“However, each one of you must also love his wife as he loves himself, and the wife must respect her husband.” Ephesians 5:33 (Yes, even during menopause)
A few people asked me if I could discuss menopausal issues. Many women are struggling with the hormone replacement issue. We all know synthetic hormones should be avoided, but the issue of bioidentical hormones is a difficult decision to make.
Just so you know I have not entered menopause yet. I am on the stoop, knocking on the door but I have not crossed the threshold. I’ve had 3 hot flashes in total. So basically, I am like one of those childless people giving you parenting advice. Fortunately, I recently finished reading a book about it! How convenient. I will be there soon and I want to be prepared when I have to decide what to do. I have been modifying my diet and exercise in hopes of lessening any symptoms. If you have any experience (positive or negative) with bioidentical HRT please share with others below. You don’t know who you might help.
So back to the book…
The title is Outliving Your Ovaries: An Endocrinologist Weighs The Risks And Rewards of Treating Menopause with Hormone Replacement Therapy. It was written by Marina Johnson, MD, FACE, doctor that is a menopause specialist. I’ve read a few books that covered the topic but they were not really in depth. This is the most thorough book I’ve read so far. Dr. Johnson references quite a bit of research and there is no way I could do it justice on this little blog page. So, I will highlight parts of the book and if it piques your curiosity, go buy the book and read it (I found it at the library). She also recommends taking it to your doctor to have a discussion with them.
First, a little about Dr. Johnson’s credentials. She is the Founder and Director of the Institute of Endocrinology and Preventive Medicine in Texas. She is board-certified in endocrinology and metabolism with a special interest in menopause.
She first questions why menopause is not considered a medical problem, considering the increased risk of degenerative problems it causes. The goal should be to “select therapies which give us the most benefit with the least risks.”
Next, she points out that menopause is a hormonal issue, yet ob-gyns and family doctors prescribe the treatments instead of the logical choice, an endocrinologist. Menopause is not considered an emergency and there aren’t enough endocrinologists to deal with it. So it is passed to the ob-gyns. Find someone who specializes in menopause.
Hormone replacement was routine until the WHI (Women’s Health Initiative) report (2002). It stated that the combination of estrogen/progestin (Prempo) actually posed more health risks than benefits. It increased the incidence of
The study used Prempo (premarin (horse estrogen) and Provera) because it was the most frequently used in the U.S.
Problems with the study:
- The average participant was postmeno for eight years before the HRT started.
- 2/3 of women were 60-79 so they may have already had heart disease.
- Increase risk of heart disease was only seen in women who started HRT 20 years after meno.
There was no significant heart disease if they started less than 10 years after menopause. The risk of stroke was the same regardless of years. 34% were obese and 50% were past smokers. Any women with low estrogen symptoms were excluded from the study. (Wait. Isn’t that why you’re supposed to take it?-me)
Another study, KEEPS (2012) (click title to view study report) was not completed when this book was written but it underscored the need for additional research on newly menopausal women, and provided reassurance to women who wanted to take hormones for the short term. (short term being 5 years or less)
The following are some interesting key points from the book.
Take into account your family history.
Diseases are made worse by poor lifestyle choices. Eat nourishing foods, exercise regularly, get sleep, be a healthy weight, don’t smoke, and have little or no alcohol. Fortify your body. Your will have a 78% lower risk of developing a disease like diabetes, stroke, cancer than those who don’t do these things. Don’t take the easy way out by popping a pill.
The benefit/risk ratio must be considered when taking a drug. No prescription pill has zero risks. Statins have a similar risk of breast cancer as HRT but this risk is considered “acceptable”. (Ever read the warnings on your prescriptions? Are these risks so different? When I watch those commercials, some are pretty scary- me)
The GI tract contains 60% of your immune system and produces 90% of serotonin which contributes to energy sleep and well being. A messed up GI system blocks the absorption of necessary nutrients. Issues should first be addressed with diet and exercise, then vitamin and mineral deficiencies, herbal therapy, then pharmaceutical drugs (considering the safety profile).
Cholesterol is a building block for hormones. Low cholesterol disrupts production of hormones.
The goal of HRT is to replenish and rebalance reproductive, metabolism, behavior, and growth.
Bioidentical hormones are made by both pharmaceutical and compounding pharmacies. Dr. Johnson recommends using pharmaceutical topical estradiol and pharmaceutical topical or oral progesterone. Topical estradiol is safer than oral estrogen because oral estrogen requires the liver to process it before it goes to the rest of the body. Topicals avoid going through the liver. Oral horse estrogen contains very little estradiol and can’t be converted in the liver to “good estrogen”
Using progesterone with the estradiol reduces the risk of uterine cancer. (unless there is no uterus, in which case it is not necessary) Progesterone (produced last half of cycle) counters estradiol to prevent excessive endometrium.
Progesterone is better than sythetic progestin. Cyclic progesterone is preferred over continuous progesterone because it mimics the body closer. Cyclic meaning you only take it part of the month not the entire month.
She recommends pharmaceutical companies over compounding pharmacies because they have stricter standards for quality control. Compounding is good for patients with allergies or special needs. However they carry the same risk as pharmaceutical. Topical compounded progesterone has the poorest absorption and shouldn’t be used.
Always use the lowest therapeutic level to relieve symptoms.
Provide testosterone if deficient.
Monitor estradiol metabolites- by-products of estradiol create “good estrogen” and “bad estrogen” products. Can be monitored in urine.
Hot flashes are a sign of low estrogen and will eventually disappear even without HRT.
*If you have surgical removal of ovaries, use estrogen therapy and testosterone if necessary. There is higher incidence of heart disease, but lower incidence of breast cancer. You may he more severe hot flashes. Start HRT as soon as possible. If endometriosis is exhibited cyclical progesterone can be taken for the short term to control.
*If you have early menopause (before age 45) , first make sure it is not due to another condition. Early menopause frequently causes depression. You may be subject to higher risk of heart disease, dementia, osteoporosis because of years of low estrogen. You should take bio-HRT until a normal age of menopause.
Risks of diseases from not taking HRT are greater. Just as many women who are not on HRT end up having heart disease. It is the biggest killer of women, not breast cancer. Not taking HRT doesn’t remove risk of breast cancer. All forms of HRT have a risk of 38%. Without HRT it is 30%. The risk is only slightly lower.
A long gap between menopause and HRT increases cancer risk more than a short gap (5 years or less). Synthetic estrogen increases by 50%, but not estradiol and progesterone.
Endometrial cancer is 6.25x higher in obese woman because estrogen levels are increased in fat cells. (BMI 30-34.9) BMI>35 = 20x increase.
Risks of not taking HRT:
- breakdown of body and systems -taking into account family history
- impacted quality of life
- weight gain
- hot flashes-severe or prolonged have a higher risk of heart disease
- heat intolerance
- fluid retention
- brain fog
- anxiety/irritability, weepies
- body aches
- itchy thinning skin frequent urination
- heart disease
- memory impairment
- inflammation of blood vessels
- increase blood pressure
- increased waistline
- insulin resistance
Who should NOT take HRT? Anyone with a history of breast cancer, blood clots or stokes.
Usage- Short term. 5 years or less carry low risk, longer carries higher risk.
Reader’s Digest Version:
- Only take bioidentical hormones
- Take topical hormones, not oral
- They should be pharmaceutical bioidentical hormones, not compounded
- It is safest to take them for the short term (5 years or less)
- If you had a hysterectomy or early menopause you should take HRT until you reach normal menopausal age.
- The risks are only slightly higher than not taking hormones
- Not taking hormones has its own risks
- Consider your quality of life vs. the risks
- Get regular screenings while on HRT.
Dr. Johnson has chosen to take it longer than 5 years because of the quality of life benefits.
The sooner you start the better, don’t wait until you are too sick.
If parts of this were confusing, let me know and I will try to explain it better.
The next Aging Well post will cover options for those who can’t or don’t want to take bioidentical HRT.
Have you used bioidentical HRT? Was it a positive experience or negative? Care to share your experience to help women struggling with the decision?
Are you struggling with the decision? What is your biggest concern?