems and just feel miserable. It is one of the most challenging aspects of caring for the postmenopausal woman. A few physicians are vigorous in their suggestion that natural progesterone cream as sole therapy is a miracle treatment for the postmenopausal woman, however a careful and responsible analysis of accepted medical literature and investigations does not support this view.

WOMEN WITH A UTERUS

HRT programs for women who have not had a hysterectomy fall into two categories, Cyclic, where progesterone is given for part of the month and continuous combined therapy (CCT), where it is given daily. 


Cyclic Therapy

Cyclic therapy usually consists of the daily administration of estrogen usually in the form of an oral estrogen tablet or a transdermal estrogen patch replaced once or twice weekly but worn continually plus progesterone in tablet form taken 10-12 days a month. Estrogen stimulates and thickens the endometrium, (the lining of the uterus) and then progesterone, which has antiestrogenic effects blocks the estrogen stimulation. Progesterone both shrinks the uterine lining and prevents the development of abnormal changes.

Alternatively, the route of administration of the estrogen can be sublingual, transdermal gel or subcutaneous implantation. The route of administration of the progesterone can include sublingual tablets and vaginal suppositories. If this works the way it's supposed to, 2-5 days after finishing the progesterone the patient experiences "scheduled withdrawal bleeding" which usually lasts from 3-5 days. And this "cycle" is repeated monthly. If the bleeding occurs at any other time during the month it is called "unscheduled bleeding" and signals the need to determine if any overgrowth or abnormal change of the uterine lining is present.

Continuous Combined Therapy

Continuous combined therapy usually consists of a daily estrogen tablet or a transdermal estrogen patch worn as above plus a smaller dose of progesterone taken daily. The purported benefit of this regimen is that in the majority of cases daily progesterone even in small doses keeps the uterine lining thin and no bleeding occurs. Menstrual bleeding is a very unattractive prospect for many postmenopausal women.

Some common oral estrogen and progesterone combinations. For years the most frequently prescribed combination consisted of conjugated equine estrogen tablets (brand name Premarin) and medroxyprogesterone acetate (MPA) tablets (brand name Provera). The congugated equine estrogen (CEE) or Premarin in earlier years was usually given in dose of 1.25 mg daily the 1-25th days of the month and the Provera was given the 16-25th days of the month. Nothing was given from the 17th to the end of the month at which time the cycle was repeated. Many women experienced symptoms such as hot flashes or sweats during the time they were off the estrogen and in more recent years the (CEE) is most commonly every day instead of the 1-25th. The dose of CEE in most HRT regimens is usually lower and is most frequently .625 mg. I have found that most of the time if a patients symptoms are not alleviated by this dose that higher doses are no more effective and another product or route of administration might be more effective. The MPA is usually given in a dosage of 10mg for 10-12 days a month. Some physicians give the MPA in a lower dose such as 5mg or every 2nd or third month to decrease the incidence of PMS like effects but this is a trade off you must be aware of as the protection of the uterine is lessened.

In more recent years additional formulations of estrogen and progesterone were developed and are often substituted in this regimen. Micronized estradiol brand name Estrace is from a plant source and has the hypothetical advantage of actually being estradiol the bioactive form of estrogen although it is altered during intestinal absorption as any other oral preparation would be. Some other brands of oral estrogen preparations include Ogen and Estratab.

Norethindrone acetate, brand name Aygestin and oral micronized progesterone brand name Prometrium are both commonly used forms of oral progesterone replacement. Aygestin is more potent in its ability to shrink the lining of the uterus and is useful as an alternative to MPA when heavy or "unscheduled bleeding" is a problem. It is available as a 5 mg tablet and can be given in doses ranging from 1/4 of a tablet to 2 tablets 10-12 days a month according to each individual's needs. Prometrium seems to cause less PMS-like effects in women who are sensitive to progestins. It is distributed in 100 mg tablets and is usually given in a dose of 2 tablets at bedtime for 10-12 days a month.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

Methods of HRT

This page discusses methods of hormone replacement therapy - hrt - and includes discussions of routes of administration including: oral, transdermal patches and gels, subcutaneous implants, creams, injections, suppositories and discusses estrogen, progesterone and testosterone. 

There is no perfect method of HRT and none precisely mimics nature. Fortunately this isn't all bad. During a woman's reproductive years, peaks and valleys of hormone concentration in the blood are necessary to trigger ovulation and if conception does not occur, menstruation. These swings in hormone levels can effect mood and sense of well being. For example many women experience a sense of euphoria during pregnancy when their levels of sex hormones are very high and PMS is related to the decline in hormone levels prior to menstruation.

It is of note that some patients request that they be given the "lowest possible dose" of HRT a reflection of a perception that somehow HRT is unwise, dangerous, unnatural or all of the above. This is contradicted by the weight of medical research which suggests HRT increases longevity and enhances quality of life. Ideally, HRT should be given in a dose appropriate for each specific individual as everyone differs in their needs and capacity to absorb and metabolize hormones. Ideally, this would be in an amount sufficient to fully accomplish its beneficial effect.

The hormones replaced in menopausal women include:

Estrogen
The ovarian hormone responsible for the development and maintenance of what we refer to as secondary sexual characteristics.

Progesterone
The ovarian hormone responsible for protecting the uterine lining from being overly stimulated by estrogen. Estrogen given alone (unopposed) when the uterus is present can result in the development of abnormal changes of the endometrium (uterine lining) including cancer. The addition of adequate amounts of progesterone to a program of HRT prevents this from occurring. Progesterone is not usually given following a hysterectomy as there is no uterine lining present to protect. Unfortunately, although necessary progesterone causes "PMS" like symptoms in approximately 30-40% of patients. This is mild in the majority of patients but can be severe in a small percentage.

Testosterone
The ovarian hormone responsible for sex drive, energy, muscle mass and assertiveness. Thought by many to be exclusively a male hormone it has important functions in women. Along with the other ovarian hormones it is markedly diminished following ovarian removal or injury and consideration should be given to appropriate replacement.

Any of these sex hormones, estrogen, testosterone and progesterone can be administered alone or in combination.

In addition there are a number of routes of administration available to get these hormones into your system. They include:

•Oral
•Transdermal Patch
•Transdermal Gel
•Sublingual
•Injections
•Creams
•Suppositories
•Subcutaneous implants


There is no "best" method for everybody and your choice may be influenced by: 

•Type of menopause
•Concurrent medical conditions
•Age at menopause
•Response to previous therapy
•Current age
•Intolerance to previous HRT program
•Symptoms
•Individual perception of HRT program
•Hormones to be replaced
•Individual psychological makeup

Ultimately, the choice of which hormone or hormones and which route of administration should depend on what each individual is comfortable with in view of what she perceives to be her needs, goals and lifestyle.

Estrogen, progesterone and testosterone can all be given using any of the described methods. But, for the sake of clarity and simplicity and to lessen confusion (mine, because I can't figure out how to do it all at once) I will first discuss the routes of administration using estrogen alone. I will then go on to progesterone, testosterone, combination therapy, indications for each and rationales.

Estrogen Therapy
The oral route of HRT, usually a tablet taken daily is the most frequently utilized method of HRT in the world. The most well known oral estrogen replacement product is sold under the brand name Premarin and is a "conjugated equine estrogen" and is extracted from pregnant mare's urine. There are several other oral estrogen products available and each manufacturer gives various reasons why their product is superior. I prefer to use brand name over generic products when possible because I believe some generic formulations of estrogen are not bioequivelent. The advantages of the oral route include that for most people it's easy to take a pill, it's relatively inexpensive and for most women it effectively delivers estrogen into the bloodstream. There are some disadvantages. It is not effective in everyone and causes nausea or other gastrointestinal upsets and occasionally headaches. Infrequently it may cause an elevation in blood pressure. Some of these problems may be related to what is termed the bolus effect on the liver. After an estrogen tablet is absorbed by the upper gastrointestinal tract it is transported directly to the liver. This supraphysiologic amount of estrogen arriving all at once induces the the cells of the liver to alter its production of enzymes.

Transdermal Patch methods for estrogen administration has the hypothetical advantage of avoiding this "first liver pass" and at times can be effective in patients who don't respond to tablets. There are a number of patches available today and they share some common elements. Estradiol the bioactive estrogen, a delivery system which allows the hormone to be gradually absorbed by the skin and an adhesive to keep it on. It is applied to the skin and replaced once or twice weekly as contrasted to the daily estrogen tablet. The estrogen is absorbed gradually over the length of time each individual patch is worn and this is more physiologic. It has the disadvantage of causing skin irritation in 10-30% of those who try it. Sometimes this is mild and can be alleviated simply by moving the patch to a different area of skin daily but can be severe enough to require its discontinuance. It is not as acceptable to some women who exercise strenuously or live in warmer climates as there is greater difficulty with adherence to the skin with increased perspiration. When skin irritation is the caused by the adhesive in the patch delivery system estrogen gel is available from a number of pharmacies and can be rubbed directly on the skin daily without the use of the patch system and is an effective alternative.

Transdermal Gel is a very useful method of estrogen replacement. A measured amount of gel is rubbed on the skin once daily. It is absorbed and in theory at least, the skin acting as a reservoir releases it gradually into the bloodstream. It is simple, well tolerated, relatively inexpensive, there is no "bolus" effect and it avoids the "first liver pass". It is basically the patch minus the adhesive and "delivery system". Pretty nifty, eh! And of course is not widely available in this country.

Sublingual administration of estrogen can be used and in this method a tablet, usually "estradiol" the bioactive form of estrogen is placed under the tongue. It is absorbed through the lining of the mouth into the blood vessels located under the tongue and then into the bloodstream. It avoids the "first liver pass" but is delivered into the blood all at one time as opposed to the gradual "trickle" delivery of the patch.

Intramuscular Injection is a common method of estrogen replacement and is used by many physicians. The hormone is usually mixed with a substance to slow its release into the bloodstream and depending on the dose and patient response is usually given at 2-4 week intervals. It has the disadvantage of relatively high levels soon after administration which decline rapidly after a week or so. Unfortunately, this may perpetuate menopausal symptoms which are often associated with declining rather than absolute hormone levels.

Creams have been used as a method of HR. for several years and is an interesting story. Vaginal dryness and loss of elasticity of the "vaginal barrel" can be a distressing symptom of hormone deficiency. Estrogen cream was considered a " local" nonsystemic therapy and was an effective treatment for this problem. Years ago (and I'm sure today) it was prescribed in those instances when the doctor (presumably not knowledgeable about HRT) or the patient or both were not comfortable using other methods. The rational being that since it was local therapy it wouldn't pose any of the "dreaded risks" of systemic HRT. Incredibly, most doctors and patients were not aware that the vaginal absorption of estrogen is much more efficient and in the doses prescribed results in significantly higher blood levels of hormone than the oral or transdermal route of administration. Wait! It gets better! Some women found it convenient to regularly use the cream as a lubricant to facilitate intercourse. After all they put in in at night anyway. Well folks, the skin of the penis absorbs estrogen pretty well too. Not as efficiently as the vagina, but well enough to result in feminizing changes and impotence in the partners of these women.

Suppositories perform the same function as the cream delivery method. They are preferred by some users who find them less messy.

Subcutaneous Implantation of estrogen pellets is a method used primarily by physicians who special interest or training in the treatment of menopausal women. It is an effective treatment for menopausal symptoms which have been unresponsive to other therapies. I have found it to be the therapy of choice when other methods of HRT have failed as is too often the case following hysterectomy and ovarian removal. It can restore quality of life when the problem is diminished interest in sex, insomnia or persistent hot flashes. The pellets which consist of estradiol, are derived from Soy a naturally occurring substance. They are inserted into the subcutaneous tissue of the abdomen or buttock usually at 3-6 month intervals.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.

About HRT

This page provides a discussion of menopause and hormone replacement therapy - HRT - including estrogen, testosterone and progesterone and includes information about menopausal symptoms... 

Hormone replacement therapy is intended to improve and/or maintain quality of life and increase life expectancy. There are many regimens that are available to the postmenopausal woman and which she chooses may depend on her individual goals of therapy, her attitude about hormone replacement therapy / HRT, and any existing medical conditions. If her physician's knowledge of HRT is limited to only a few basic regimens it will influence which hormone replacement therapy program will be offered If she feels an alternate program is more suited to her needs she should consider finding a physician who is more knowledgeable about hormone replacement therapy.

In my private practice most of my patients came to see me either because they continued to experience significant symptoms in spite of being on an HRT (i.e.; lack of libido, persistent hot flashes, insomnia, heavy vaginal bleeding), and were told, " Nothing else can be done" or "You just can't take hormone replacement therapy" or "How are things with you and your husband", or "Maybe you need to see a therapist". This is an all too persistent theme in new patient interviews.

It is unfortunate for a number of reasons. First, this is a very unhappy woman, desperate to feel better and afraid she never will. She has been told nothing else exists to make her feel better, and worse, that she's part of the problem. The physician, who has limited skills in the treatment and care of menopausal women, is sincere and actually believes this to be true. The physician's rational works something like this; "I gave her the treatment the book and conventional wisdom says works, so the problem can't be me or the treatment...it must be her". If she stops looking for an answer she never will feel any better.

The "gold standard" for determining if a problem is due to your menopause is simple. If you didn't have it before before your natural/surgical menopause and there is no other rational cause for your symptoms, it's menopausal until proven otherwise. In fact, there is a very good chance it can be improved by appropriate hormone replacement therapy.

That being said, hormone replacement therapy regimens consist of first the administration of estrogen and if indicated progesterone (progestins) and/or testosterone. Progesterone is given to prevent overstimulation and/or abnormal changes of the lining of the uterus and so is not usually a part of an HRT program after a hysterectomy. Testosterone is the sex hormone most closely associated with sex drive and is also a factor in energy levels and the preservation of muscle mass.

There is a great deal of hysteria among some physicians and laypersons about testosterone. Shouts of "you'll grow a beard" are interspersed with plaintiff wails of " women are too aggressive if they take testosterone". It's normal for women to have testosterone levels, the ovary produces testosterone prior to menopause and continues to do so following menopause for several years in most women. If the ovaries have been removed or are not functioning appropriately testosterone levels may be very low. Replacement is done with the idea of approximating normal levels in women and significant growth of male-like facial hair at these levels would be rare and I have not seen it in my practice except in women who have a preexisting problem with excess hair growth and this can usually be helped by taking Aldactone, a medication that prevents the skin receptors for hair growth from being stimulated by testosterone. As for women being too aggressive on appropriate doses of testosterone I have not found that to be true and have a concern that women who are testosterone deficient may be too passive.

Dr. Jerry Nosanchuk is a practicing physician who has specialized in the care of menopausal women for over 30 years.  His office is located in Bingham Farms, Michigan.  Appointments with Dr. Nosanchuk can be made by calling: (248) 644-7200 and speaking to Caroline Monday through Friday from 10AM to 6PM

IMPORTANT: This website is for educational purposes only.  It is not intended to suggest a specific therapy for any individual and must not be construed to establish a physician patient relationship.