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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.

To Part 2 of the article.
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