Estrogen:
The wonder drug of our generation?
In this article Madonna
Sophia Compton explores the pros and cons of taking estrogen
to counter the effects of menopause. The information presented
is part of a book which discusses the options open to women at
this important time. The book and other relevant information is
available for sale on-line at Sophia's
homepage.
Although the mention of menopause no longer evokes an embarrassed
silence, women still have little opportunity to be instrumental
in their treatment program, unless they opt for treating themselves
without ever going to the doctor. Many of us are now aware that
menopause has been "medicalized" and actually taken away
from women. The majority of doctors prefer to start women on Hormone
Replacement Therapy as soon as they begin experiencing symptoms.
This is the time a woman should begin to seriously research the
hormone controversy so she can make a more informed decision by
the time she is done menstruating altogether.
With the publication, in the mid-60's of the book, Feminine Forever--written
by a male doctor touting estrogen as the only option women had to
keep from withering into a hopeless old hag-- Hormone Replacement
Therapy began to have widespread popularity. Dr. Robert Wilson argued
that women needed to take estrogen from puberty until death, believing
menopause itself to be a serious crippling disease. Women who did
not subscribe to his campaign to take estrogen forever would inevitably
encounter a dangerous risk indeed:
"I have seen untreated women who had shriveled into caricatures
of their former selves...Some women, when they realize they are
no longer women, subside into a stupor of indifference..."
(1)
God only knows how many thousands of women climbed onto the estrogen
band-wagon as a result of these threats. With the dawning of the
next decade, however, sales of estrogen plummeted as new research
demonstrated an increased incidence of endometrial cancer in women
on estrogen therapy. Estrogen use dropped dramatically by almost
30% from l975-l977. Doctors then began routinely prescribing a synthetic
progesterone, progestin, since it was believed that this was a hormone
that opposed the tumor-stimulating effects of estrogen. Progesterone,
we recall, acts upon the uterine lining during the second half of
the menstrual cycle, blocking the accumulation of estrogen in the
endometrium. It is inactive when taken by mouth, however, because
it is broken down by the digestive juices. We will investigate the
problem of synthetic verses natural progesterone in the next two
chapters.
The 70's also brought concern over HRT when some experts began to
suspect that estrogen may be responsible for an increase in blood
clots, heart attacks, and strokes. In the l980's reports began to
surface that linked estrogen with breast cancer. Nonetheless, since
the l970's doctors have routinely prescribed progestin with estrogen,
even though the synthetic progesterone causes multiple problems
in many women who use it. Most believe that estrogen is now safe
and its use continues to increase as the medicalization of menopause
becomes big business for both the medical profession and the drug
companies. Since one third of the population will be over 50 within
the next decade, and women have now entered the work force in unprecedented
numbers, menopausal women have become the number one target for
preventive health care. Most of the books on menopause again boast
that estrogen, as it is prescribed today, is safer than ever before.
The dosage of estrogen used in HRT today is considerably lower than
it was in the past. In addition, the incidence of uterine cancer
has decreased with the addition of progestins to HRT. However, many
questions remain unanswered. Each woman must weigh the choices and
make her own decision about taking hormones during her menopause,
and sometimes this decision can be an agonizing one. For many women,
estrogen, whether from purely natural or from chemically synthesized
sources is the only relief for certain symtomology. However, if
a woman does choose to take HRT, she certainly should understand
that there is a wide range of choices available, which need to be
critically examined.
In this article, we will look at some of these options.
Sometimes, it takes a good deal of time to discover what feels best
and what works most appropriately to fulfill each woman's needs.
What works for one woman may be impractical or unsuitable for another.
There is no single panacea, whether from a doctor's office or from
the local health food store.
In l975, the FDA required that any drug containing estrogen must
have a package insert describing the potential health risks associated
with using the hormone. This was the first great "eye-opener"
for me. Had I just taken the advice of my doctor unquestionably
and tossed the package insert material away, I would never have
embarked upon my journey for alternative sources to meet my own
menopausal needs. For other women, the benefits of taking estrogen
outweigh the risks and I respect these women's choices--if they
are well-informed. One of the most ironic statements made by a doctor
who fought the FDA's decision to pass the regulation about informing
women concerning what they were putting in their bodies demonstrates
a very paternalistic bias with no regard whatsoever for a woman's
intelligence and discernment: It is hard to imagine a class of patients
more susceptible to adverse psychological reaction from the patient
package insert than the menopausal woman.(2)
The Pharmaceutical Manufacturers Association and the American College
of Obstetricians and Gynecologists argued that this kind of labeling
was dangerous and would lead to self-diagnosis and treatment on
the part of menopausal women. Thankfully, we can now more adequately
weigh the risks and do just that. One of the useful advantages of
the package insert material is to help dispel the estrogen-as-panacea
myth. There are certain things that this hormone simply will not
do, although somehow these beliefs have accrued to and become part
of the "estrogen story." Behind the many questions about
menopause lingers the nagging hope for many women that "The
Change" will be "No Change." For too many, estrogen
represents the hopeful elixir of life, a desire perpetrated by a
consumer society which insists upon selling success, youth, beauty
and sex-appeal via the mass media. Here is what you can expect HRT
not to do:
* Estrogen will not prevent a woman from gaining weight. In fact,
in some women, it causes weight gain. Ranchers use estrogen to fatten
cattle. * Estrogen will not prevent wrinkling of the skin. Like
any cream, it may help to plump up the underlying tissue, but in
some women, it actually causes the skin to dry out more and brown
blotches to appear more quickly. * Estrogen will not improve memory
or cognitive functioning. Studies indicate that there is no difference
in the strength or deterioration of these functions between women
who take estrogen and women who don't. (3) * Estrogen will not alleviate
depression. It will, however, cure the problem of night sweats,
thus restoring sleep. This may go a long way toward eliminating
irritability the next day, caused by lack of sleep, but estrogen
alone is not a cure for a more severe depression. * Estrogen will
not restore libido. Libido is a function related more specifically
to other hormones, like progesterone and testosterone, and to the
kind of relationship one has with one's partner. * Estrogen will
not increase bone mass (bone formation). That is, it is not an effective
long term aid for osteoporosis. See chapters 11 and 12 for a more
detailed explanation of this problem.
The principle things a woman can rely on estrogen to do are to eliminate
hot flashes, night sweats, vaginal dryness and urinary tract problems.
However, once HRT is discontinued, menopausal symptoms will return.
Taking estrogen continuously mimics a pre-menopausal condition.
Therefore, most women will continue to have periods indefinitely
as long as they are taking hormones. There are ways of experimenting
with progestins that may decrease the flow, but for most women this
is one of the greatest disadvantages of HRT. Many women, even in
their 70's or 80's, who begin HRT will start to menstruate again.
Because menopausal symptoms will reappear upon discontinuing HRT,
it is important to gradually decrease the dose if you want to stop.
You may wish to cut your pills in half or even quarter them if taking
hormones orally. Since this is another common complaint about HRT,
it is helpful to know that these symptoms can be minimized by taking
herbal supplementation, or even by taking natural progesterone alone.
This will be explained in more detail in Chapter 11. These two major
complaints (i.e., prolonged menstruation years during HRT use and
the severe reoccurrence of symptoms after discontinuing estrogen)
generally only come from women who are on traditional HRT regimes,
particularly when taken orally, which is the highest dosage. Women
who use an estrogen vaginal cream on occasion, for example for treatment
of vaginal dryness as needed, will stop menstruating and many find
that their menopausal symptoms eventually disappear with herbal
supplementation. Because many doctors are impatient to start women
on HRT while they are still peri-menopausal, it is important for
each woman who contemplates this possibility to know her previous
menstrual history, i.e., how long she has been "skipping"
periods, their regularity or irregularity, etc. It is impossible,
of course, for a woman to know when she is having her "last"
period, although the older she is the more likely the possibility
that after six months, she will probably not bleed again. The statistics
are 52%, age 45-49 and 70% if over 53. (4) Business and professional
women tend to have an earlier menopause, as do vegetarians or women
who have had tubal ligations. The longer it takes to move through
the peri-menopause, or to move from irregular periods to no periods,
the more likely is the occurrence of physical or emotional symptoms.
With menopause, ovulation finally ceases altogether and progesterone
all but disappears, although the ovaries may still produce small
amounts of estrogen. The ovaries also produce testosterone and androstenedione,
generally thought to be male hormones. A woman's body usually converts
these to the hormone estrone, a type of estrogen. In some women,
the conversion into estrone is excessive and may lead to hyperplasia
or cancer. This is probably because, even naturally, estrogen unopposed
by progesterone can be quite dangerous. Often women who are overweight
or hairy have an abundance of either testosterone or estrogen occurring
naturally in their bodies, which may in turn also cause diabetes
or high blood pressure. Very thin or small boned women, on the other
hand, may suffer from estrogen deficiency and be more prone to osteoporosis
or heart disease. During a pre or "peri-menopausal" stage,
a woman may have a variety of different ways of adjusting to her
changing hormone levels. A woman's periods often become not only
less regular, but less symptomatic, or even pain-free. Other women
have excessive bleeding and cramping. Even if menstrual periods
are irregular, however, and they are accompanied by excessive bleeding
when they do occur, it could be dangerous. While such irregular
bleeding is probably due to the adjustment of a woman's body to
decreasing estrogen, it could also be an early sign of hyperplasia
or cancer and should always be investigated if bleeding continues
to be excessive. Spotting is common during early menopause and may
last for years. The important thing to note is if it follows a regular
pattern. Irregular or "breakthrough" spotting should also
be checked. A pap smear is not sufficient to determine the cause
of abnormal bleeding. Generally an endometrial biopsy is used to
rule out cancer. Some physicians insist on yearly biopsies for women
on estrogen anyway. Cancer of the cervix is no longer considered
to be an estrogen-dependent cancer by most doctors, (5) but even
this is still controversial. As recently as l992, the International
Journal of Cancer wrote that, "cervical cancer is stimulated
in response to excess estradoil." (6) If the uterus has been
removed, doctors generally do not advise taking a progestin, since
there is no uterine lining to protect. Newer studies, which we will
examine later, indicate that this may not be wise, since other parts
of a woman's body may be prone to cancer if she takes unopposed
estrogen. If ovaries have been removed, estrogen is often given
immediately to prevent menopausal symptoms. The earlier a woman's
ovaries are removed, the greater the shock to her body and often
more estrogen is required to control symptoms than for a normal
menopausal woman with her ovaries intact.
Kinds of estrogen and side effects
Most estrogen compounds currently sold in the United States are
types of either estrone or estradoil. Some believe they can be used
interchangeably, paying very little attention to a third type of
estrogen, estroil. Estrone is the hormone naturally present after
menopause; estriol is produced in large amounts during pregnancy.
Estradiol is the type of estrogen women produce before menopause.
It is the prime ovarian estrogen secreted by the ovary. Estrone
is the estrogen synthesized from estrodial or else from the androgenic
(masculinizing) hormone androstenedione. Estrone is believed to
be more carcinogenic than estradoil. Both estrone and estradiol
are vulnerable to mutation. "Conjugated" estrogens are
not themselves physiologically active, but can be converted into
active components in the body. All conjugated estrogens orally administered
are converted to estrone in the small bowel, unfortunately. Because
postmenopausal women produce more estrone than estradoil naturally,
it is the most likely reason older women are more prone to breast
cancer. Adding extra estrone is therefore an added risk. A chart
listing the various kinds of estrogen prescribed today can be found
at the end of this chapter. Although estrone and estradoil are the
only forms of estrogen available in the U.S., the third type, estroil,
is commonly used in Europe and is the only form of estrogen thought
not to be cancer-causing. If a woman has a very healthy liver, the
carcinogenic forms of estrone and estradoil may be broken down before
they lodge in the estrogen receptors of the breast and uterus. However,
it would seem to make more sense to use the safest form of estrogen,
estroil, to begin with.(7) High levels of estroil have been found
in vegetarians and in Asian women, who consistently appear to be
at much less risk of breast cancer. (8) Research is accumulating
that estriol has protective, anti-aging benefits. Of the three estrogens,
it has been found that estradiol is the most stimulating to the
breast tissue, estroil the least. (9) Estroil does not convert to
estrone in the body. Studies indicate there is no sign of hyperplasia
even without the addition of progestin, and in one case, weight
and blood pressure readings remained stationary.(10) As far back
as 1966, it was demonstrated that women with breast cancer had a
reduced excretion of estriol, linking it to the estrogen-cancer
puzzle. (11) Dr. Alan Follingstad, in the Journal of the American
Medical Association, called estriol the "forgotten estrogen,"
and said that any woman in a high risk category (such as a family
history of breast cancer, prior dysplasia or fibrocystic disease
of the breast, or even early menarche or late menopause) should
have the option of taking estroil rather than one of the other kinds
of estrogen:
The popular estrogens in use for many years can still be used for
low-risk patients, but when the high risk patient desperately needs
estrogen...what shall we do? We can take the easy way out and say,
'No estrogen for you.' However, if our concern leads us to...stick
our necks out and prescribe estrogen, let us have the estrogen that
causes the least risk. Let us have the opportunity of doing our
own clinical trials. (12)
In more than one study estriol was demonstrated to inhibit or even
arrest metastatic (cancerous) lesions of the breast, thus indicating
that it may actually prevent cancer. (13) Interestingly, breast
cancer is more likely to appear in women who have never been pregnant
or who have never carried to term (through induced or spontaneous
abortions). This may indicate that estroil, produced in large amounts
during pregnancies, is the unknown protective agent. U.S. doctors
generally dismiss estroil as a weak or ineffective estrogen, but
studies have demonstrated that all that is necessary is to increase
the dose and it works quite well in alleviating menopausal symptoms.
A dose of 2 to 4 mg of estriol is generally equivalent to .6 to
1.25 mg of conjugated estrogens.(14) A l993 study found it to be
most active on the vagina,cervix and vulva, thus making it the most
effective estrogen for vaginal atrophy, cystitis and vaginal infections.
(15) If you are interested in the safest form of estrogen, check
with your doctor and see if she will order it for you. (I had to
search around before I found one, but they're out there!) My doctor
calls in a prescription to Women's International Pharmacy and they
deliver it to my door, billing me later. They will make the formula
in any strength determined by you and your physician. It is unfortunate
that more doctors are not even aware of this alternative form of
estrogen; or if they are aware of it, shun it nonetheless. Dr Gaby
has said:
Living under the constant threat of rejection by colleagues, scrutiny
by medical disciplinary boards, malpractice lawsuits, and an unwritten
law that they are supposed to know everything, doctors often find
it easier to run with the pack than to risk being different--even
if being different means practicing a superior brand of medicine.
(16)
If you cannot find a doctor in your area who will prescribe the
kind of hormonal formulas you request, the Women's International
Pharmacy has a physician referral list; their 800 number is 1-800-279-5708.
An added plus is that studies indicate that estriol will not normally
cause the menopausal woman to continue having periods like other
forms of HRT. Much more research needs to be done on this valuable
hormone. Why, one wonders, are there not more studies done on alternatives
such as this in this country? Is needed medical research lacking
becauseWyeth-Ayerst, the sponsor of the most widely used estrogen,
Premarin, has a monoply on the market? Whether estrogen comes from
plant or animal sources, every woman should have a series of tests
before embarking on HRT. This includes a pap smear and breast exam,
a urinalysis, hemoglobin or hematocrit tests, as well as additional
tests that include blood sugar, liver and thyroid function, cholesterol
tests, tests for calcium and phosphorus levels, and a bone density
test to determine the degree of bone loss during menopause. Most
doctors will also give what is known as "progesterone challenge
test" which will be explained in a moment. With the possible
exception of estriol, estrogen should never be taken if there is
a previous history of breast or uterine cancer. It is contra-indicated
if a woman has thrombophlebitis (blood clotting problems) or hypertension,
hepatitis, migraines, or liver problems. There is at least one chance
in 20 that estrogen will release enzymes that elevate blood pressure,
especially if taken orally. It is also likely to aggravate gallstones
and worsen diabetes. Estrogen reduces the oxygen levels in all cells
and can interfere with thyroid functioning. Fibroid tumors and most
cancers grow when stimulated by the common estrogens used in this
country. Here is a list of the most common side effects reported
by women who use HRT, as well as some of the more serious ones.
yOni now blogging at cliterallyspeaking.blogspot.com
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