What is menopause, anyway?

Starting as early as the late thirties, a woman’s levels of estrogens and progesterone gradually decline.  This “peri-menopausal” period can start up to ten years prior to actual menopause, when the menstrual periods cease, which usually occurs in the late forties to early fifties.  During this time, the apparent symptoms of hormonal changes may begin, often in the early to mid-forties.  The individual variability is considerable.  Some women notice few, if any symptoms, until one day their period simply stops and they have no further problems.  Other women have severe and troubling symptoms for many years that can lead them on a roller coaster of emotions, physical problems, medications, and even surgery. Women may report changes in their mood, energy level, and sexual desire, and often experience fatigue, memory loss, hot flashes, and night sweats.  Smokers on the average begin to experience menopausal symptoms two years earlier than non-smokers.  Menopause is a natural event in a woman’s life and not something to be afraid or ashamed of.  It is an important transition into a new stage of life and can be an opportunity for a woman to refocus her life.  By making positive choices, women can relax, move into a new productivity, and enjoy this time of life.  Natural hormonal replacement can help to maintain a sense of well-being, prevent troublesome menopausal symptoms that may interfere with a smooth transition, and support feeling healthy for many years.

Understanding Hormonal Cycles, Changes, and Symptoms

To fully understand menopausal symptoms, an understanding of the normal menstrual cycle is helpful.  Female hormones, estrogen and progesterone, fluctuate throughout the menstrual cycle.  Following the menstrual period, the pituitary gland releases follicle-stimulating hormone (FSH), which stimulates the development of a follicle in the ovary, which produces an ovum (egg).  FSH also stimulates increased production of estrogen in the ovary.  As estrogen rises, it stimulates the growth of the endometrial lining of the uterus in preparation for the implantation of the fetus, should the women become pregnant.  Next, around mid-cycle or day 14 of a normal 28-day cycle, a sharp rise in the pituitary hormone, LH or lutienizing hormone causes a rise in progesterone, which in turn triggers the release of the ovum, which begins its journey toward the uterus.  Progesterone remains high for the next 14 days, which is called the luteal phase, maintaining the corpus luteum (the remains of the follicle which released the ovum).   If pregnancy does not occur, both estrogen and progesterone fall dramatically around day 28, triggering the onset of menstrual flow.  The first day of the period is referred to as day one of the cycle.

Estrogens can be thought of as “stimulating” or “excitatory” hormones.  Estrogens tend to elevate mood, even to the point of anxiety, lower blood sugar, increase appetite, and maintain normal elasticity in the skin.  There are actually three estrogens produced by the body: estriol, estradiol, and estrone. All of them are bio-identical. Estriol is the weakest of the 3 hormones. The other two of these hormones, estradiol and estrone, are stronger estrogens and, in excess or if metabolized by the body in certain ways, can stimulate breast tissue, cause breast fullness, tenderness, cysts, and may stimulate the growth of existing breast cancer.  Estriol, on the other hand, actually blocks these negative effects from occurring by blocking estrogen receptor sites and preventing estradiol and estrone from exerting their effects. It is important to balance these estrogens when using bio-identical hormones.

Progesterone, on the other hand, can be thought of as a “calming” or “balancing” hormone, blocking many of the over-stimulating effects of estrogen, calming the mood, raising blood sugar, and helping the body release excess fluid from the tissues.  While this is somewhat of an oversimplification, it is helpful to understand the pattern of menopausal symptoms.

Generally, the progesterone level begins its decline before estrogen.  Changes in a woman’s menstrual pattern, such as a flow that is unusually heavy or light, are the obvious sign that she is beginning to feel the effects of hormonal shifts.   Excess estrogen or estrogen unopposed by adequate progesterone can excessively stimulate the endometrium, causing heavy or prolonged bleeding.  The stimulatory effects of estrogen can be felt as increased PMS (premenstrual tension syndrome) symptoms, such as water retention, bloating, weight gain, breast tenderness, sweet or chocolate cravings, mood swings, anxiety, depression, irritability, or anger.  These symptoms often can be corrected or improved by the prescription of natural progesterone in the second half (day 15-28) of the cycle, along with magnesium and pyridoxine (vitamin B-6) for which there is an increased demand at this time.  Excessive menstrual flow caused by excess estrogen stimulation of the endometrial lining of the uterus can be reduced by this cyclical use of progesterone.  Many surgical procedures such as D&C’s and hysterectomies could be prevented in this manner.

After a period of time, the estrogen levels begin to fall also, resulting in hot flashes, night sweats, insomnia, depression, loss of libido (sex drive), fatigue, loss of elasticity of the skin, wrinkles, urinary frequency or other problems, uterine prolapse, vaginal dryness and atrophy, sometimes causing discomfort or pain with intercourse.  The periods become less frequent and with lighter flow due to the decreased estrogen stimulation.  Eventually the estrogen levels become so low that the period stops altogether.   Hot flashes are the classic sign of menopause.   Falling estrogen levels trigger elevated levels of FSH and LH from the pituitary.  High LH levels trigger hot flashes (sensation of being overheated), hot flushes (intense warmth throughout the upper part of the body, accompanied by anxiety, palpitations, sweating, and flushing of the neck and face), and night sweats.   Some conditions that seem to diminish hot flashes include cooler room temperature, wearing natural fiber clothing that breathes and layering clothing, regular exercise and relaxation, taking vitamin E, folic acid, or boron supplements, and avoiding red wine, alcohol, caffeine, spicy foods, and stress.

Some estrogens, particularly estradiol, are produced by fat cells so women who are overweight sometimes feel the effects of menopause less than thin women.  However, replacement of estrogen can diminish all of these symptoms.  Two other vital hormones, testosterone and DHEA, also decline at this time of life.  These are androgens or “male” hormones but are present in women also in smaller amounts.  The lower level does not make them any less important for the maintenance and repair of muscles, bone, and other tissues and for normal libido and sense of well-being.  Replacement of these hormones, using small physiologic doses of naturally derived DHEA and/or testosterone may also aid in balancing a woman’s hormones and health.

Why should a woman take hormonal replacement therapy?

In my opinion, there are five main reasons:

First, the treatment of the above symptoms can improve the quality of life and sometimes prevent the necessity for surgery.  Women who don’t experience any of these effects, however, may wonder if there is any reason for them to take HRT.  There are advantages to estrogen and progesterone treatment for long term maintenance of bone density and prevention of cardiovascular risk.  With the arrival of menopause, a woman’s risk begins to rise for developing heart disease, Alzheimer’s disease, and osteoporosis (decreased bone density which is the major cause of hip fractures and collapse of vertebrae in the spine in later life).  Memory loss is common with estrogen deficiency.  Untreated, this can increase the risk of developing senility/Alzheimer’s disease. Among women over 50, cardiovascular disease, including heart disease and stroke, is responsible for more than 50% of all deaths.  Osteoporosis is reported to affect one in three post-menopausal women.  More than 1.3 million fractures due to osteoporosis are reported annually.

Studies have shown that HRT decreases the incidence of adult-onset diabetes by 35 % (Annals of Internal Medicine 203:138, 1-9.)

Natural progesterone has been shown to arrest and even reverse bone loss by stimulating osteoblasts that build new bone, increasing both bone mass density and bone strength.  In a study done by Dr. John Lee, bone density was increased by up to 10% in the first 6 months and by 3-6% yearly thereafter, until stabilizing at healthy (35 year old) levels.  Those with the lowest bone densities seem to improve the fastest.  Side effects are minimal and include sedation, fatigue, and occasionally symptoms of estrogen deficiency.  (References:  Lancet 90; 336 (8726): 1327; International Clinical Nutrition Review, 10(3): 384-391,1990.  Endocrine Reviews, Vol. 11, No.2, pp. 386-398, 1990.)  Estrogen blocks the osteoclasts that are cells that break down bone.  Decreased amounts of estrogen following menopause may increase bone loss.  Estrogen replacement therapy alone slows bone loss but it does not build new bone. Natural progesterone can also balance estrogen and block xeno-estrogens, diminishing the stimulatory effect on breast tissue.

Almost every culture uses plant medicinals to support women through menopause, and with good reason.  Plants such as soybeans, Mexican yams, and certain herbs are loaded with both estrogens and progesterone identical to those produced in a woman’s body.  These are called phytoestrogens (“phyto” meaning plant) and include progesterone, estriol, and others.   They are relatively inexpensive and have a safety record of centuries.  However, most doctors are not aware of these naturally derived phyto-estrogens and usually prescribe Premarin (conjugated estradiol derived from the urine of pregnant mares) and Provera, which is not progesterone but a synthetic progestagen with some progesterone-like effects.  Synthetic hormones, unlike balanced bio-identical hormones, have been linked to cervical cancer, according to Raymond Peat, Ph.D. whose study of progesterone has advanced our understanding considerably.

Provera has been estimated to be 10 to 200 times stronger than bio-identical human estrogens. Hormone replacement with Provera has been associated with increased breast cancer in several studies.  The most famous study, the Women’s Health Initiative, received a great deal of publicity, but unfortunately has been widely misquoted.  The small but significant increase in breast cancer risk was noted in the Premarin with Provera group in the study but not in the Premarin (estrogen only) group.  In fact, the overall risk of dying (from all causes) was actually decreased in the Premarin group over those women who had never taken any hormones! This study actually demonstrated the anti-aging effect of estrogens, although the bio-identical hormones would be less likely to cause side effects.

Provera has more than 30 negative side effects listed in the Physicians’ Desk Reference, the doctor’s bible of drug information, including water retention, weight gain, irritability, coronary artery spasm (which could result in sudden death), and others.  The advantage of Premarin and Provera is that they are well absorbed when taken orally and achieve good blood levels, whereas, natural hormones can be susceptible to some is destruction as they pass through the liver.  Many of the risks, particularly breast cancer risk, from estrogen replacement can be diminished by using bio-identical estrogens, especially estriol, and by using estrogens in conjunction with natural progesterone.  (Reference: JAMA Jan. 2, 1978-Vol.239, No. l.)

Bio-identical hormones can be prescribed in an oral capsule in a low-dose daily combination form or in cyclical manner, mimicking the pre-menopausal hormonal cycle.  Since hormones are readily absorbed through the skin, topical creams, gels, and patches are also a good method of replacement.  Plant-derived progesterone topical creams also can work wonders while avoiding the use of estrogen, if the woman cannot or does not want to take estrogen.  Estriol (or estradiol) can be prescribed, with progesterone, or can be compounded in individualized combinations.  An individualized treatment approach in the management of menopause is important since there is no single regimen that is appropriate for all women.  Dosage and method of administration is best tailored to the individual woman’s needs.  Any woman receiving hormonal therapy should see their doctor at regular intervals for follow-up care, including thorough evaluation of symptoms, physical exam with a breast and pelvic exam, pap smear, and possibly thermography or ultrasound of the breasts or uterus, endometrial biopsy, or bone density evaluations.

Why are most doctors not aware of the benefits of natural hormonal replacement?

The answer to this question is, unfortunately, economic.  In order for a pharmaceutical company to be able to afford the drug approval process and the costs of advertising and widely marketing a new drug, they must get a patent, which enables them to be the exclusive manufacturer of the drug for a number of years.  For medication to be patentable, it must be a unique molecule.  Since hormones are naturally occurring substances that are widely available, they cannot be patented, similarly to vitamins, minerals, herbs, and amino acids.  Therefore, a company must synthesize a new hormone by adding extra molecules to the naturally occurring substance, creating a unique and patent-able new substance.  Unfortunately, this alters the structure of the hormone.  Since hormones must fit into receptor sites like a key fits into a lock, this alteration profoundly affects the hormone’s function.  The naturally occurring hormone fits perfectly into the receptor site therefore it works better for humans and has fewer side effects than synthetic ones or those from animal urine (Premarin).  However, estriol and progesterone are not widely marketed and are only available through compounding pharmacists, who will make prescriptions to the order of the prescribing physician.

It’s Your Choice… and Your Health

More than one million women turn 50 each year.   By the year 2000, there will be 20 million menopausal women who will be facing these choices.  With the current life expectancy of 80 years, women can expect to live 30 or more years in the post-menopausal stage of life.  Of the more than 16 million women currently past menopause, only about half start hormone replacement therapy and only about half of those stick with it.  Many drop out because of side effects or fear of cancer, not knowing that they have other alternatives.  Greater awareness and assertiveness about your health, becoming a more informed healthcare consumer and asking questions, taking the initiative in making preventive choices, and becoming an active participant in your healthcare empowers you to find the unique solutions that are best suited to you.   Understanding the pros and cons of various hormone replacement therapies are important in order to make the best choices for your long-term optimal health and prevention of disease.