Book Excerpts

CHOICES FOR WOMEN AT MIDLIFE
NATURAL HORMONE REPLACEMENT AND ALTERNATIVE MEDICINE

By Amelia Greacen, Licensed Acupuncturist,
Diplomate Acupuncture and Chinese Herbology, NCCAOM

This book is to be used for educational purposes. The information in this book is based upon the research and experience of the author. It is not intended as a substitute for consulting with your physician or other health provider. All matters pertaining to your health should be supervised by a health care professional.

Copyright © 1999, 2001, 2003, Amelia Greacen, 3625 Conifer Court, Boulder, CO 80304, USA. 303-546-0987, www.womanmedicine.com All Rights Reserved

Menopause - a journey to the wisdom years

In Celtic cultures, the young maiden was seen as the flower: the mother, the fruit; the older woman, the seed. The role of the post-menopausal woman is to go forth and reseed the community with her concentrated kernel of truth and wisdom.

Christiane Northrup MD, Women's Bodies, Women's Wisdom

Cycles of a Woman's Life

Our female bodies are magical and powerful. Throughout history, the Goddess has been revered in many forms from Isis to the Virgin Mary, to our own beloved mothers and grandmothers. When we look at the different life stages that we go through as women, we are filled with awe. Historically these stages have been named the maid/virgin, the mother, and the crone. I would like to add a stage the queen/matriarch. Since women are living so much longer, and we are so much more active in the world, not confined to roles of mother and the home, this stage seems to most appropriately describe our early years after menopause.

As the maiden, we are the flowers. Young women usually experience menarche, or their first period, from the age of 11 to 17. The mother is represented by the image of the fruit. We bear the fruit of our bodies over many years, and technology is expanding that greatly! Peak reproductive years are from 21 to 35. Women begin to move towards menopause in a stage called perimenopause, which can last from 35 to 55. The postmenopausal woman's energy is represented by the image of the seed. Our life experiences become crystallized into this small potent and life giving part of the plant, which holds the wisdom for the tribe or people. Menopause is usually from 45 to 55, the average age being 52.

In the beginning, people prayed to the Creatress of Life, the Mistress of Heaven. At the very dawn of religion, God was a woman. Do you remember?

Merlin Stone, When God Was A Woman

The challenge that midlife women today are facing is to discover and claim our personal power and wisdom. Menopause is the passage that women have traditionally gone through in order to open up to a deeper, richer, more powerful expression of ourselves. As we leave the role of mother and caretaker behind, we have the opportunity to embrace new parts of ourselves that have been dormant. This also applies to men, of course, but women uniquely go through this dramatic physical change in our bodies. After the hormonal balance is recovered, following menopause, we come into a time of a new surge of energy; we experience the potential for creativity and self-discovery. This journey is about learning to trust our inner wisdom. As we begin to empower ourselves, focus more on what nourishes us, our lives will blossom. It is also a time for processing unresolved emotional issues from the past that hold us in old dysfunctional patterns.

Unfortunately, we are fed negative messages from our culture, which would have us see ourselves as old, isolated, disempowered, and no longer valued. It is the challenge of our generation of women to create a vision different from our mothers! Currently the average life expectancy for U.S. women is 84. Potentially we have another 35 to 40 years to live following menopause. There are 40 million postmenopausal women in this country today. We are creating a new model for aging as women. Our health will reflect our ability to hold this positive vision.

Hormones What they do

Hormones are very complex and powerful. Science is only beginning to understand the complexity of hormonal functioning. The reproductive hormones work together with other steroid hormones (made in the adrenal glands). They affect every cell in the body including the brain, bones, circulation, digestion, liver, kidneys, nerves, muscles, reproductive system, and the immune system.

Estrogen

Estrogen is stimulating, nourishing, moistening, and protective. When there is not enough progesterone to balance it, it can be overstimulating to the nervous system and the brain. It is produced by the ovaries, and after menopause in the adrenals and fat cells in the body. It is responsible for more than 400 actions in the body. There are three types of estrogen produced in our bodies: Estradiol is the main form present before menopause. It is in most hormone replacement therapy. There is a concern with its potential for side effects and tumor growth. It has the strongest effect for maintaining bone density. Estrone is the main form present after menopause. Estriol is the weakest form. It may be protective against cancer

• increases calcium absorption in bones
• increases energy, helps with mood swings and depression
• decreases cholesterol and risk of heart attack and stroke
• strengthens capillary walls
• increases vaginal lubrication and muscle tone, prevents atrophy, increases urinary tract lining
• increases sex drive
• nourishes brain and memory
• protects joints by increasing lubrication
• decreases with cigarette smoking
• plumps up the skin

Potential side effects of estrogen replacement can occur if the dosage is too high, or if synthetic or non-human identical estrogen is used.

• increases water retention and bloating
• proliferates uterine lining, can cause cancer if unopposed
• is metabolized by the liver can cause side effects to liver and gall bladder
• headaches
• nausea
• reoccurrence of bleeding
• leg cramps
• recurrent vaginal yeast infections
• depression
• thinning of hair
• increases overall body fat

Risk Factors For Using Estrogen Replacement

Estrogens are known for their proliferative effects on estrogen sensitive tissue, which could result in tumors for some women. Research shows that our bodies make metabolites in the process of breaking down estrogen. The metabolite 16 beta hydroxyestrone has been shown to promote cancer, while other metabolites (such as 2-hydroxyestrone and 2-hydroxyestradiol) are protective. Research shows that the enzyme (CYPIAI) that catalyzes 2 hydoxyestrone (the beneficial one) can be made in our bodies by eating lots of cruciferous vegetables (the brocolli and cabbage family), by taking supplements indole-3-carbinol or DIM (diindolylmethane), omega 3 fatty acids (fish oil, flax seed oil), or by taking phytoestrogen products (such as black cohosh or combination formulas such as Pro Estrone) which exert favorable effects on estrogen metabolites, thereby reducing the cancer risk. (Estrogen Metabolism and the Diet-Cancer Connection: Rationale for Assessing the Ratio of Urinary Hydroxylated Estrogen Metabolites, Lord, Bongiovanni, Bralley. Alternative Medicine Review 2002; 7(2):112-129)

For women who have a strong family history of breast cancer, there is a urine or blood test that can be run which gives information about how your body metabolizes estrogen, which can be an indicator of your risk factor for breast cancer. It is called Estrogen Metabolism Assessments, and is available through the Great Smokies Lab. This test can be ordered by your health practitioner.

See appendix B Side effects of HRT and Progestin

Progesterone

Progesterone is calming and soothing, and acts as a natural antidepressant. It is produced by the ovaries, and after menopause in the adrenal glands. It is a precursor of other sex hormones and steroid hormones. During perimenopause, it can become very depleted, and in some cases, the ovaries stop producing progesterone all together. This leads to estrogen dominance. One of its important roles is in promoting the survival of the embryo and fetus throughout pregnancy.

• protects against fibrocystic breasts and breast cancer
• decreases salt and water retention, increases urination, diuretic
• raises core body temperature, promotes fat burning for energy
• stabilizes lining of uterus, protects against endometrial and breast cancer
• decreases uterine fibroids and fibroid tissue in the breast
• helpful when uneven bleeding from anovulatory cycles
• helps keep blood sugar levels normal
• promotes bone building and protects against osteoporosis
• aids thyroid function

Testosterone

Testosterone is responsible for our drive and zest for life, the impetus to get up and go, and to stand up for ourselves. It is produced by the adrenals and the ovaries, even after menopause. Women produce about 1/20 of what men produce. Some women will have an increase of testosterone following menopause. But it is also very common to see very low levels. If a woman suffers with adrenal exhaustion due to chronic stress, she will see a corresponding drop in testosterone levels. It is also depleted following hysterectomy, chemotherapy and radiation, or autoimmune diseases.

• increases sex drive
• increases energy , confidence, assertiveness, and a sense of well being
• strengthens muscles, tendons, ligaments and bones
• increases vaginal lubrication and elasticity
• too much causes acne, deepens voice, facial hair, irritability and anger

DHEA

DHEA is another androgen (like testosterone) which is produced in the adrenal glands. Our levels of DHEA decrease dramatically with age, and it is a marker for aging. DHEA provides a sense of quiet wellbeing and energy. It has many wonderful benefits.

• neutralizes the harmful effects of cortisol (the stress hormone)
• strengthens the immune system, is anti-inflammatory, protects the brain from aging
• increases energy and sex drive
• builds bone
• makes skin younger and plumper
• good for arthritis
• lowers cholesterol levels
• supports thyroid function
• strengthens the heart
• helps sleep

Pregnenolone

Pregnenolone is another hormone made in the adrenal glands. It is the grandmother of all the other hormones. (All other hormones are made from it. see page 14.) It has safely been used for 40 years. Its helpful effects on arthritis (both osteo and rheumatoid), memory, and brain function have been well researched. (It was eventually replaced by cortisone for inflammatory joint pain, which is a drug with many side effects!).

• supports brain, memory, learning
• increases energy and endurance
• combats stress, for arthritis, inflammation

Comparing Estrogen and Progesterone:

Perimenopause can begin as early as age 35, and last as long as age 55. It is characterized by symptoms which can come and go. The first symptoms which women usually experience is irregular periods, sleep disturbance and hot flashes. This stage is characterized by gradually decreasing levels of estrogen and progesterone. Women experience peak levels of estrogen at age 26.

• *Cycles change: can shorten or lengthen.
• Anovulatory cycles occur, causing a decrease of progesterone and imbalance of estrogen/progesterone, causing estrogen dominance and PMS symptoms.
• As we get closer to menopause, there is an increase of FSH (follicle stimulating hormone) because the pituitary tries harder to stimulate ovaries. This causes hot flashes.
• Fertility decreases. Follicles of eggs get less sensitive to stimulation of FSH and LH, or the body may have exhausted supply of follicles by menopause.

Estrogen Dominance

Progesterone production can become greatly reduced as a result of ovulation not occuring. This results in a condition called estrogen dominance, which can cause distressing symptoms such as bloating, anxiety, PMS, irritability, excessively long or heavy periods, spotting, weight gain (especially around abdomen and hips), headaches (especially with PMS), decreased sex drive, promotes growth of breast and uterine fibroids, and breast tenderness. A simple treatment for this imbalance is to take natural progesterone cream (over the counter, with at least 2 % concentration) from midcycle until the menstrual period begins (1/4-1/2 tsp. 2-x day). Another approach is to use DIM (di-indolylmethane), a supplement avalable in health food stores, which helps your body metabolize estrogen more efficiently.

Changes at Menopause

Menopausal symptoms, like those of puberty, demand that we pay attention to the body. If we name the experience as falling apart, we inadvertently are guilty of evil sorcery that is naming our experience in a way that constricts life. The positive Magician has another option: to trust the process and be open to learning what it means. For magical women, the coming apart of former ways of being initiates us into expanded powers. As we move through the initiation of menopause, we reclaim the wisdom of the body the bones, the womb. Postmenopausal wisdom is whole body wisdom.
Bonnie Horrigan, Red Moon Passage

During early menopause, egg follicles begin to atrophy, which results in decreasing estrogen levels and fewer ovulations. The brain produces FSH in response to these dropping levels of estrogen. This stimulates the ovaries into overdrive. The result is increasing levels of estrogen until the ovaries are finally exhausted. When this occurs, the ovaries permanently stop producing estrogen and the menses ceases.

As the body is getting closer to menopause, cycles become more erratic. Estrogen levels can drop quickly, causing hot flashes, erratic bleeding and possibly heavy bleeding. This explains why some periods are seemingly normal, followed by an erratic cycle with more PMS and hot flashes. When women experience a slower rate of estrogen loss, the symptoms are milder. Women in third world countries who eat less fat (estrogen is stored in our fat calls) have much fewer menopausal symptoms because they start out with lower levels of estrogen.

Why do some women experience heavy bleeding? As a result of the temporary increase in estrogen, the uterine lining grows thicker. A lack of progesterone also causes the lining to thicken further, until it outgrows its blood supply and begins to shed, causing heavy irregular bleeding which could occur 2 x per month, or continue up to 60 days! Over time, this process runs its course, and the periods cease. Other effects of these hormone imbalances are intense PMS, mood swings, irritability, anxiety, depression, fatigue, bloating, breast tenderness, food cravings, and feeling spacey. Some women with uterine fibroids experience an increase in their size due to the temporarily increased estrogen. Lucky women skip their periods with gradually increasing intervals, with bleeding getting lighter, until cessation of menstrual cycles.

The average age for women to cease having periods is 52, and a common range is from 48 to 55. A fortunate 1/3 of women experience few or no uncomfortable symptoms with menopause.

The following changes occur for many women at menopause:

• vasomotor changes (hot flashes and night sweats)
• brain function changes, including short term memory loss and difficulty concentrating
• mood changes: fatigue, depression, anxiety, a decrease in neurotransmitters and endorphins
• increased risk for heart disease
• Atrophy changes occur to ovary, cervix, vagina and uterus; increases elasticity to breast tissue. We become more susceptible to infection in the vagina and bladder as well as prolapse of these organs. Regular sex (3x month) increases vaginal tone and slows down these changes.
• bone loss an excess can lead to osteoporosis
• Sleep disturbance is caused by changes in neurotransmitter levels in the brain.
• Dryness can effect eye, joints, skin, and cause discomfort with intercourse.
• decrease in sex drive
• joint pain/arthritis
• change in metabolism, weight gain, loss of muscle tone
• hair changes hair loss as well as gaining hair in new places

Aging: How can we slow this process?

This process of staying youthful and vital is really about self-care. As we get older, we begin to appreciate why our mothers nagged us about eating our vegetables! When we make a commitment to improving our health, we are taking an empowering step. It is important to take that step every day!

When you plant a seed, it attracts everything necessary for its germination. Planting an idea in your conscious awareness is like planting a seed. The subconscious responds by attracting all the things necessary to bring that due, whether positive or negative, into fulfillment.
Paula Gunn Allen quoted in Red Moon Passage by Bonnie Horrigan

Hormones and Aging

As hormones decline, our bodies begin a slow, degenerative cascade of symptoms related to the aging process. Many people would argue that the risk of not taking hormones (normal aging) far outweighs the risk of taking hormone replacement. However, this is a very personal decision that we must each make.

Since we have numerous options available , it makes sense to make use of the very positive benefits of diet, supplements, herbs, and acupuncture, along with a carefully chosen combination of natural human identical hormones. Taking a balance of hormones seems to be the best approach. The information needed can be obtained through blood or saliva hormone testing. After starting on hormones, it is recommended to re-check hormone levels every 3 months, 6 months, and then yearly to make sure that there is no over-dosing, and that we can take a minimum of supplemental hormones.

From the Chinese medical point of view: Chinese medicine has a very long history of treating aging, emphasizing tonic herbs (to strengthen blood, chi and kidney jing hormones), as well as herbs that improve blood circulation. As Kidney Jing declines with age, it effects brain, bones, sex drive, muscles and ligaments, metabolism, reproductive organs, etc.

Western medical point of view: HRT (Hormone Replacement Therapy) cures the disease of menopause, protects bones, brain, and heart. All women should be on HRT. The most commonly prescribed drug in the U.S. is Premarin with Provera.

How To Decide If You Need Hormone Supplementation

Step One:

Get a blood or saliva test for hormone levels to determine if your symptoms are related to low hormone levels.

Step Two:

Get clear about what your particular needs, goals and health risks are, including your family history. (This might include heart disease, osteoporosis, memory, Alzheimer's Disease, any personal or family history of cancer, uterine fibroids, or endometriosis).

Step Three:

Educate yourself regarding the risk factors for using estrogen replacement. (see page 10, Risk Factors For Using Estrogen) Consider doing some testing if you have a strong family history of breast cancer.

Step Four:

Educate yourself on the many options available, the pros and cons for each hormone for your particular conditions. I have included a reading list in the back of this book where you can go for further information. (For instance, plant estrogen products along with natural progestesterone is a very conservative choice. Natural progesterone and testosterone have a balancing effect on estrogen dominance, and can be used in place of estrogen.)

Step Five:

Determine how long you want to be on hormones. Natural hormonal supplementation can be used for a few years during the menopausal transition for relief of symptoms and to protect bone density, and then discontinued. However, many women may choose to stay on hormones for their health and anti-aging benefits. For example, if you are 50 years old and already have osteopenia or osteoporosis, you may decide to stay on estrogen and progesterone, as well as add some DHEA and testosterone. Other ways to increase bone is to use natural progesterone, soy protein powder, supplements for building bone, and adding weight-training 2 x per week. Another choice, in place of using hormones, would be Fosamax or Evista, which also build bone.

If you have urogenital symptoms (incontinence, vaginal changes, bladder infections, and urinary frequency), you may decide to use vaginal estriol cream. Estriol is the mildest form of estrogen, and when used topically, is the safest form of estrogen supplementation. If natural progesterone, Chinese or Western herbs, soy products, and fatty acids are not enough, then using some testosterone cream would be another option. Women who have premature or early menopause, or have had a hysterectomy and no longer have their ovaries, will have lower hormones levels, and usually will benefit from some form of hormone supplementation.

Step Six

Find a MD, nurse practitioner, or naturopathic doctor who can prescribe these natural hormones, as well as monitor you while you are taking them. Most of my patients find that their own doctors are willing to prescribe these natural hormones then they are provided with the necessary information. For a referral to MDs and other practitioners who prescribe natural bio-identical hormones, go to www.naturalwoman.org or call Professionals and Patients for Customized Care at 800-927-4227. You can also go to Dr. Christiane Northrup's website for further information that you can give to your healthcare provider. Women's Health America is a wonderful compounding pharmacy, as well as an educational resource for women, which can work with your doctor to do the necessary testing, send the hormones directly to you, and monitor your progress with periodic testing, (the results of which are all sent to your doctor.) You can contact them at www.womenshealth.com or 800-558-7046.

Brain function

Mood: fatigue, depression, anxiety, mood swings

Complex hormonal changes can occur, especially in very sensitive women. There is a delicate balance between too much progesterone (causing fatigue and depression), too much estrogen and not enough progesterone (causing us to feel anxious and irritable), and not enough estrogen (making us moody and depressed). The limbic system in the midbrain is the location of fight or flight response. With a decrease in estrogen, we get a decrease in neurotransmitters in the brain. Then it is easy to trigger stress, tension, getting upset and angry.

• Estrogen improves our mood, affects brain and nervous system function, improves sleep, memory, and sex drive. It stimulates and relaxes, increasing seratonin and endorphins, and reducing cortisol.
• Progesterone has a calming effect.
• Testosterone has a stronger effect on our well being, appetite, energy, and sex drive.
• DHEA promotes a sense of calm energy and well-being.

Another factor is life changes which can occur at midlife with children leaving, career changes, frequent divorce, and parents dying. Women are questioning their identity and purpose.

What Helps?

• Reduce excess adrenaline by avoiding stimulants caffeine, alcohol, sugar, tobacco.
• Possible side effect of HRT or birth control pill? Change to natural hormone replacement.
• yoga and QiGong
• massage, sunlight, 30 minutes aerobic exercise daily
• homeopathy and bach flower remedies
• tonify the adrenals
• supplements: lecithin, B complex, Vitamin E
• aromatherapy: rose and lavender
• western herbs: St John' Wort (300 mg 3 x per day with meals), black cohosh, passion flower, skullcap, chamomile, valerian root, milk thistle, dandelion root, sage, nettle, oatstraw, vitex, motherwort, liferoot flower, ginko, Pro Estron combination
• acupuncture and Chinese herbs for kidney, liver and heart shen
• natural progesterone, estrogen and testosterone
• western medicine recommends: HRT, antidepressants, tranquilizers, and sedatives

Decreased Libido

Many women experience some sexual changes during menopause. Painful intercourse can result from thinning and drying of the vaginal tissue, caused in part by inadequate estrogenic stimulation of the vaginal lining. Lack of sex drive may be due to several factors, including relationship problems, lowered kidney/adrenal energy, low estrogen or testosterone. Research shows that low estrogen can affect cell functions in the nervous system, affecting a woman's sensitivity to touch and sexual response, as well as reducing blood flow to the vagina and uterus. Estrogen replacement needs to increase blood levels to 50 pcg/ml (blood test) or 1.0 to 5.0 pcg/ml (saliva test).

Christiane Northrup M.D. recommends using estradiol if there is vaginal dryness, burning and pain with intercourse. If symptoms are limited to the vagina only, with burning, dryness and itching, she recommends Replens or Sylk (lubricating products) or estriol cream (which has no systemic effects which can act as a growth hormone) (Dr. Chris Northrup's Health Wisdom for Women Newsletter, September 1999, page 6.)

What Helps?

• herbal black cohosh (Remifemin), Pro Estron combination, vitex, Rehmannia 6 or 8 Combination, Achyranthes and Rehmannia Combination, kidney yang tonic herbs
• Natural estrogen, progesterone, testosterone, DHEA

Appendix

Appendix A

Hormonal Products

Guidelines

Judiciously use appropriate hormones! The best way to do this is to prescribe hormones based on a woman's test results and symptoms, so that she is taking only what is needed to maintain optimal hormone levels. When using estrogen, especially the pharmaceutical brands, use the lowest possible dosage to avoid causing anxiety, mood swings, fluid retention, and breast tenderness. If a woman has had a hysterectomy, she may need more. The younger a women begins menopause, the more she may need.

Hormone replacement or hormone substitution? When we are taking hormonal products, what are we actually doing? Human identical hormones have the same structure as human hormones when you look under a microscope. They are derived from plant sources from soy and wild yam. The plants can be broken down into components which are structurally identical to human forms of estradiol, estrone, estriol, progesterone, and testosterone. They can be obtained by your doctor or nurse practitioner's prescription from compounding pharmacies. (See Appendix J Compounding Pharmacies.) What happens when we take drugs which are not human identical? We often experience side effects because of metabolites, which are formed in our bodies, when we ingest them.

An important difference between using human identical hormone replacement versus Premarin and Provera is that prescriptions must be tailored to the individual women, and adjustments should be made regularly for the first year or so until an optimal dosage is reached. It may require readjustment as a woman goes through perimenopause and menopause.

Hormones can be taken in different ways, depending upon a woman's preference or condition. This include oral, trandermal (cream or patch), or vaginal cream.

Progesterone
PLANT FORM OF PROGESTRONE

You can use vitex, to help increase progesterone levels. A good brand is Herb Pharm. Dosage is ½ tsp 3 times per day.

Natural or human identical progesterone

Use oral micronized natural progesterone in place of Progestin (synthetic) use 100-200 mg continuously or for 10 to 13 days out of the month. It works just as well, with minimal side effects. You can obtain it from a compounding pharmacy, or it is now available as a pharmaceutical drug called Prometrium, which is natural progesterone in peanut oil. It comes in 100 mg. capsules. Primary side effect is sleepiness. (Natural progesterone from a compounding pharmacy tends to work slightly better, as it releases slower over time.) Crinone is a vaginal gel (4 or 8%) which is made by Wyeth Ayerst.

Natural Progesterone Cream

Progonol, Progest, etc. 2% strength can be purchased at health food stores. Dosage is taken from midcycle to first day of menses, ¼ to ½ tsp., 2 x per day, very gentle and safe to use. This dosage provides 32-64 mg. per day. (Progest contains 16 mg. per ¼ tsp. or 1 gram). Often women need a higher dosage, which can be obtained by prescription from a compounding pharmacy at 5% to 10%. 10% contains 100 mg. per ¼ tsp. or 1 gram. 300-400 mg are prescribed for women who are experiencing breakthrough bleeding.

Note: It is very important to choose a brand that has at least 2 % of natural progesterone, or you will be wasting your money and not getting the desired result. These products contain at least 400 mg per oz. Avoid products that are labeled wild yam cream. Good brands include Progest, Progonol, ProgestE Complex, Pro-Alo, Bio-Balance, Happy PMS, Fem-Gest, Ostaderm, Serenity, Pro-Balance and Phyto-Gest.

see Appendix I, Ordering Products

Side effects: Occasionally women report drowsiness or depression while using progesterone.

Pharmaceutical Products

Progestin Brand names include Provera, Megace, Cycrin, Amen, and Aygestin. It is used along with ERT ( Estrogen Replacement Therapy) for many women, 5-10 mg to slough off lining of uterus in order to prevent endometrial cancer, when a woman still has her uterus. Can reduce to 1.25 mg. Also available as vaginal or rectal suppository. 15 to 20 mg. can be used to treat excessive uterine bleeding; it stops hemorrhaging

Side Effects include depression, mood swings, breast tenderness, increased appetite and cholesterol, headaches. When changing from Provera to natural progesterone, 5 mg of Provera = 100 mg. progesterone.

Estrogen

Estrogen administered through the skin by patch or cream often results in higher estrogen levels in the body, as compared to taking pill form. Some women may need only 1/10 of the dose they would use for the pill. Monitoring on a regular basis (every 6 or 12 months) by blood or saliva testing will insure that you are not getting too much. You can also tell by how your body feels.

Natural or human identical Estrogen

This is the safest form of estrogen, for women who want to avoid side effects, and want to minimize uterine or breast activity as a result of using estrogen. These are all made from soy and wild yam root.

First three products are available only with prescription from doctor or nurse practitioner and are ordered from a compounding pharmacy:

Bi-Estrogen a recent update, 80% (or 2 mg) estriol, 20% (.5 mg) estradiol. Common dosage is 2.5 mg. estrogen along with 100 mg. natural progesterone.

Tri-estrogen 80% (2 mg) estriol, 10% (.25 mg) estrone, 10% (.25 mg) estradiol common dosage 2.5 mg. used along with 100 mg. natural progesterone

These two products are protective for bones and heart. You can test for levels of estradiol in blood or saliva, in order to maintain 60 pcg/ml in blood, or 3 pcg/ml in saliva, which will protect bone density.

The cost for these estrogen products usually runs about $20-$25 for a month's supply. This is for estrogen combined with natural progesterone in one pill.

Estriol milder and safer, can be used with cancer survivors, post-chemotherapy with premature urogenital atrophy. Main effect is on the receptors found in vagina, bladder and urethral tissue. Appropriate dosage has little or no stimulatory effect on endometrial lining. It does not convert to estradiol or estrone. Estriol will help to maintain your bone density, but is not shown yet to increase it. Available in pill, vaginal cream and transdermal cream. Starting dosage of oral is 2 mg./day. Estriol vaginal cream is particularly effective for urogenital symptoms, vaginal changes, urinary frequency, and vaginal atrophy.

see Appendix E What To Take If You're Concerned about Tumor Growth

The following products are not prescriptions and are available from other alternative health practitioners. (They are milder than the formulas above):

Phyto B is tri-estrogen formulation, (made by Bezweken), from wild yam, soy, and licorice, in pill form.

Ostaderm is tri-estrogen plus progesterone in cream form (Bezweken), made from licorice, soy, yam.

Ostaderm Vulva Cream is tri-estrogen plus natural progesterone, in a topical vaginal cream for vaginal dryness and atrophy, (Bezweken), made from wild yam, soy and licorice.

Osta B3 is estriol alone, in pill form (Bezweken), made from wild yam, soy and licorice. 8 tablets per day = 2 mg. estriol.

Side effects of estrogen replacement: Occasionally natural estrogen can cause bleeding from hyperplasia (thickening of lining of the uterus). You can increase natural progesterone in order to balance the estrogen. Estriol is pretty safe, because the dose is too low to build up the endometrium. Other side effects could include breast tenderness, weight gain, PMS, fluid retention, headache, increase in fibroid tumors and endometriosis. In this case you can decrease the dosage, or go to a milder estrogen (estriol). Estrogen replacement depletes Vitamin B6, so it is good to add B Complex to your diet. The cream or patch works best for women who don't want to increase their blood pressure, blood lipids (cholesterol or triglycerides) or insulin.

Pharmaceutical

These products are all made from wild yam and soy, except for Premarin, which is made from pregnant mare's urine. Sharon Myoji Schnare, RN, FNP, CNM, MSN gave a talk on hormonal products at a nurse practitioner's conference in Colorado, Summer, 1999. She rated the following estrogen products:

Good choice: Human identical beta-estradiol, (the generic brand name of estradiol is Estrace) Starting dosage is 1 mg-1.5 mg. Also available as patch (Estraderm) and vaginal cream. Other brand names include Climera, Allura, Vivelle, Fem-Patch. E String is a vaginal silicone ring (placed in the vagina like a diaphragm).

Not very good choice: Estrone sulfate or estropipate Brand names include Ogen, Ortho-Est, Estra-Tab, FemHRT, and Menest. Ogen also available in cream form. Contains 66% estrone, 33% equaline sulfate, not human identical hormone.

Worst choice: Premarin estrone from pregnant mare's urine. This is the most commonly prescribed drug in the U.S. There is a concern with metabolites and side effects with this product because this is not human identical. Most common dosage 0.0625 mg., can reduce to .03 mg if also using alternative therapies. This is also available as a vaginal cream, used when vaginal dryness or atrophy is a concern, and want to avoid oral use. For some women, this is the drug that they feel the best on. So it is good to have many options from which to choose.

see Appendix B Side Effects of Premarin and Progesterone

The birth control pill is widely prescribed for perimenopausal women (especially if there is heavy bleeding and irregular periods). It is a synthetic form of estrogen, and also masks natural hormonal rhythms. Side effects include blood clots, headaches, bloating, edema, PMS.

Combinations with estrogen replacement:

Menrium is Premarin with a tranquilizer added

Estratest combination of esterified estrone and methly testosterone

Prempro and Premphase combination of Premarin and Cycrin (synthetic progesterone).

Ortho-prefest and CombiPatch are bio-identical estradiol combined with synthetic Progestin.

Usage: continuous therapy

If intact uterus, Progestin added day 14-25 for cancer protection. If bleeding symptoms are annoying, Progestin added first ½ of cycle, irregular bleeding goes away in about 6 months)

Drawback: goes through digestive system, more side effects and aggravates candida

appendix E What To Take If You Are Concerned About Tumor Growth

This is of a concern for many women who have had cancer or have a family history of cancer. Also, women who currently have uterine fibroids or endometriosis need to be careful about using estrogen. It will prolong or worsen these conditions, which will be greatly reduced or go away entirely when women go into menopause and are no longer producing high levels of estrogen.

Products which increase hormone levels in a safe way (avoiding estradiol and estrone) include soy products, soy protein powder, and herbal medicine. (Chinese herbal prescriptions are the strongest and most sophisticated, with the longest track record, but western herbal combinations are useful too.) I often recommend black cohosh (remifemin) or Pro Estron combination. Other supplements include Vitamin E, borage, flax seed or evening primrose oil. Estriol is being used by some practitioners who consider it to be the safest form of human identical estrogen and cancer preventative. Estriol vaginal cream is an even safer way to go, to treat vaginal dryness and atrophy. Progesterone is generally considered safe to use, unless you have active cancer. Progesterone metabolizes into other things that the body needs. You can also use testosterone cream in small dosages as well as pregnenolone. DHEA is more risky, as your body can make estrogen from it. Some practitioners are using DHEA-Keto 7, which is a form of DHEA which does not convert into estrogen or testosterone. Remember that whenever you take hormones, you need to be monitored with regular blood tests, because each body is different in the way it breaks it down hormones and into which hormones the body converts it. By monitoring with frequent testing, (every 3-4 months), you can make sure that estradiol levels do not rise over 50 pcg/ml in blood, or 1.5 pcg/ml in saliva.

Tamoxifen is a medication used to prevent a reoccurrence of breast cancer. Some doctors are now prescribing it for women who have a strong family history for breast cancer, to be used preventatively. It blocks estrogen receptors on breast cells, while maintaining positive estrogenic effects on bone, uterine tissue, and cardiovascular tissue. It is currently used by almost one million women, as it has a good track record for preventing a reoccurrence. However, it has side effects, including visual problems, blood clots to the lungs, endometrial cancer, and negative changes to the brain. After 5 years, it has been shown to reverse its effects and cause tumors. It is not advised to take more than 5 years. If you are taking this medication, you can ameliorate the side effects with Chinese herbal medicine, soy products, Vitamin E, anti-oxidant vitamins, lecithin, B Complex and B12, pine bark or grape seed extract, ginko, and essential fatty acids like flax seed oil. Natural progesterone might also be an option to discuss with your doctor.

Appendix J

Compounding Pharmacies

• Pharmaca Integrative Pharmacy 1647 Pearl Street, Boulder, Colorado, 80302, 303-442-5164.
• Belmar Pharmacy 800-525-9473
• College Pharmacy- 800-888-9358
• Women's Health America www.womenshealth.com 800-558-7046
• Women's International Pharmacy --800-279-5708
• International Academy of Compounding Pharmacists 800-927-4227