Estrogen and menopause in women
Menopause is defined as one year after the last menstrual period. Prior to that time, however, symptoms will begin and blood tests will reveal low estradiol levels and high FSH (follicle-stimulating hormone, a pituitary hormone that increases when estrogen is low). Menopause is characterized by hot flashes, night sweats, depression, insomnia, weight gain, reduced libido, vaginal dryness and atrophy, and skin changes. Many women are spared severe symptoms. Other medical conditions are initiated with menopause, including osteoporosis, cardiovascular disease manifested by heart disease and stroke, and memory and cognitive loss.
According to numerous studies in major medical journals, estrogen replacement resolves most menopausal symptoms, reduces osteoporosis, and in numerous studies has prevented cardiovascular disease and cognitive decline. We avoid oral estrogens because of evidence for increased blood clotting factors with oral administration. We order sublingual drops, and transdermal creams or gels, or we use pellets. These are usually obtained through a compounding pharmacy, which can prepare formulations in specific dosage. Initially they are prescribed twice a day, but eventually can be taken once a day.
Estrogen increases bone density, maintains vascular elasticity, produces collagen in the skin to prevent wrinkles, and likely supports cognitive function. There is perhaps a slightly increased risk of breast cancer with estrogen therapy, but this is reduced by using bioidentical formulations only and keeping with a lower dose. Indole-3- carbinol and calcium D-glucarate are nutrients that direct estrogen metabolism away from carcinogenic metabolites. Adding estriol to estradiol may also provide protection against breast malignancy.
Testosterone in men and women
Testosterone declines in some women at the time of menopause, while in others the level is maintained by adrenal production. In men, testosterone declines gradually with age. Testosterone replacement maintains bone density, increases libido in both men and women, raises the blood count, and increases muscle strength and athletic performance. It is usually taken as a transdermal preparation, sublingual drops or an oral troche.
Men often administer testosterone as an injection into the buttocks given once or twice a week. Testosterone may not be used in men who have prostate cancer unless the cancer has been effectively treated. In some men we have also prescribed human chorionic gonadotropin, an injection that stimulates the testes to increase testosterone production. Clomiphene, a medication, can be taken twice a week to raise testosterone production in most men.
Pellet therapy for men and women
We use subcutaneous estrogen in women, inserted as tiny pellets under the skin of the buttock. Pellets last 3–4 months or more, and have the advantage of maintaining stable blood levels throughout the day. They are inserted through a small incision made under local anesthesia, during an office procedure that takes about five minutes. Estrogen pellets are particularly effective in preventing and reversing osteoporosis.
Women who have not had a hysterectomy will also require progesterone replacement to avoid an otherwise increased risk of endometrial cancer. Progesterone may be taken as a capsule, and has the additional benefit of enhancing sleep. It is also available as a transdermal cream, and may be combined with estrogen.
Testosterone for men may also be inserted as pellets under the skin of the buttocks, providing an even blood level for 3–4 months or more. The dosage in men is several times higher than in women. The pellets also contain anastrozole, a medication to prevent conversion of testosterone to estrogen within fat cells.
DHEA is a testosterone-related hormone that declines with age in both men and women. It is often referred to as the master hormone because the body uses it to make other hormones. Levels decline further in people on steroids and in sicker patients. DHEA increases libido, supports bone density, supports immune function and prevents depression. It is often taken as an oral supplement, 5–10 mg daily in women, and 25–50 mg in men. It is usually avoided in circumstances of prostate cancer.
Thyroid hormone levels are often low in both men and women, though more often in women. The thyroid gland is frequently involved in autoimmune processes, and is also very sensitive to environmental toxins and to radiation. We provide thyroid in oral formulations combining T3 and T4, usually using the TSH level to guide the dosage. Sometimes iodine deficiency is present. This can be diagnosed through a blood or urine test to measure excretion of a known iodine dose. Low urine excretion indicates deficiency. Iodine is then given in oral dosage, up to 12.5 mg daily.
Human Growth Hormone (hGH)
Human growth hormone also declines in both sexes with age. Growth hormone deficiency causes osteoporosis, depression, reduced energy and strength, increased abdominal fat and reduced muscle mass. IgF-1 levels are measured to assess the body’s production of growth hormone. Low IgF-1 levels are associated with heart failure, the major cause of hospitalization in older people. Growth hormone is usually administered in a dose of 1–2 units daily by subcutaneous injection. Specific laboratory testing is necessary to evaluate growth hormone deficiency.
We have experience in directing hormone replacement therapy in thousands of patients. Every patient is different, and it is important to make individual assessments to assure proper treatment.
Do Hormones Cause Cancer?
In men, a large study of 20,000 men showed no increase in prostate cancer in men treated with testosterone. But testosterone supports the growth of prostate cancer, and a main treatment of prostate cancer is to give agents that block testosterone production and activity- Lupron, Proscar, Casodex, Xgeva.
After a period of years prostate cancer is no longer controlled by blocking testosterone. Experiments are going on to see if alternating testosterone blockade with testosterone supplementation may prevent resistant cancer cells from growing.
In women data on breast cancer and hormone therapy are conflicting.
After menopause, when hormone levels are very low, the incidence of breast cancer in women goes up, not down. It continues to rise until the age of 85, even though estrogen levels are extremely low. Therefore other factors must be involved- impaired immune function, poor diet, overweight, diabetes, lack of exercise, stress, heredity.
The Women’s Health Initiative, a major study conducted in 2002, showed a slight increase in breast cancer in women given Premarin and Provera. These preparations are both non-human identical hormones. Provera the synthetic progesterone, has been shown in some studies to increase incidence of breast cancer. We never use it.
A 10- year follow-up study on the Women’s Health Initiative, in women with hysterectomy and thus on estrogen only and no progesterone, showed no increase of breast cancer in those women.
Testosterone therapy in menopausal women has been shown to reduce breast cancer incidence. Compared with placebo, women on testosterone only or testosterone plus estrogen, had half the incidence of breast cancer as women getting no hormones. A 90 year old woman had regression of breast cancer when she was treated with testosterone.
What should women do? Use bio-identical hormones only.
Follow lifestyle that reduces breast cancer risk: exercise, avoidance of overweight, reduce alcohol consumption (not more than drink a day) and eat cruciferous vegetables that reduce breast cancer risk- such as brussels sprouts, broccoli, kale, cabbage.
See how you feel with hormones. Remember that hormones improve bone density, mood, sleep, skin quality, sense of well-being, libido, vaginal health, energy, cognitive function, and may lower risk of heart disease and stroke. They may also lower risk of dementia.
-Allan Sosin MD