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Part 2 of Madonna Sophia Compton's article exploring the pros and cons of taking estrogen to counter the effects of menopause.


Common side effects

Fluid retention, bloating, weight gain
Thrombophlebitis
Breast tenderness
High blood pressure
Vaginal discharge
Thyroid problems
Headaches/Migraines
Fibroid tumors
Nausea
Cancer
Acne
Gallstones
Depression not attributable to other factors
Hyperplasia
Dizziness,
Shortness of breath
Hypoglycemia


Dr. John Lee, author of numerous books on treating menopause using natural hormones and a good nutritional program, believes that most of these symptoms are caused by estrogen dominance. Unfortunately, estrogen opposed by a synthetic progestin does not remedy any of these problems, with the exception of the build-up of the endometrial lining (hyperplasia). (17) As noted earlier, most physicians do not give estrogen without prescribing some form of progestin. The most common is Provera which is tolerated by some, but can have a host of disturbing symptoms, including irritability, breast tenderness, increased appetite, fluid retention, moodiness and loss of libido. There is a much longer list of problems, which we will examine shortly, but these are the most common complaints. Provera is generally prescribed in a 10 milligram tablet for 10-13 days per month, although the dose is frequently cut down to 5 milligrams if symptoms are too intolerable. Other doctors switch a patient to Norlutate if Provera is not tolerated at all. Progestins are given in what is commonly called a "progesterone challenge test" if a woman is no longer having periods. It is taken for 10 days to see if the uterine lining is still being stimulated by estrogen. If bleeding starts at the end of the test, it indicates a woman is still producing estrogen. A progesterone test is often also given to clean out the uterine lining if a woman's periods are prolonged or accompanied by heavy bleeding. If endometrial hyperplasia is suspected, cyclic progesterone (given 10-13 days a month) may be given for three months to see if the uterine lining returns to normal. What is the most useful way to take hormone replacements? The most commonly prescribed are pill, creams and patches, and each has its advantages and disadvantages.

Pill form

The most commonly prescribed estrogen used by doctors in the U.S. is Premarin, derived from mare's urine. (If interested in how this hormone is procured, see the next chapter.) All conjugated estrogens taken by pill or capsule are advised to be used in conjunction with a progestin, unless the uterus is already removed. As noted earlier, this has the disadvantage of causing a woman to continue having periods. Sometimes if the progestin is cycled throughout the month, a lower dose can usually be given and often after some time (usually at least a year) periods will decrease or cease altogether. However, it is not completely certain if progestin's opposition to estrogen reduces or eliminates the risk of uterine cancer when administered in this way. The more normal schedule is to take estrogen for the first 25 days of the month, and then progestin for a shorter time, usually 10-14 days. Different doctors have different regimes. The most common complaints when taking HRT in this way are fatigue, weight gain and irritability. If a woman does not have a uterus, she should take a few days off each month from taking estrogen, but doctors rarely advise her to take progestin. If a woman is producing quite a lot of estrogen on her own during her menopause or peri-menopausal phase, sometimes doctors advise taking progestin alone to keep excess uterine lining from building up. If Premarin or other oral estrogens are used, they become concentrated in the digestive tract, where they are transformed chemically. Dr. Susan Lark explains that "this can change the type as well as the potency of the estrogen that is reabsorbed back into the body...[therefore] women with a history of liver or gall-bladder disease or hypertension and clotting problems may do well to avoid oral estrogen." (18) Since all estrogen must pass through the liver when taken by pill form, some is metabolized by the liver and some is bound by proteins produced in the liver, which renders it incapable of entering the cells. Therefore the percent which is biologically active, or available for use is considerably less than what was ingested. Since estrogen taken by tablet often stimulates the production of a substance which causes hypertension in some individuals, blood pressure should be monitored more closely if taken in this way. This is especially true if taken with progestins, which are also implicated in high blood pressure, as well as with heart disease and strokes. Estrogen should never be taken in a form which also contains a tranquilizer (such as Menrium, which contains Librium) or Mediatrix, which contains an amphetamine. Such medications can easily become habit forming, and must be ingested with the estrogen whether it is always needed or not. They do not treat the cause of the anxiety, depression or fatigue, but only the symptoms. Managing mood changes by more natural methods is treated in other sections of this book. A woman likewise should never take Ortho Dienestrol, which is a synthetic estrogen, whose effects have not been tested, or non-steroidal estrogens, such as DES, which is associated with a history of causing cancer in the women children whose mothers took it while they were pregnant. The benefits or risks of estrogen taken by mouth depends largely on how it is metabolized by the liver. Many tablets can be split in half, but some women prefer other forms of estrogen which do not affect the internal organs such as the liver or gall bladder. Check to see what doses the kind of estrogen you may choose to take comes in. A good suggestion is that you should start with the lowest possible dose; then go higher if it does not offer symptom relief. Many doctors believe that Estrace is a safe form of estrogen, since it is a pure product of the same estrogen found in the ovaries, 17B-estradiol. It is much stronger than estriol, however, and its safety for women with a high risk for breast cancer should still be taken into account.

Skin patch or cream

Absorbed transdermally, patches and creams avoid the problems inherent in oral estrogen's passage through the digestive tract and the liver. It simply passes into the blood stream through the skin. This is especially helpful in women with hypertension and blood clotting problems. The more natural forms of estrogen made from soybean derivatives, such as estroil and other hormonal compounds, are most readily available in skin creams. Transdermal studies began in France in the early l970's and demonstrated that hormones work very well if taken in this way. The only drawback to the cream is that it may be messy or it rubs off before it is fully absorbed. Whenever using a cream, either on the skin or vaginally, care must be taken that the male partner not be exposed to the extent that he absorbs it himself. He doesn't need your hormones. The patch has the advantage of controlling the dose a little more effectively. It permits estrogen from seeping through the patch on the outside, while permitting it to seep only into the part of the body where it is positioned. They are usually quartersized patches that need to be changed every few days. These are often worn on the hip, thigh or stomach. In some women (about 20%), it causes a skin irritation and the patches need to be rotated or discontinued. This is more of a problem in warm, humid climates. A major advantage to transdermal estrogen is that, because it dispenses estrogen continuously, instead of in a huge burst like the pill form, it more closely replicates the natural cycles of the body. With the patch there is less binding and breakdown of estrogen by the liver, so the dose is usually more potent. Therefore, lower doses are often prescribed, often starting at .5 or .10 mg. or less. Since the woman is getting smaller doses of estrogen on a regular basis, she is not as likely to suffer the side effects which often happens to a woman who is taking estrogen orally. Some women cannot tolerate wearing patches because they look or feel too obtrusive. Although they can be worn in the shower, they should probably be removed before swimming or a hot tub. An estrogen cream has been developed which has a rapid-drying property and this may be more suitable than patches for some women, since it doesn't rub off onto clothing and it disappears instantly. Many report that the natural creams available from Women's International Pharmacy to dry quickly and to work extremely effectively. Sometimes women complain of breast tenderness with both skin creams and vaginal creams, but this often goes away in a short time. Patches are usually a little more expensive than oral estrogen.

Vaginal creams

Inserted with a vaginal applicator, the cream is applied directly to the vagina. This method of using estrogen is especially helpful for women who experience vaginal or urinary tract discomfort. It begins to work immediately for vaginal problems, from severe atrophy to mild itching, by rebuilding the vaginal walls. Often doctors seem to worry that when taken through the vagina, the amount of estrogen absorbed is so variable that it is difficult to know if the woman is getting too much. The estrogen is absorbed directly through the vaginal epithelium into the blood stream. If taken regularly, especially without a progesterone, estrogen can be dangerous when absorbed in this way. Women with a history of breast cancer in their family are advised to use creams in very small doses. Again, please note: not all creams are alike. There is a big difference between taking a gram of cream if one brand gives 1.5 mg. per gram and another only .1 mg. per gram. In the case of Estrace, for example, a woman would only get .4mg when taking a full applicator, which is less than 1/4 of an application compared to other brands. (See chart.) Estriol is often prescribed in low doses for seven continuous days, then two or three applications a week to effectively control vaginal dryness or cystitis. The advantage to the vaginal cream is that it can be used only when needed; some women can insure that they keep their estrogen levels very low this way. Even though not advised by many doctors because the dose can get out of control too easily, many women I know feel that a wise woman can use very small amounts of vaginal estrogen safely, with or without progestin. I use it only once a week or to protect vaginal and urethral walls. Numerous women have reported success with using just 2 to 4 grams (.1 mg each) a month, which is very little compared to taking .6 to 1.2 mg daily for 25 days a month. English researchers offer evidence that only 1/8 of the dose normally recommended by American doctors is sufficient to plump up vaginal tissues. (19) Vaginal use of Estrace tablets is also an option: most women prefer to use only 1/2 or 1/4, since the tablet strength is considerably stronger. Sometimes, there is some fluid retention in some women when taking estrogen this way, but it usually disappears early in treatment. Since women often take the cream for vaginal atrophy, it tends to be absorbed quickly at first; then it slows down as the estrogen thickens the vaginal walls. This does not serve the same purpose as lubrication, by the way, and should not be used immediately before love-making to avoid absorption by the male partner. Vaginal gels or creams are often still needed for lubrication from the friction caused by intercourse. Many doctors feel that estrogen used in this way does not seem to offer the advantage of protection against osteoporosis or cardiovascular disease, which seems to be guaranteed more by the pill. These benefits, however, are still being debated and will be discussed more in a later section. Estratest is a combination of estrogen and testosterone, and can be made by the pharmacist in a cream base. Sometimes women who have their ovaries removed need a small amount of testosterone to feel sexual or energetic; most women get enough of the "male" hormones, called androgens, from their adrenal glands.

Injections and implants

Shots have the disadvantage of injecting very large amounts of the hormone directly into the blood, which diminishes over time. This generally produces more than you need initially, then drops to less than what you need, giving a sea-saw effect. They are often given once a month. Subcutaneous pellets are somewhat outdated. They are injected through a small incision and absorbed through the fatty tissue. They are difficult to remove, except through a surgical procedure, and therefore have a distinct disadvantage if there are side effects.

A woman who chooses to use estrogen has a variety of choices, but in the last analysis, none may be suitable if she just cannot tolerate the side effects or if she has too many contraindications for hormone replacement therapy. In any event, look at all of your possibilities before making your decision. And, by all means, read the rest of my book on this subject for even more options! It may be that you don't need estrogen at all.

Estrogen Brand information

BRAND NAME KIND OF ESTROGEN VARIOUS STRENGTHS
Premarin (tablet) conjugated estrogens .3mg/ .625mg/ .9mg/ 1.25mg
Premarin with Methyltestosterone (tablet) conjugated estrogens with testosterone .625 mg E. & 5mg. T.1.25 mg E. & 10 mg T.
Estratest (tablet) esterified estrogens & methyltestosterone .625 mg E. & 1.25 mg T.1.25 mg. E & 2.5 mg T.
Estrace (tablet) estradiol 1 mg/ 2mg
Estraderm (patch) estradiol .05mg/ .1mg
Ogen (tablet) estrone .625mg/ 1.25mg/ 2.5mg/5mg
Estrace (vaginal creme) estradiol 1 gram= .1mg
Premarin (creme) conjugated estrogens 1 gram= .625/1.25/2.5mg
Estriol (creme or gel)(natural product from soy) estriol 1 gram=.5mg/1mg/2mg


REFERENCES

1. R. Wilson, Feminine Forever (N.Y.: M. Evans, l966), p. 44.
2. See S. Perry & K. O'Hanlan, Natural Menopause (N.Y.: Addison-Wesley Pub. Co., l992), p. 41.
3. E. Barrett-O'Connor & D. Dritz-Silverstein, "Estrogen Replacement Therapy and cognitive function in older women." JAMA 269, # 20, pp. 2637-41(l993).
4. B. Sherman et al., "The menopausal transition." Journal of Biosocial Science, (Supp. 6.) Ed.by A.S. Parks, et al., l979), p. 30.
5. See, e.g., M. Beard, & L. Curtin, Menopause and the Years Ahead (Tucson, AZ.: Fisher Books, l988), pp. 33,63.
6. J.O.White, et al., "The human squamous cervical carcinoma cell line, HOG-1, is responsive to steroid hormones," International Journal of Cancer, 52 (2): 245-51 (Sept.9, 1992).
7. A. Follingstad, "Estroil, the forgotten estrogen?", JAMA 239 (1):29-30 (1978). See also A. Gaby, Preventing and Reversing Osteoporosis ((Rocklin, CA,: Prima Pub., l994), pp. 134-38.
8. H. Adlercreutz, et al., "Dietary phyto-oestrogens and the menopause in Japan," Lancet 330:1233(l992).
9. L. Bergkvist, et al., "The risk of breast cancer after estrogen and estrogen-progestin replacement," New England Journal of Medicine 321:293-97(l989).
10. V.A. Tzingounis, et al., "Estriol in the Management of the Menopause," JAMA 239:1638-1641(l978). See also, D. Gerbaldo, et. al., "Endometrial morphology after 12 months of vaginal oestriol therapy in post-menopausal women," Maturitas 13 (4): 269-74 (1991).
11. H.M. Lemon, et al., "Reduced estriol excretion in patients with breast cancer prior to endocrine therapy," JAMA 196: 1128-36 (l966).
12. A. Follingstad, op.cit., p.30.
13. Ibid. Follingstad indicated a 37% remission or arrest of metastasized lesions. See also, H.M. Lemon et al., 1966; H.M. Lemon, et al., "Pathophysiologic considerations in the treatment of menopausal patients
with estrogens:the role of estriol in the prevention of mammary carcinoma," Acta Endocrinol Suppl. 233:17-27 (l980).
14. A. Gaby, op.cit., p. 132.
15. R. Raz, et al., "A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections," New England Journal of Medicine 329: 753-56. (l993). See also, A Brandberg et al., "Low
dose oral estriol treatment in elderly women with urogenital infections," Acta Obstet. Gynecol. Scand. supp 140:33-8 (l987); A.L. Kirkengen et al., "Oestriol in the prophylactic treatment of recurrent urinary tract
infections in postmenopausal women." Scand. Jour. of Primary Health Care 10:139-42 (l992).
16. A.Gaby, op.cit, p. 135.
17. J.R.Lee, Natural Progesterone: The Multiple Roles of a Remarkable Hormone (Sebastopol, CA.: BLL Pub. l993); What Your Doctor May Not Tell You About Menopause ( N.Y.: Warner Books,l996).
18.S.M.Lark, The Estrogen Decision (Los Altos, CA.: Westchester Pub.Co., l994), p27.
19.G.I.Dryer,et al., "Dose-related changes in vaginal cytology after topical conjugated equine oestrogens," British Medical Journal 284, p. 789 (1982)

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