Hormone Dilemma

By Catherine Winters
Posted On Mar 16, 2017
Hormone Dilemma

By Catherine Winters

Whether you’re in menopause or getting closer to it, you need to understand the pros and cons of hormone therapy. Is it right for you? Or is there another way? Read on for some options.

If you’re a woman of (ahem) a certain age, not a day goes by that you don’t think about your hormones. In truth: Many of us have a love-hate relationship with our hormones. But what to do when they don’t love you?

First off, hormones make us who we are. “If they’re balanced, they are definitely our friends,” says Pamela W. Smith, MD, MPH, director of the Fellowship in Anti-Aging, Regenerative, and Functional Medicine of the American Academy of Anti-Aging Medicine. Our body’s chemical messengers, hormones, are produced by our endocrine glands. Think pituitary, pineal, thymus, thyroid, adrenal, and pancreas. Gender-specific glands churn out hormones, too. In women, it’s our ovaries, and in men, the testes.

And these messengers stay busy throughout our lives. The teeny amounts our glands produce have major effects on growth and development, circulation, metabolism, bloodsugar levels, mood, sexual desire, and reproduction. They keep our minds sharp and our bones strong, our skin young, and our blood vessels supple. They tell us to flee a charging bear or make us feel totally stressed out. They cause our hearts to go pitter-patter when we spot an attractive guy, and allow us to carry a baby and nurse it.

But hormones also have a downside. The thyroid can go out of whack, causing thyroid disease. The pancreas can stop producing enough insulin, causing diabetes. Then there are the mood swings, crying jags, cramps, and uncontrollable cravings for chocolate that plague many women when hormones fluctuate in the days leading up to their period.

Nothing, however, prepares women for menopause. That’s why women have traditionally turned to hormone replacement therapy (HRT) to return their hormones to more-youthful levels, easing symptoms like hot flashes and night sweats and preventing some of the physical changes.

While estrogen and progesterone come to mind when women think about HRT, levels of testosterone, dehydroepiandrosterone (DHEA), and melatonin also decline as we age, and boosting those may be a good idea as well. Optimal hormone levels, say experts in the field of anti-aging medicine, not only ease menopausal symptoms, but they also may help slow down the aging process.

“If you don’t mind being your age and deteriorating like everyone else your age, keep your hormone levels normal,” says Neal Rouzier, MD, director of the Preventive Medicine Clinic in Palm Springs, California. But if you decide to take hormones, after weighing the risks and benefits, choosing bioidentical ones (plant-derived hormones that have a similar structure to what we naturally produce) may be wiser.

“No matter where it comes from, it’s very clear that life force can be measured in some way by hormones,” says noted OB/GYN Christiane Northrup, MD, author of The Wisdom of Menopause, The Secret Pleasures of Menopause Playbook, and other bestsellers. “You want to make sure you have something coming from somewhere. It’s lovely if it comes from your own body. But if it’s not, it’s better to get it from a plant.”

The Botanical Life Force

Doctors who practice preventive medicine or anti-aging doctors regularly treat women and men with bioidentical hormones. Derived from soy and yams, options such as bioidentical estrogen, progesterone, and other hormones have the same chemical structure as the hormones our body makes, says Dr. Smith. Because of this, they can’t be patented. Bioidentical estrogen and progesterone are available as either FDA-approved or compounded formulations.

Synthetic hormones, on the other hand, are manufactured to mimic our own hormones as closely as possible, says Dr. Rouzier, author of How to Achieve Healthy Aging. The common synthetic estrogen in Premarin is derived from the urine of pregnant mares. Progestin, which is used in Provera, is a chemical compound made in the lab. FDA-approved synthetic hormones can be patented by pharmaceutical companies, whereas natural hormones cannot because they occur in nature.

In July 2002, Women’s Health Initiative (WHI) researchers reported that postmenopausal women taking synthetic estrogen and progestin had an increased risk of breast cancer, coronary heart disease, stroke, and blood clots. Though the women had a lower risk of colon cancer and osteoporosis, the trial was stopped. In March 2004, the estrogen-only arm of the study was also halted when researchers noticed an increased risk of stroke in women. Though estrogen users had a lower risk for invasive breast cancer than women taking a placebo, it wasn’t considered significant. As a result, countless women stopped taking hormones—and plenty were miserable.

Then the criticisms came. The WHI studies were flawed, many maintained. The average age of women in the study was 63 and many may have already been at risk for heart disease and stroke when they started hormore therapy. It takes years for cancer to develop and the duration of the estrogen-progestin arm of the WHI study—5.2 years—was too short to prove a link between hormones and breast cancer. What’s more, any risks the WHI researchers found were small.

Fast forward to 2013. Follow-up studies have shown that while hormones certainly have risks, they also have benefits. In 2012, Danish researchers reported that women who started hormone replacement early in menopause had a significantly reduced risk of heart attack, heart failure, or death with no apparent increase in breast cancer, blood clots, or stroke. Another study reported that women who start HRT early in menopause had a 26 percent decreased risk of dementia.

How It Starts
Perimenopause typically begins four to eight years before menopause. Progesterone levels may not rise during the last half of the menstrual cycle and as a result women don’t ovulate as much. Some months, a woman may ovulate twice. When that happens, estrogen levels climb, causing breast tenderness and heavy bleeding. Other months, a woman’s period will be normal. Estrogen levels can also drop, triggering hot flashes. What makes perimenopause tough is its unpredictability. “Some women have very little change in their menstrual cycle until they reach their last period,” says Margery Gass, MD, executive director of the North American Menopause Society (NAMS). “It is quite a variable time frame in terms of what hormones are doing. Everything is possible.”

When hormone levels aren’t in sync, “there can be estrogen dominance, which can lead to an overgrowth of the lining of the uterus and in some instances, cancer,” says Dr. Gass. Mood swings may become increasingly common. “Some women experience ‘global PMS,’” she says. “Instead of getting PMS the week before their period, it might spread out across the entire cycle.” Many women also complain about gaining weight and memory problems.

North American women enter menopause, on average, at age 51. But some reach it as early as age 30 and others may not do so until their 60s. You’re not officially diagnosed with menopause until you’ve gone 12 consecutive months without a period. At that point, “hormones are at a nice stable plateau,” says Dr. Gass. “They don’t keep swinging up and down.” But because estrogen levels are low, hot flashes and night sweats—which last one to five minutes on average— plague many women, causing sleepless nights and depression. In some women, symptoms are severe. Others have them intermittently for a long time, says Dr. Gass. Eventually they get milder and less frequent and fade away. Because of low estrogen levels, bone loss— which starts in a woman’s 30s— picks up. Some women can lose up to 20 percent of their bone density during the first five to seven years of menopause, setting them up for osteoporosis, according to the National Osteoporosis Foundation. Without estrogen to lubricate the vagina, tissue dries out and thins (called vaginal atrophy), making intercourse painful. What’s more, without estrogen, a woman’s risk for heart disease rises.

Hormones 101
Given all this, it’s no wonder many women consider HRT to stabilize hormones during perimenopause and ease symptoms after menopause. But when is HRT actually necessary?

“A normal healthy woman whose adrenals and ovaries are functioning well, who is getting enough rest, who is well nourished, and who is generally happy with her life does not need hormone replacement of any kind,” says Dr. Northrup. However, supplements to reduce menopausal symptoms and support bone and estrogen deposition in tissues is beneficial.

The NAMS supports the use of FDA-approved hormone therapy for perimenopausal and postmenopausal women “to treat symptoms of menopause and prevent osteoporosis in women at risk for fracture.” According to NAMS, a woman should only be prescribed hormones “when the balance of risks and benefits is favorable for the individual woman.”

However, doctors who prescribe bioidentical hormones maintain they also deliver health benefits without the risks associated with synthetic hormones. “All hormones have health and feel-good benefits,” says Dr. Rouzier. “You want to get more health benefits by taking vitamins. The same analogy applies to hormones.”

Any risks, he maintains, are small. “There are hundreds of studies reporting that bioidentical estrogen and progesterone are far safer, than synthetic hormones,” says Dr. Rouzier, posing no increased risk of cancer, heart disease, or blood clots.

Whereas synthetic hormones are prescribed in preset dosages, bioidentical hormones are not a one-size-fits-all type of therapy. The hormones and dosage you need are determined after your doctor measures your hormone levels via saliva, blood, or urine. (The exception: FDA-approved bioidenticals come in set dosages.) “Hormones have to be in balance,” says Dr. Smith. “Hormones are literally a symphony. All the players have to play in tune.”

A Glossary of Hormones

DHEA. Produced by the adrenal glands, DHEA, or dehydroepiandrosterone, can convert into estrogen, progesterone, and testosterone. Like other hormones, it declines as we grow older. But Dr. Northrup says a woman doesn’t need DHEA if she is taking estrogen and progesterone. Dr. Rouzier calls DHEA the “age gauge,” since high levels have been associated with longevity. DHEA bolsters the immune system and protects us from the harmful effects of stress, lowering the risk of diseases such as diabetes, cancer, and heart disease.

Side Effects: At high levels, acne and excess hair growth.

Estrogen. Originating in the ovaries and adrenal glands, estrogen is produced in three forms: estrone (E1), estradiol (E2), and estriol (E3). All work throughout your reproductive years. Once you reach menopause, estradiol is the most important estrogen to have, though doctors who prescribe bioidentical hormones may also prescribe estriol. “Most doctors believe this helps prevent breast cancer,” says Dr. Smith. It’s also used topically to treat vaginal atrophy. Estrogen helps balance levels of HDL (the good cholesterol) and LDL (the bad cholesterol), and keeps blood vessels supple and arteries plaque-free, protecting against heart disease, says Dr. Rouzier. It helps bones stay strong and skin looking youthful. It protects against Type 2 diabetes and may reduce the risk of Alzheimer’s disease and dementia, adds Dr. Rouzier.

It may also be a lifesaver: From 2002 through 2011, researchers at the Yale School of Medicine analyzed declines in hormone use among women ages 50 to 59 (after the WHI findings were released.) What they found: In 2010 and 2011 the WHI reported estrogen had fewer deaths yearly for 10 years and were less likely to have developed breast cancer or heart disease than women who took a placebo. During that same period, the death rate from breast cancer and heart disease for women not taking estrogen was 13 more per 10,000 women. That adds up about 50,000 unnecessary deaths over 10 years, according to the study, published in the American Journal of Public Health.

Side Effects: “Higher doses may cause weight gain, fluid retention, and headaches, and affect blood sugar,” according to Dr. Rouzier. Synthetic estrogen has been associated with a small, increased risk of stroke.

Melatonin. Produced in the pineal gland, deep within the brain, this hormone helps regulate sleep—which is why it’s widely used to treat jet lag and insomnia. Melatonin levels drop as we age, which can interfere with sleep patterns. And without enough shut-eye, our immune system may weaken, raising our risk for health problems, including cancer.

Side Effects: Headache, short-term depression, daytime sleepiness, dizziness, cramps, and irritability, according to the National Institutes of Health.

Progesterone. If estrogen is the ying, progesterone is the yang. “When we give estrogen, we always prescribe progesterone for balance,” says Dr. Smith. Progesterone is produced in the ovaries and adrenal glands and, when a woman gets pregnant, in the placenta. It helps maintain pregnancy, regulates the menstrual cycle, and fuels sexual desire.

According to Dr. Rouzier, bioidentical progesterone in tandem with estrogen can help protect against breast cancer, uterine cancer, osteoporosis, and heart disease. In younger women, he says, it eases menstrual cramps, mood swings, heavy bleeding, bloating, and menstrual migraines.

Side Effects: “With no known side effects, progesterone can be taken by women who still have a uterus,” says Dr. Rouzier. “A synthetic hormone with similar attributes as progesterone, Progestin, has been associated with breast cancer, depression, weight gain, blood clots, water retention, bloating, and breast tenderness,” he adds.

Testosterone.This hormone isn’t just for the guys. Testosterone is produced in a woman’s ovaries and adrenal glands, albeit at much lower levels than in men. It boosts sex drive and mood and is needed for bone and muscle mass. It may keep skin from wrinkling and thinning. “There are lots of health benefits to it,” says Dr. Rouzier. “If you want to improve strength and endurance and feel good, take it.”

Side Effects: In high doses, facial hair, and acne, but that’s rare. In low doses, there are no serious side effects.

Thyroxine (T4) and triiodothyronine (T3). Hyperthyroidism, common in people over 40, occurs when the thyroid gland at the base of the neck slows its production of thyroid hormone. The result: weight gain, fatigue, depression, sensitivity to cold, dry skin and hair, constipation, or sluggishness. Typically, doctors prescribe synthetic medication to raise levels of T4. But most of the thyroid’s metabolic effects are caused by T3. According to Dr. Rouzier, both T3 and T4 are needed to boost thyroid hormone levels above and beyond the “normal-foryour- age” threshold. “Normal is not optimal,” he says.

Side Effects: “In some people, high doses of thyroid hormones can cause sweating and tremors,” says Dr. Rouzier.