Part 3: What Is Optimum Hormone Replacement?

What is optimum hormone replacement?

In this section Dr N discusses optimal hormone replacement regimens.

Few women in the United States are on an optimal hormone replacement regimen. It is always sub-optimal to be on oral estrogen. The issue becomes not whether to use hormone replacement, but how.

Orally administered estrogen is transported to the liver and during its metabolism induces the liver to produce undesirable elevations of a number of substances. Oral estrogen raises the level of triglycerides and C - reactive protein (CRP), as well as increasing insulin resistance.

All of these alterations are known to be associated with an increased risk of cardiovascular events. In addition, levels of Sex Hormone Binding Globulin (SHGB) are elevated, which has the effect of decreasing libido, sexual response and energy levels.

Optimum estrogen replacement is always non-oral and utilizes estradiol, the biologically active form of estrogen secreted by the ovary. It is delivered intact into the bloodstream by the use of a transdermal patch, gel or subcutaneous implant.

In contrast to oral hormone replacement, these methods do not cause unwanted elevations of liver substances. In those instances where symptoms persist, an implant of an estradiol pellet is almost always effective.

In women who have had their ovaries removed, or are deficient in androgen production, testosterone can be safely administered non-orally and will enhance libido, sexual response, preservation of lean body mass and sense of well being.

Progesterone

When the uterus is present, administration of a progestin is almost always indicated to prevent the development of abnormal changes of the uterine lining associated with unopposed estrogen stimulation.

Natural progesterone is the hormone of choice, but as it is relatively weak in its activity an alternate form of progesterone is often necessary. The progesterone can be administered orally, vaginally, or in some instances by transdermal patch, or intrauterine device.

It is most physiologic to use the progesterone for 12 days every 4-8 weeks depending on individual response. However, some women find that the “withdrawal bleeding” associated with progesterone given at intervals is unacceptable. In those instances, the use of a combined estrogen-progestin patch, although not as physiologic, can be useful. It is also important to note that some women are intolerant to progesterone experiencing PMS-like symptoms. Altering the type of progesterone, dose or method of administration can reduce this problem.

Important considerations

Hormone replacement with Prempro appears to have a less favorable risk-benefit profile than other replacement preparations, particularly those that are non-oral and those where a progestin component is not used continuously. This is “old news” and has been recognized by menopausal experts since the latter part of the 1990’s.

If your doctor has suggested that you discontinue hormone replacement because of the Heart and Estrogen/progestin Replacement Study Follow Up (HERS II) and The Woman’s Health Initiative (WHI) study both (both published in the Journal of the American Medical Association in July), ask the following two questions: Have you read either of the studies and why any of the recommendations apply to me? What are the short and long-term effects of hormone deficiency on my health, longevity and quality of life?

If you are on an orally administered estrogen consider switching to a non-oral preparation containing estradiol. If a man in the United States was determined to be hormone deficient, he would almost certainly and without trepidation be offered hormone replacement.

Whether you choose to be a user, or non-user of hormone replacement this decision is yours and cannot be dictated by your physician. Remember: “A woman in the autumn of her life is entitled to an Indian summer rather than a winter of discontent.”

 

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.

Part 2: Hormone Replacemnet Therapy Is a Personal Choice

Appointments with Dr. N can be made by calling (248) 644-7200 and speaking to Caroline

Whether you choose to use hormone replacement therapy must always be your personal choice.  Your physician should never be able to tell that you can or that that you can't.

The key to making the appropriate decision is based on both the knowledge of what menopause represents in terms of its potential impact on health, quality of life and sexuality and an understanding how hormone replacement options differ in their potential benefits and risks.

Without this knowledge, a woman cannot effectively participate in her own healthcare decisions. In essence, she becomes the passive recipient of her doctor’s store of knowledge and individual bias.

Acquiring the necessary information may be difficult for most women as the physician is the source she usually turns to for information. Doctors may have only scant knowledge of the menopausal process, its global nature, or the extent of its potential impact on health and quality of life. In addition, most physicians are not aware of what constitutes an optimum hormone replacement regimen.

Menopause 101

A “natural menopause” is characterized by cessation of the monthly menstrual cycle and occurs because of an expected age-related failure of the ovaries to continue to produce estradiol, the biologically-active form of estrogen. Most often, this will occur between the ages of 48-52. It is the rise in the estradiol level at puberty that is responsible for the physical and mental metamorphosis from a young girl to an adult female. This includes all the changes that that we characterize as “secondary sexual characteristics.”

An early or “premature menopause” is one that occurs prior to age 40 and can be the result of genetic factors or autoimmune processes. An “induced menopause” can be due to surgical removal of the ovaries with or without a hysterectomy, by chemotherapy or radiation.

After menopause, estradiol concentrations in the blood fall to their prepubertal level. The aging process is accelerated as the hormonally-dependent tissues that have relied on estradiol for their support begin to regress and their ability to function optimally is compromised. Virtually every organ system is affected including the vagina, bladder, brain, skin, skeleton and cardiovascular.

Hormone Deficient

Many women think in terms of “going through menopause.” What they usually mean is that they have stopped having symptoms such as hot flashes, sweats and insomnia. However, unless a menopausal woman chooses to use hormone replacement she will spend the remainder of her life in a hormone-deficient state. The central issue for most menopausal women is whether to use hormone replacement.

Menopause - assuming it is a “natural menopause” - is normal. There is no “right choice” for everyone. Whether a woman chooses to live in a hormone-deficient state or use hormone replacement is a personal decision. In most cases, menopausal symptoms such as hot flashes, sweats and insomnia will disappear within 2 years. However, long-term consequences of estrogen deficiency cannot be predicted on an individual basis, but many women on the surface do not seem to be affected.

If a woman has experienced a premature or induced menopause the effects are magnified. Those who have had their ovaries removed are at greatest risk of osteoporosis, cardiovascular disease and atrophic changes of the vagina, urinary system and skin especially when this occurs prior to an expected natural menopause.

Women who choose to use hormone replacement have a better quality of life according to a recent pole conducted by The Gallup Organization. This is not meant to imply that postmenopausal women who are not on hormone replacement are incapable of a fulfilling life and sexual experience. They are capable of both. We have all heard about “Aunt Sadie” who never touched a hormone, or any other medication for that matter, yet lived to age 94, remained “sharp as a tack,” had a sexually satisfied boyfriend thirty years younger, drove a car every day and mowed her own lawn. However, the point is that it is unlikely that anyone, regardless of gender, can function optimally in a hormonally deficient state.

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.

Part 1: Hormone Replacement Therapy, Panacea or Poison?

Appointments with Dr. N can be made by calling (248) 644-7200 and speaking to Caroline

Appropriate Hormone Replacement Therapy (HRT) remains a viable and important health care option for postmenopausal women.

The most significant effects of HRT are increased longevity, a better quality img_8227of life and prevention of the accelerated aging associated with hormone deficiency. This remains true despite a media conflagration generated by the publication of the findings of The Women’s Health Initiative (WHI). The study was published in the Journal of the American Medical Association (JAMA) in July 2002. The article seem to question the wisdom of hormone replacement.

The media response was explosive. Although there was no difference in the number of deaths between hormone users and non-users, many postmenopausal women were concerned and stopped taking their hormones. This impression was reinforced as scores of physicians told their menopausal patients -based on the results of the study, which most had not read - to discontinue hormone replacement therapy.

Are these legitimate responses that reflect the findings of the published study It doesn’t seem so. Five key points follow: 


1) It was not clear to most women that the study did not address hormone replacement in general, but was limited to users of Prempro, which is a sub-optimal hormone replacement preparation.  Prempro is a combination of conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) and is taken daily as continuous combined therapy. It is indicated for use in women who have not had a hysterectomy and require protection of the uterine lining with a form of progesterone, in this case MPA.

2) Hormone replacement with Prempro appears to have a less favorable risk/benefit profile than other replacement preparations, particularly those that are non-oral and those in which a progestin component is not used continuously. The summary of WHI trial suggested that the specific combination in Prempro resulted in: 1) a less favorable effect on coronary arteries than other regimens and 2) a small, but significant excess of breast cancer that in the opinion of the head of the WHI study, Dr. Jacque Rossoux was not due to the hormones used in the study and that the cancers found in the study were there before the study began as the trial was not long enough for any new cancers to be discovered.

3) The weight of previous research utilizing other regimens of hormone replacement had suggested a more positive outcome. The commentary in both studies did state that it was “possible” that the unexpected negative findings were due to the combination in Prempro. Surprisingly, unencumbered by the limitations of the data, the researchers included all forms of hormone replacement in their conclusions and recommendations.

4) Physicians are encouraging women to stop using HRT, without a legitimate rationale. This is an irresponsible and potentially life-altering recommendation. Dr.Rossouw stated that it was his impression that few physicians had actually read the studies or had an in-depth knowledge of the details, or conclusions and went on to say that in his opinion appropriate hormone replacement does not cause breast cancer, or coronary artery disease and that he was “comfortable” with this type of hormone use “for as long as it is necessary.”

5) The big losers are menopausal women who have been deterred from using hormone replacement as a valuable health care and quality of life enhancing strategy.

Dr. Trudy L. Bush, who was one of the nation's preeminent researchers and teachers of issues related to women's health - particularly the effects of hormones and replacement therapy on the cardiovascular and reproductive systems - published a hallmark study in the Journal of the American Medical Association in February of 1983. This examined all-cause mortality in estrogen users compared with non-users. During the 5.6 years of the study, the risk of death among non-users was twice as high as users of estrogen if they had no gynecological surgery. It was three times higher if they had a hysterectomy and eight times higher if both ovaries had been removed. Since that time, Dr. Bush and a number of other respected authors, have published numerous articles confirming the association of estrogen use with lower all-cause mortality.

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.