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In answer to a reader inquiry in September’s “Endocrine Perspective” [IHR Sep. 2004], I discussed the differences between hormones that really are natural (i.e. those normally made by the human body) and the hormones called “bioidentical hormones” (which are promoted as natural — but are not). The term “bioidentical” has become popular since its use by Suzanne Somers in her book The Sexy Years. Unfortunately, because this term has no precise meaning and no legal regulation; anyone can apply it to their products. In Part I of my response to the question, I explained how hormone therapy can be designed to closely mimic what the ovaries would do if they were still functioning. In this column, I will discuss the various preparations — synthetic and natural — that are available to women with different hormonal patterns and needs. As noted in the September column, estrogens produce many changes in liver activity, and can (albeit rarely) lead to blood clotting problems. Another consideration is that after estradiol is taken orally, the liver changes much of it to estrone, generally considered a less desirable form of estrogen. The way to take estradiol which most closely mimics natural release by the ovary is through the skin, either in patch or gel form. This way, the estrogen does not hit the liver all at once, and blood levels are smooth, without the peaks and valleys that occur with oral forms. Although gels have been widely used in Europe, they have just been introduced into the U.S. Though gels are effective, patches are generally easier and, more importantly, give more flexible and accurate dosing. One of the most popular patches is Vivelle Dot which is quite small. Other good ones include Alora, and Climara. For a few women a less-commonly used patch called Esclim sticks better than the others, but it is quite large. The patches are changed once or twice a week – and the user must be sure that they know the right change schedule for the patch they are using. Some preparations emphasize that they come from plant sources – yams and soy; however, all estradiol is derived from plants. Only Premarin, which does not contain much estradiol, comes from animals (pregnant mares). Compounding pharmacies often imply that their products are more natural than those made by the large pharmaceutical companies. This is misleading because all companies buy their hormones in bulk. Since pharmacy production processes are essentially unregulated, you cannot be sure of what you are getting. For this reason I feel it is best, whenever possible, to stick with preparations made by companies that meet strict government standards for purity and potency. What about progesterone? I’ve emphasized that the ovary only makes this during the second half of a normal cycle. After menopause, the ovary makes almost no progesterone. As part of hormone therapy, progesterone has only one function: to protect the uterus from the increased risk of cancer which occurs with estrogen alone. Though lately promoted as a cure-all for women’s problems, progesterone is by no means innocuous. In the widely publicized Women’s Health Initiative (WHI) study of hormone replacement therapy — halted in July 2002 when the hormone combination used in the study was found to increase the risk of breast cancer — it was not the estrogen content that accounted for the increase in breast cancer but the synthetic form of progesterone (medroxyprogesterone acetate, MPA, Provera) that was used. For this reason, it seems prudent to use natural progesterone and limit use to the minimum necessary to provide uterine protection. A reliable form of natural progesterone is available by prescription; the brand name in the U.S. is Prometrium. Since progesterone levels are naturally low after menopause, the only reason for using progesterone is to protect the uterus in women on estrogen who have not had a hysterectomy. Progesterone came into favor in alternative medicine because of early claims that it helped PMS. More recent research has shown that rather than alleviating PMS, progesterone may sometimes set it off. This is particularly true of the synthetic forms such as the notorious MPA (Provera) just mentioned. More complete knowledge about progesterone’s effect on long-term health is needed; in the meantime, women still must make decisions about its use. My view is that given the apparent association of MPA (Provera) with breast cancer, women should avoid long term use of this form unless there is no alternative. One option is to take (Prometrium) 200 mg at bedtime for twelve days every other month. This usually protects the uterus but avoids continuous exposure of the breast to this hormone. Though it is often suggested that the problems reported in the WHI study were due to the specific forms of estrogen and progesterone being used, no large scale study has yet been carried out to test this. Though using the most natural forms available makes sense, we cannot assume that there is no risk. In her book, Ms. Somers had the courage to state a truth about estrogen which the mainstream media ignored: that millions of women simply do not feel well without it. Low estrogen levels produce not only hot flashes, night sweats, and insomnia, but also generalized aches and pains, vaginal dryness and discomfort with sex, slower thinking and low mood. Despite the possible risks, many women doctors continue to take estrogen because they feel that they cannot function effectively without it. Despite this, we need to take what Suzanne Somers says about hormones with some caution. It’s true that on her cover picture, Ms Somers looks great, despite being in menopause. This does not mean, however, that her personal decisions about her own health care are necessarily the right ones for all women. Her advocacy of what she calls “bioidentical” hormones does not tell us anything about their safety. Thanks to the internet and a variety of other media, we have moved from an era of scant information into one of too much. The problem used to be that little medical information was available to those outside the health care establishment. Now the problem is information overload with the resulting problem of separating what is reliable from that which is not. Since any preparation can be called “natural” or “bioidentical” consumers must not take claims at face value but delve deeper to be sure they are getting what is best for them. I must remind readers that what I have written here is general advice. Many factors enter into deciding what is best for an individual and so it is essential to discuss all decisions about hormone therapy with a qualified health care professional. |
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