To Replace or Not To Replace: That Is The Question Regarding Natural Hormones.
There has been a lot of fear and confusion about hormone replacement therapy (HRT) in menopausal women, all of which started with the Women's Health Initiative (WHI) Study of June of 2003. The initial reaction to the study's main findings of an increased risk of breast cancer, coronary heart disease, stroke, and pulmonary embolism in those using the drug Prempro was that physicians and patients both stopped using the pharmaceutical hormone drugs completely. Whereas before the study every woman was given them, after the study no one wanted to give them or take them. But you will soon see that what we are finding is that, given a few common sense guiding principles, the baby has been thrown out with the bathwater.
A new look at this study, and more information from recent studies allow us to add some additional important observations.
First, this group was a full 12 years older than the mean age at menopause (51). SO, this group may have had well established arteriosclerosis at the onset of the study. They also took 0.625mg of the Premarin, and 2.5mg of medoxyprogesterone (Provera) every day orally, Today half the amount of estrogen is used, real progesterone is often substituted for Provera, and transdermal patches are replacing oral administration. All these changes will reduce complication rates. Regarding breast cancer rates, they were up in the group that took the combination drug therapy for 5 years, but down a little in those who only took estrogen. The predominance of data (including that from a heart focused study in 1998) indicate that HRT has no impact on heart attack incidence or deaths from coronary causes in a group with pre-existing coronary disease.
Thus a fresh look at the hormone issue now gives us the
following guidelines.
1. Hormone replacement therapy is still the most effective treatment for the menopausal syndrome and vaginal dryness.
2. HRT should probably be avoided or at least minimized (avoiding estrogen use) in people with a strong family history of breast cancer, or a personal history of fibrocystic breasts, fibroids, endometriosis, stroke, coronary heart disease, or venous blood clots.
3. If HRT is started nearer to the onset of menopause, complications of any sort are much less frequent.
4. Despite a strong natural medicine suspicion to the contrary, it appears that unopposed estrogen therapy does NOT increase breast cancer rates. Still, prudence dictates that estrogen be balanced with natural progesterone almost always.
5. Although perhaps not protective against coronary disease, it appears that HRT at least does not aggravate the condition.
6. HRT has a definite effect in improving bone density, and in greatly reducing (down 33%) fractures due to osteoporosis .
7. A new revelation for orthodoxy, but always a guiding principle for the natural medicine doctor, the patient should be placed on the lowest possible dose of hormones, they should be identical to natural molecules, and they should be prescribed in the same balance as when naturally occurring in the body. I call this Natural HRT (NHRT).
8. Never take conjugated equine estrogens with medroxyprogesterone (Provera) for any reason (increased breast cancer and stroke). That was the "standard of care" until just a few years ago! But I've been warning women to avoid it for over 20 years.
9. NHRT packs the greatest punch to slow and even reverse the aging process, and improve quality of life. That's the more primary reason why I prescribe them...not just to
control "hot flashes". Not everyone cares to invest in themselves for a more youthful look and greater vitality. But if you are peri-menopausal and you wish to do so, NHRT should be the cornerstone of your anti-aging program.
10. Testosterone is almost universally ignored as a replacement therapy for women. Yet it has huge importance in energy, vitality, minimizing body fat, and maintaining or enhancing libido.
11. There are still concerns over the length of time HRT should be continued. I do not agree with the published guidelines since they are saying a 3-5 year max for the estrogen/progestogen combo, and I say NEVER take these drugs. For estrogen alone (which I never recommend" orthodoxy says 7 to 10 years is the limit. I think as long as bioidentical hormones are prescribed in low dose transdermally, in proper balance, and with lab monitoring
of hormone levels, NHRT can and should be started as soon as needed, and continued as long as it is helpful and desired. I have never seen any woman develop any of the known serious "side effects" of the pharmaceutical hormones when she was being treated properly with bioidentical hormones in accordance with this principle in the 15 years I've been prescribing them. Currently I have one patient who is having a susipcious lump biopsied. However in treating thousands of patients, this is the first one that I know of to require such attention. Overall it appears clinically to me that BHRT actually reduces the incidence of
breast cancer and precanceous changes like DCIS.
Robert Filice, MD
708-307-8717
