June 17, 2010
Note: this text came from http://www.pyramidpreventativemedicine.com/education.html . It is not my own. But I found it so informative I wanted to make sure I posted it here as well.
The controversies surrounding hormone replacement therapy (HRT) is confusing for menopausal women and to the medical community. In 2001, the Women’s Health Initiative (WHI) suggested that the risks associated with HRT use outweighed any benefits. The new evidence showed an increased risk for heart disease, breast cancer and strokes. When the trial was ended early many physicians were taking their patients off of HRT and giving them an antidepressant and or were told to use the herbal remedies for menopause.
As a health care provider the duty is to understand what each study is telling the medical community. The guidelines regarding hormone replacement therapy were driven by findings from a number of research studies such as the Nurses Health Study, a 20-year prospective cohort study of 120,000 women. It found that HRT use was associated with significant reductions in cardiac events as well as cardiovascular and total mortality. The more recent Women’s Health Initiative, a 5-year randomized trial with 16,000 women, found an increased incidence in cardiac events associated with HRT, although with no increase in either cardiovascular or total mortality. Why are the conclusions at variance? The truth is that the outcomes from both studies were largely correct. They were both right but differed principally in the timing when hormone replacement therapy was initiated. Women in the Nurses’ Health Study generally started HRT within 2 years of menopause, while those in the WHI did not start HRT until 10 years after menopause.
Estrogen has protective properties against cardiovascular disease in premenopausal women, and that the risk for atherosclerosis begins to rise as estrogen levels decline after menopause. Substantial evidence supports the use of hormone replacement therapy for primary prevention of atherosclerosis in women, but only if started during the early postmenopausal period and before the onset of atherosclerosis. Once atherosclerosis has already developed, however, HRT has no effect at reversing the process and may actually promote plaque destabilization and thrombosis. This largely explains the different outcomes from the Women’s Health Initiative compared to earlier studies.
What about an increase in cancer risk with hormone replacement therapy? The WHI consisted of two clinical arms. The first arm was the Hormone Replacement Therapy (HRT) trial, using premarin (an oral form of estrogen) and progestin (an oral form of synthetic progestin, known as medroxyprogesterone acetate). The Estrogen Replacement Therapy (ERT) trial made up the second arm, using only premarin. The HRT trial found 8 more cases of breast cancer but 6 fewer cases of colon cancer for every 10,000 women, compared to the control group. The women receiving only premarin in the ERT trial actually demonstrated a small, though not statistically significant, reduction in breast cancer cases, in addition to fewer cases of colon cancer. Several observational studies also found HRT to be associated with reduced mortality for colon cancer. The conclusion from this and previous studies is that the synthetic progestin used in the HRT trial of the WHI increases a woman’s risk for breast cancer. Synthetic progestin appears to be the culprit regarding breast cancer risk, not estrogen. It should be noted that the WHI found no increase in breast cancer deaths or total cancer deaths in either trial. Other recent trials, the NHANES and USC study, did not find any evidence of an increased risk for breast cancer.
Osteoporosis a progressive bone disease is a greater risk for menopausal women than breast cancer. One in six Caucasian women in the U.S. will fracture her hip, and this is greater than the risk of developing breast cancer or gynecological cancer. In Caucasian women 50 years and older, the lifetime risk of osteoporotic fractures approaches 40 percent and 33% of hip fracture patients die within one year of injury. Osteoporosis is responsible for almost 1 million vertebral and hip fractures annually. The Women’s Health Initiative demonstrated that hormone replacement therapy is associated with a 35% reduction of hip fractures.
Hormone replacement therapy has beneficial effects in conditions other than cardiovascular disease, cancer, and osteoporosis. Some studies have shown that HRT is associated with a reduction of cases of new-onset diabetes mellitus by as much as 35%, and a 60% reduction in recurrent urinary tract infections. Moreover, it reduces the risk for Alzheimer’s disease. In cell cultures, gender-specific bioidentical estrogen or testosterone supplementation appears to slow the accumulation of tau protein, neurofibrillary tangle, and amyloid in human neurons, reducing the potential for Alzheimer’s disease.
The Journal of Internal Medicine, 2004 published findings from a meta-analysis of 30 randomized controlled trials involving hormone replacement therapy. The report analyzed several notable trials, including the Women’s Health Initiative. The authors concluded that while the risks of initiating HRT in older women or in the presence of coronary heart disease may outweigh the benefits, HRT use was not associated with any change in mortality. Furthermore, the authors concluded that the benefits of HRT outweigh the risks if treatment is begun in younger women who do not have coronary heart disease or breast cancer. The report found that initiating HRT in younger postmenopausal women actually resulted in a 39% reduction in mortality.
American College of Gynecology guidelines for hormone replacement therapy have unfortunately confined its use to short-term symptom treatment only, using the lowest dose possible. A better understanding of the conflicting evidence suggests that hormone replacement therapy provides significant health benefits and disease protection for many women if begun early. The PEPI trial in 1990 with 875 postmenopausal women proved the safety and efficacy of natural micronized progesterone combined with estrogen for the best cardiovascular protection. Other health benefits from this trial were less weight gain with women taking hormones after menopause, an increase in the HDL (good cholesterol) and protection against endometrial cancer. Later studies with natural estradiol and natural micronized progresterone have shown protection against cardiovascular disease, osteoporosis, alzheimers disease, urogenital atrophy, colon cancer, endometrial cancer and hypercholoesterolemia. Also, it helps to prevent depression, fatigue, incontinence, weight gain and the loss of feminity.
We as health care providers are compelled to look at the evidence in the older studies with the evidence in newer studies that supports natural hormone replacement. We are the front line to educate women in hormone replacement so that they become a partner in their health decisions for long term disease prevention.
© Copyright 2010 Pyramid Preventative Medicine. All Rights Reserved
June 17, 2010
Most people have heard something about the controversy of menopausal women on hormone replacement therapy (HRT). You might have heard that it causes breast cancer. There is research that supports that. There is also research that refutes it. And there is also research which suggests that hormone replacement therapy has NO bad effects if you use the bio-identical hormones instead of synthetic hormones or “natural” hormones from animals. I really don’t know the ins and outs of the research and the science on all that. Here’s what I DO know:
With my condition the health risks are GREATER if I DON’T do HRT. So that’s kind of an easy, no-brainer decision to make. I need the hormones – without out them I am at greater risk for some not so nice conditions – like osteoperosis for example. And heart disease. With the hormones I will almost certainly avoid those conditions and research is, at best, inconclusive about the risks for women my age (those studies were all done on older women with a natural decline in hormones).
The other thing I know is that anything natural is likely preferable to anything synthetic if it’s going in my body. And I’d rather it be a human hormone than a horse hormone even if that’s also “natural” (as opposed to synthetic). Some people say that HRT is the devil even if you use bio-identical hormones. Others, like my cousin, claim that as long as you use bio-identical hormones and keep them in balance then there’s zero risk. Because the hormones are exactly the same your body would make if it still could. There’s a logic in that that I just can’t refute (although I’m not sure about continuing it until I’m 90). Unfortunately science was never my strongest subject and even if it had been the intricacies of how hormones work are quite complex. I just know that it seems logical to me to use bio-identical hormones if they are available.
And so I choose the Vivelle patch for my estrogen instead of Premarin or Prempo. Regular birth control pills are also an option for some women but I still have hot flashes while on BCPs so I need something more. If anyone is nervous about wearing a patch instead of taking a pill I can tell you that, for the most part, it’s super easy. Here are some drawbacks:
– It is a little annoying to remember to change it out every 3-4 days (a daily pill is more easily incorporated in to a schedule).
– Sometimes my skin gets a little irritated if use the same spot too often
In the 4 months I’ve used it it has never come off in the shower. It stays in place and mostly you don’t notice it’s there. It’s clear so it’s not that noticeable to others (it is summer after all and we’re all showing a bit more skin). Although I usually place it somewhere on my back so it’s hidden.
And I choose Prometrium instead of Provera for my progesterone. I think I need to get my doctor to adjust the dosage a bit. The pros and cons of Prometrium are the same for me: It knocks me out. I actually wait until I am in bed to take it because I am completely out within 15 minutes of swallowing that pill. It’s a pro that it helps me sleep (and it’s some GOOD sleep). But it’s a con that I can barely get up the next day. I think a lower dosage will help that.
There is also another benefit to using the bio-identical hormones. If I stop doing fertility treatments and go back on the bio-identical hormones I can still try for a natural pregnancy. The bio-identical hormones will not harm a fetus while the synthetic ones might. Obviously the odds of that happening are much lower and that’s exactly why I’m trying the treatments. But it’s nice to know that it could still happen naturally and none of the drugs would harm the baby.
UPDATE: I just found this link that has an excellent explanation of all the misinformation out there about Bioidentical hormones.
I’m not sure if this information will remain at this url for long however so I’m going to also post the full text of it here: Controversies of Hormone Replacement Therapy.
June 14, 2010
So my cousin is a doctor and every so often he sort of “reinvents” himself by completing training/certification in some new area of medicine. And then he opens a new practice. This time he is opening a practice in Age Management Medicine and I built the website for the new practice. He wants me to be a patient. I’d essentially be paid for the website in services. Part of what he does with age management medicine is hormone replacement and balancing. And we all know my hormones could use some balancing.
The difference between what he would do and what my RE does is that he looks at ALL your hormones. Not just the reproductive ones. He’s of the opinion that I probably need some testosterone. Obviously he would confirm that with bloodwork before putting me on it. He’s super excited about all this. I’m taking it with a grain of salt. I’m willing to try it to some extent but only if it doesn’t interfere with trying to get me pregnant. Even if it doesn’t “fix” things, I’ll be healthier for doing it.
The four elements of his program are nutrition/diet, natural supplements, hormone replacement and exercise. Well… we all know we should exercise more (most of us need more anyway). And most of us could eat better. I’m already doing some HRT (even though I’m off it at the moment it’s something I need long term) so even if I don’t do all the hormones he would like I’m still doing some. And when I remember to take it I try to take Fish Oil. So I don’t think it’s a huge leap for me to step up the exercise, change the diet and try to remember to take the vitamins and supplements.
So… the diet begins today. I’ll post more on that later. For now I’ll just say it’s low-glycemic. And since I am currently not taking any medication, the bloodwork is tomorrow. My cousin also wants me to get a bone scan and a body fat scan (they’re done at the same time apparently). I was already planning on asking my doc for a bone scan since I’m high risk for osteoperosis. So again, trying this out is not a big leap from what I’m already doing.
It might seem odd for a 36 year old to be doing anything called “Age Management.” But my body, at least hormonally, is acting like it’s 50 so… there you go. I’ll likely be following up this post with several more about the individual elements in this program. I’ll definitely write more about the diet and I’ve been meaning to do a post about bio-identical or “natural” hormones anyway. I’m also going to tell my RE about it. I have no idea what her reaction will be. In short, I think it’s gonna be a busy week or two here on this blog.