Menopausal Madness

20111013-121226.jpgAre you a woman of middle age or maybe even older who feels like your health is just slipping away? If everything up north is now going south, and you have lost your overall vibrancy and spark of life, hormonal imbalance may be your problem. With all the conflicting reports regarding hormones and replacement, it is no wonder it drives most women crazy. There is little doubt that hormones are highly effective in age management, as they directly enhance cellular communication and turn on genes that are responsible for our overall metabolic health. Symptoms of hormonal decline may include hot flashes, night sweats, vaginal dryness, incontinence, and memory issues. Patients often become depressed and tearful. There may be sleep disturbance, headaches, and generalized aches and pains. Women may also become fatigued and become highly sensitive to chemicals and noticed an increase in allergies. There may be weight gain in the waist and hip area as well as decreased libido. Hormonal decline is often associated with mood swings, nervousness, irritability, and generalized anxiety. Symptoms may also include decreased stamina, reduce muscle size and strength. There may be swelling or puffiness in the eyes and face. These are just a few symptoms of hormonal decline or imbalance.

Since WHI study was released in 2002, there has been increasing controversy regarding the replacement of hormones and their safety. Many additional studies since that time are now available, and continued research has allowed us to clear up many of these issues. It has become quite clear that the type of hormone used is very important, and when using the same hormone that the body makes (also called bio- identical hormones), the efficacy and safety of hormonal replacement is greatly enhanced. Let’s just take a look at a few of the hormones that your body would typically need as you enter into menopause. These sex hormones include estrogen, progesterone, and testosterone. Estrogen is in three forms: Estrone or E1, Estradiol or E2, and Estriol or E3. Estradiol is the most potent of these hormones and declines in postmenopausal women. Estrogen is highly responsible for memory, as it directly stimulates acetylcholine in the brain which is a memory neurotransmitter. Progesterone balances estrogen and has receptor sites throughout the body which makes it important in the overall management of hormonal replacement. Unlike progestin, which is synthetic in nature and contains an acetyl group, progesterone is the body’s natural form which has been shown to enhance safety. Testosterone is also very important in women’s health. It is one of the most powerful anabolic hormones, and will help the body build muscle and burn fat. Cortisol is a catabolic hormone, and is known to build fat and reduce muscle size and strength. Cortisol must be kept under control and checked during hormonal balancing as it often rises with age as well as the body’s exposure to stress.

So if hormones are important in age management medicine, what about the issues of safety. There has been a great concern regarding hormone use and blood clots (such as heart attack and stroke), cardiovascular disease, and cancer particularly in the breast. In reviewing the latest literature, the following conclusions can be made to date: Estrone, or E1, increases both thrombosis and cancer risk. Estradiol, or E2, may be pro-thrombotic when taken orally, but there has been no pro-thrombosis reported in transdermal delivery. Estriol, or E3, has no reported increase in thrombosis. For these reasons, I generally do not use oral estrogen over the age of 35. I have not seen any good studies on the use of transvaginal estrogen, and I’m often concern regarding the male partner’s exposure to estrogen in this application. Synthetic progestins have been shown to increase the risk of breast cancer, while natural progesterone does not seem to show this increased risk. Oral progesterone may have a more calming effect as its metabolite can cross the blood brain barrier and stimulate the calming neurotransmitter in the brain called GABA. Transdermal progesterone, although an adequate form of delivery, does not seem to have these calming effects. Testosterone is usually given transdermally across the skin, or injected subcutaneously or into the muscle. Testosterone, as well as estrogen, can also be applied utilizing pellet therapy. Testosterone is typically not given orally as it may have effects on the liver. Transdermal delivery of testosterone must be used with some caution as an enzyme in the skin can convert testosterone to DHT, this may increase the risk of hair loss, oily skin, and/or acne.

So let’s take a brief overlook in the risk of breast cancer and cardiovascular disease using hormone replacement. In cancer risk, bio-identical Estradiol and Estriol appear to be safe. Adding progesterone is good and reduces the risk of breast cancer, while synthetic progestins increase the risk of cancer. In cardiovascular disease, oral estrogen increases thrombosis and cardiovascular risk, and should be avoided as a women approaches 35 years. Transdermal estrogen is protective against cardiovascular disease. Bio- identical progesterone reduces the risk of cardiovascular disease, while synthetic progestins increase the risk. There appears to be no difference in risk with either oral or transdermal use of progesterone. Low levels of testosterone increase the risk of cardiovascular disease in men, while low levels in both sexes increased risk of bone loss and the loss of muscle mass.

I hope this clears up some issues regarding hormone replacement therapy and safety. If hormones are used appropriately which includes proper laboratory testing in dose management, following hormonal metabolites for safety, and the addition of nutritional supplements when needed, hormonal optimization can certainly improve the quality of your life.

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