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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