The World Of Hormone Replacement Therapy for Women
Reviewing the complex world of hormones and hormone replacement is often a daunting task. In this review entry, my hope is to give some information regarding the many choices available to women as they contemplate hormone replacement therapy and to decide if it is right for them.
Before considering the aspects of hormone replacement therapy is it essential that the functional and foundational aspects of life should be addressed initially. Sleep, movement patterns, food, stress and community are large influences on overall health. Imbalances in these areas can cascade into imbalances in other areas, including hormones. Start with a basic functional medicine analysis first and make the necessary changes in the foundations as the initial part of any plan.
START WITH THE GUT
Our gastrointestinal track has a great deal to do with our energy, vitality, immunity and inflammation. An unhealthy gut can often lead to imbalances in other areas. Avoidance of refined foods as well as food sensitivities and irritations, as presented in the basic IFM Elimination Plan, is a great start to restoring the natural balance in the gut. Replacing nutrient deficiencies with complete and robust nutrition is also a critical part in healing the gut so that balance can return.
GET TESTED / GET TREATED
Signs and symptoms of hormone excess as well as deficiencies in women can be both obvious and subtle. Make sure you get a complete analysis from a functional medicine physician to help pinpoint any functional imbalances. This type of analysis should include a complete history and physical to evaluate any and all symptoms associated with the imbalances.
After that, it is helpful to be tested for your hormones. Serum and blood test are often adequate, but sometimes this is not enough to have a complete picture of the problem. Specialized testing using saliva or urine may be necessary to get the complete picture and develop the best treatment plan.
NATURAL OR HORMONAL
After the complete history, physical and analysis, you and your physician should have a good idea of the problem and how to approach it. One option is to approach symptoms and imbalances in a more natural way using plant extracts and botanicals. Often symptoms relating to low hormone states can be alleviated and improved by using plants and botanicals. This should be considered first in mild imbalances. Some options to consider for hormonal imbalances are:
Dehydroepiandrosterone (DHEA) is produced in the adrenal gland and is a precursor to testosterone and estrogen. Supplementing with this precursor is believed to help elevated testosterone and estrogen levels while at the same time lowering cortisol levels.
Aromatic herb believed to improve sex drive in women as well as alleviate menopausal symptoms.
Dwarf palm tree believed to alleviate unwanted hair growth in females. Also believed to be helpful in chronic pelvic pain.
Also known as Chasteberry, is a shrub believed to assist with menstrual disorders including dysmenorrhea, PMS and PMDD.
I-3-C / DIM:
A compound, and its derivative, found in cruciferous vegetables. These compounds assist with the metabolism of estrogens. It is also being studied for its anti-cancer and anti-oxidant properties.
A wildflower believed to assist with symptoms of menopause as well as symptoms of premenstrual syndrome.
A complex, and controversial, array of plants that have a weak ability to bind to estrogen receptors. This binding assists and alleviated symptoms associated with menopause as well as menstrual symptoms. These substances are found in soy, red clover, flax, hops to name a few.
This proprietary phytoestrogen from the extract of Siberian rhubarb seems to have a more powerful effect than others. Siberian rhubarb root extract does not contain estrogen but appears to be a selective ERb agonist. This in turn acts as a down regulator for symptoms often associated with menopause.
HORMONE REPLACEMENT (Estrogen / Progesterone)
For better or worse, hormone replacement therapy for women is much more complex and complicated than it is for men. The many conflicting reports and studies can make this decision very challenging. If, however, in the end, the use of hormones is decided upon, a low and slow approach is always best. Focusing on the least amount of estrogen for the shortest amount of time is often the most conservative and safest approach. With that in mind, let’s enter into the world of bio-identical hormone replacement therapy.
There actually may not be much difference between an FDA-approved bioidentical and the custom-compounded version. Both are made from the same hormones and manufactured according to the requirements of the United States Pharmacopeia (a nongovernmental authority that sets standards for prescription and over-the-counter drugs). At a compounding pharmacy, hormones are placed in a capsule, gel, cream, suppository, or other vehicle. A pharmaceutical company follows the same procedure, but it must use a standard dose in a specific vehicle because the two have been tested and approved as a unit. In this respect, an FDA-approved bioidentical may be more reliable.
However, the closer a hormone is to the natural design, the better. It is likely, then, that the risk and side effect profile is lower…but this depends on the purity and quality of the compounding pharmacy. So as with many things, you need to trust and rely on the expert physician you are working with to find if bio-identical hormones are right for you.
Progesterone, or better categorized as progestins, is a hormone that naturally occurs in the body. It is thought of as the hormone that opposes and balances out estrogen. Changing progesterone levels can contribute to abnormal menstrual periods and menopausal symptoms. It is most used for the return to normal rhythm of the menstrual cycle and used with estrogen as a component of hormone replacement therapy. It is also helpful for the treatment of breast pain and premenstrual syndrome.
In addition to its traditional uses, progestins are used to help with mental clarity and calmness as well as sleep quality and quantity. It may also be of assistance to combat weight gain in menopausal years. Although there is collected evidence to support these claims, there is a need for more evidence to determine if these claims are valid.
Progestins are often administered orally or topically for the symptoms and disorders listed above. They can be used with or without estrogens. Stand-alone progesterone/progestins are Prometrium, Crinone and Endometrin.
Estrogen comes in 3 major forms (E1, E2 and E3) and each have different roles in the human body.
Estrone (E1) is the estrogen most commonly found in increased amounts in postmenopausal women. The body derives it from the hormones that are stored in body fat. Estrone may do the same work that estradiol does, but it might be considered weaker in its effects. Estrone is rarely used as a supplement.
Estradiol (E2) the principal estrogen found in a woman’s body during the reproductive years. It is produced by the ovaries. Estradiol may be very effective for the symptomatic relief of hot flashes, genitourinary symptoms, osteoporosis prophylaxis, psychological well-being and reduction of coronary artery disease.
Because it is much more potent form of estrogen, it might be more effective for symptomatic relief than other forms. When estradiol is replaced using a parenteral or non-oral route (i.e. sublingual, pellet implant, percutaneous, or transdermal), it may not be subject to first-pass metabolism by the liver, and therefore does not produce high levels of estrone.
Estriol (E3) is the weakest of the three major estrogens. In fact, it is 1,000 times weaker in its effect on breast tissue. Estriol is the estrogen that is made in large quantities during pregnancy and has potential protective properties against the production of cancerous cells.
Often a combination of these estrogens (known as Biest or Triest) is used when hormone replacement therapy is chosen. Different physicians have different opinions about these combinations, so again, it is important that you trust and rely on your physician for this decision It is equally important that your physician is educated in all of these estrogens and their combinations.
Methods of delivery and dosage also vary widely and include oral, topical, injectable and intravaginal delivery systems. Dosages equally vary between physicians, but again a low and slow approach is conservative and safe.
And let’s not forget that these estrogens and their combinations breakdown in the body as well, so the breakdown products must be monitored when hormone replacement therapy is chosen to minimize the risk of estrogen related cancers.
Often the choice of hormone replacement therapy is to control vasomotor symptoms and vaginal dryness associated with perimenopause and menopause. Other claims such as improved cognition, younger looking skin and stronger bones may occur, but there is less rigorous evidence of this.
On occasion, if symptoms and labs support it, testosterone is added into hormone replacement therapy for women. Testosterone, like estrogen, decreases in women over time and this decrease can lead to a decrease in sex drive, decrease in energy and decrease in muscle mass. Adding testosterone to HRT can help with these symptoms. However, it is important to note that testosterone breaks down into estrogen and must be monitored as such. Your physician should compensate dosing of both estrogen and testosterone knowing these biochemical pathways.
HOW DO I CHOOSE?
The methods and pathways to balance out your hormones is very personal decision, but it is best to be guided by an experienced professional to gain maximum effect with minimal risk. In the end, however, returning hormones into balance can be a truly life enhancing experience when done safely and correctly. The major questions to consider are:
- Are my personal lifestyle factors in balance (sleep, movement, food, stress and relationships)?
- Should I use hormone regulating / enhancing botanicals or prescription hormones?
- How will my hormones be monitored and regulated by my physician?
- Does my physician have the knowledge and experience to manage my hormones?
Always make sure that you have a functional medicine physician who is educated and well versed in hormone replacement therapy because not all functional medicine physicians are. Also, as stated previously, make sure that your physician takes a complete history, physical and hormone analysis before entering the world of hormone replacement therapy. Lastly, make sure that you are teaming with your physician…that he or she is listening to your needs, teaching you about risks and benefits and giving you all the options available to you.
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