Alpine Women's Healthcare, P.C.

Wisepassage.com

First of all, the facts:  In July, 2002, the Women's Health Initiative study (WHI for short) announced it was halting one portion or "treatment arm" because of unacceptably high risk of breast cancer, heart attack and stroke in the patients under study.  These patients had been taking the most widely used form of hormone replacement, Prempro, for about 5 years.  The patients who were taking only Premarin (possibly because they had had hysterectomies) displayed no such increased risk, and are still being studied.

There are several issues to consider here.  First, the increased health risks should be put into perspective.  The increased breast cancer risk amounts to an extra 8 cases per 10,000 women per year.  The increase in heart attack and stroke is somewhat less.  These figures sure sound less scary than the "25% increase" in breast cancer quoted in some news reports.  It's good to keep in mind that statistics can be very misleading, even if true.

Second, the findings apply to Prempro, and cannot be extrapolated to all HRT, as many media reports so irresponsibly implied.  Prempro is a combination of Premarin (a mix of estrogens obtained from pregnant mares' urine) and Provera, a synthetic progestin which is sort of like, but not the same as, your body's progesterone.  All we can tell from this study is that in this group of women (mostly over 60), on this particular form of hormone replacement, at this "one size fits all" standard dose, there is a definite small increase in breast cancer and cardiovascular events.

Now that hopefully some perspective has been introduced, a rational discussion should be possible.

You should know that there are many ways to replace hormones besides Prempro.  In my view the optimal way is with bioidentical (i.e. exactly the same as your body makes) types.  ALL the estrogen patches (except Combipatch) are bioidentical, as are Estrace tablets and Ogen tablets.  The only commercially made bioidentical progesterones are Prometrium, a pill form, and Crinone, a vaginal gel.  Other brands such as Menest, Aygestin, Activella and FemHRT contain some or all synthetic hormones.  Some claim to be "natural" because they are obtained from plants.  The truth is that all forms of hormone replacement therapy besides Premarin are obtained from either soybean or wild yam; the plant compounds are converted in the lab to whatever hormone is desired (bioidentical or not).  So the words "natural" or "plant based" are not too helpful.

Outside of pharmaceutical companies, bioidentical estrogen and/or progesterone can be obtained (with a prescription) in every type of vehicle (tablet, capsule, lozenge, cream, gel) at compounding pharmacies.  These are pharmacies that custom-make medicines to a physician's order.  There are many of these pharmacies in the Denver metro area, such as Pen-Col, Belmar, Cornell, and The Herbal Remedy.  A popular blend of estrogens offered by the compounding pharmacies is Tri-Est, which some of you will have heard about.  It contains estradiol, the most potent of the body's three estrogens and the one found in the patches, as well as estrone (found in Ogen) and estriol, a weaker estrogen seen in the body mostly in pregnancy.  The estriol is included because of some interesting but very preliminary data that indicate it might protect breast tissue from cancer.  Estriol is fairly popular in Europe for hormone replacement.  I use compounded hormone preparations quite often to meet particular patient preferences or needs.  Their downside is they are not always covered by insurance, and cost $30 per hormone per month.

Are bioidentical hormones safe?  We don't really know.  There is some good evidence that progesterone is more heart protective than the synthetic, Provera.  Maybe now that the WHI has stirred everyone up, we'll get some badly needed studies on the bioidentical preparations.  Meanwhile, the most appealing reason to go with them in my view is simple common sense.  The body is incredibly precise and elegant.  Tiny alterations in molecules can be catastrophic (such as the slightly altered hemoglobin which results in sickle cell anemia).  Hormones are some of the most potent substances in the body and have effects on nearly every organ, including the brain.  If you are going to replace such a substance, it makes sense to use that exact substance whenever possible, and not something "pretty much like it."

Enough about the wide range of hormone replacement options.  There are plenty of you who have made up your minds never (or never again) to take any hormones.  Good news!  You have plenty of options too.  Less good news!  Even more than the hormone-replaced group, you will need to pay close attention to taking good care of yourself---body, mind, and spirit.  Some women sail through menopause, some are nearly incapacitated, but most will experience discomfort somewhere in between.  For all of you, dealing with menopause symptoms starts with a good foundation.  Diet:  lots of fresh whole foods (fruits, vegetables, whole grains, fish, lean meats, nuts).  Minimize refined carbohydrates (sweets and sweet drinks, most cold breakfast cereal, anything made with white flour) and hydrogenated fats (anything deep fried, most margarines, most commercially made baked goods).  Include 1-3 servings of soy protein daily.  Caffeine and alcohol are notorious for bringing on hot flashes, aggravating mood swings and interfering with sleep.  You decide.  Exercise: it's more important to be regular than heroic.  30 minutes daily of brisk walking, biking, or "sweatin' to the oldies" beats a once weekly mega-workout at the gym.  Herbs and supplements:  The best known herb for fighting hot flashes is black cohosh.  Dose is 40mg 2-3 times per day.  The max. effect will be seen after 8 weeks, so this is not a quick fix.  Other helpful herbs include Vitex (chastetree), red clover, and sometimes dong quai.  It's OK to try a "women's herbal blend" which contains several of these.  When possible buy an herbal tincture (concentrated extract) rather than capsules; potency is much better.  Helpful supplements include omega-3 fats (fish or flax oil), 3000mg per day; a calcium preparation (not carbonate) that includes magnesium also, about 1000 and 500mg per day each, and a good quality multivitamin such as Thorne or Rainbow Light.  Mind/Spirit: menopause is when many women discover journaling, women's groups, regular meditation, massage, yoga and other forms of managing stress and processing emotions...out of necessity!  The emotional changes at this time are similar to adolescence (remember THAT roller coaster?).  Luckily we don't have parents who can take away the car keys, so we have more options.

To sum it all up:  go with what makes the most sense to you.  We're all going to get health problems eventually.  The role that hormones play is probably much less important than our overall lifestyle and emotional state.  The goal is to feel good and be happy.  If that means staying on hormones by whatever route feels best, fine!  If it means choosing not to take a pill every day that scares you, that's OK too!  And if you decide later on that you want to choose differently, you're allowed to change your mind.
 

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