I write today for the woman who truly suffers from Hormone changes at menopause. Not the woman sitting with questionnaire and calculator trying to figure out her long term risks of taking hormone therapy -- but the woman crying in her doctor's office right now because she is miserable with HRT and miserable without it.
by Patricia Rackowski
Can women get relief from hot flashes, night sweats, insomnia, mood swings, vaginal dryness and other menopausal complaints without suffering irregular bleeding, headaches, nausea, bloating, depression and worse mood swings frequently caused by HRT? For many women this question is a lot more pressing than will they get heart disease, osteoporosis or breast cancer in the distant future.
Back issues of AFI are filled with letters from women who have tried to take HRT for symptom relief, and felt worse. Many women have tried a variety of herbal and complementary therapies, but these too have not brought relief. Some have already had their ovaries removed, and they are desperate.
That's the women's side. Meanwhile, Menopause, the Journal of the North American Menopause Society, has an article in almost every issue bemoaning the fact that 80% of North American women still do not use HRT, which the doctors are convinced is almost universally beneficial. The most recent issue (Vol. 5, No. 4, 1998) estimates that up to 54% of women who start on HRT quit within a year. From other surveys we know that as many as two-thirds of women who start stop within two years. Most of these surveys do not explore why. While some authors do acknowledge the need to fine-tune hormone therapy to an individual woman's situation, they rarely examine what this really involves in terms of time, expertise and the quality of care.
This article shares some of what I have learned through personal experience and research about fine-tuning hormone therapy. Standard, one-size-fits-all HRT doesn't work for everyone, no matter how much you explain it, halve it or double it!
Most HRT prescriptions are now given out by internists or primary care physicians, who don't have adequate time to counsel patients about possible problems that may develop. The ob-gyn who delivered your babies, if he's still in practice, may not be up on the latest in menopause. The nice young woman who took his place may be too busy delivering babies and doing hysterectomies to have time to keep abreast of her patients' mood swings. "Nice" is not all that we need when it comes to doctors; what we really need is doctors who know what they're doing.
Finding the Right Doctor
All too often, women find themselves handed a prescription and told: "See you in three months". There might be a nurse or nurse practitioner to call for advice, but they are rarely hormone specialists. Many women, who are leery of HRT to begin with, stop taking their prescription relatively quickly when unexpected side effects arise. A practice or clinic devoted to menopause can make a big difference in the initial evaluation, counseling, and follow-up.
The woman who is desperate with severe menopausal symptoms -- and many women have other health issues to address as well -- needs a menopause specialist. For this article, I interviewed two such specialists in the Boston area to explore what they consider when they prescribe hormone therapy. By now, most large metropolitan areas in the U.S. and Canada have menopause clinics or practices. If you live in a smaller center or rural area where such services may not be avail- able, you might consider traveling for a consultation -- you're worth it!. If that's not possible, take opportunities to educate yourself, find resources through libraries and the Internet. Then you'll have to educate your own doctor to be what you need her/him to be.
"Specializing in menopause is not a big money-making practice, but it is professionally rewarding," says Dr. Alan Altman of Brookline, Massachusetts, a gynecologist and member of the North American Menopause Society. It takes time to listen to patients with complicated problems, to explain physiology and treatment plans to baby-boomer patients who want to understand everything, and to return phone calls at night. "This type of practice goes against the current direction of health care," he points out, "but it is satisfying to a doctor who has an independent streak and a desire to be of service. You can't be just a gynecologist-- you also have to be part internist, psychiatrist, sexologist, and social worker, and an empathetic human being".
A Menopause Practice
Dr. Altman sees many women who have already been on HRT, the standard prescriptions of PremPro® or PremPhase®, both combinations of Premarin® and Provera®, and who have difficulties. I asked him to elaborate on the theme "you can take HRT without suffering side effects."
"Patients need to realize that HRT is not one thing," he began. "We start down a road and we don't know where we'll end up. As you go along, your body continues to change, and new products come out that offer more choices than before. Drug companies realize that the baby-boomer menopause is a big market and they are trying to answer the needs. Look at what's out just in the past year--Combipatch®, the vaginal ring and Prometrium®. If the patient is miserable on HRT, then the HRT can be changed". He has a "somewhat systematic" approach which would make for a pretty complicated flow chart.
Fine-tuning Hormone Replacement TherapyWhen Dr. Altman sees a patient who is not doing well on standard HRT, he starts all over again. His approach begins with an evaluation of where the patient is in menopause. Is it perimenopause or postmenopause? How long since the last period? What are the complaints of the patient?
If she is in perimenopause and still getting a bleed, then her body is still making estrogen. He might discontinue the HRT temporarily, test her hormone levels and see what symptoms exist. A woman with heavy bleeding and swollen breasts, who is making estrogen without opposition from progesterone (from lack of ovulation), might be put on Prometrium™, natural progesterone capsules, with no additional estrogen unless she also has a lot of hot flashes. Dr. Altman prefers to use Prometrium™ over Provera® because of its better cardiovascular benefits. [Women usually prefer it because it has fewer side effects than Provera®.]
A perimenopausal woman who has little bleeding but is heavily symptomatic with hot flashes, night sweats, etc. might just take a little estrogen augmentation, either herbally or with a low-dose patch or a formulation called Tri-Estrogen (10% estradiol, 10% estrone, and 80% estriol, a "weaker" estrogen in terms of endometrial stimulation ) Her bleeding pattern would be monitored until she went longer than three months without a period, in which case it might be time to add some progesterone to the regimen to reduce her risk of cancer of the endometrium.
Early perimenopause can also be successfully treated with low dose birth control pills, but despite their "low-dose" name they do contain pharmacologic doses of hormones which are much higher than HRT and some women don't tolerate them well.
Postmenopausal women who have used only herbs such as dong quai and black cohosh, or soy phytoestrogens, up to this point could be given the "progesterone challenge" (13 days on progesterone) to see if they get a withdrawal bleed. Women who deal with menopause symptoms successfully with herbs may have naturally higher estrogen levels than women who couldn't find relief with herbs. But without progesterone, they are at slightly higher risk of endometrial hyperplasia.
Obese women should also get the progesterone challenge, because their own bodies make more estrogen in fat cells. If these patients bleed, they should have an endometrial biopsy. They may need to take progesterone cyclically for awhile, even if they aren't taking estrogen. Obesity by itself is a substantial risk factor for endometrial hyper- plasia and endometrial cancer.
If a postmenopausal (or hysterectomized) woman on HRT has complaints such as frequent bloating and swollen breasts, nausea, weight gain and headaches, this may indicate too much estrogen. Dr. Altman would stop the present HRT and start again with a low .3 mg Estratab® and no progesterone. Transdermal estrogen in the patch, creams or gels, might be appropriate, to give greater freedom in dosage amounts than pills do. Once a woman is comfortable on estrogen, he would add progesterone. If a withdrawal bleed occurs, then cyclic Prometrium™ would be added to the regime. If not, then a continuous/combined regime of estrogen and progesterone can be followed, with no bleeding expected. Some natural progesterone can be given even to a woman who has had a hysterectomy as this may improve mood and energy levels and counteract fluid retention.
If a postmenopausal women on HRT come back with complaints of hot flashes returning, and estradiol and estrone levels measure around 60 pg/ml each, Dr. Altman is likely to add testosterone to the formula, usually with Estratest HS® (Half Strength). He explains that he would add testosterone before more estrogen because testosterone reduces SHBG (sex hormone binding globulin) and estrogen increases it. A lower level of SHBG in the blood means more free estrogen and testosterone, reducing hot flashes and increasing libido. He hasn't seen masculinizing effects from Estratest HS®, such as acne, facial hair growth, or hair loss.
For older postmenopausal women who are tired of having a withdrawal bleed on a cyclic progesterone regimen, or intermittent spotting and bleeding on the continuous/ combined regimen, Dr. Altman has been using a "cyclic/combined" HRT regimen. On this regimen, the other- wise daily progesterone is stopped for five days a month. The explanation for this is a bit too technical for this article, but it works to stop the bleeding. Unexpected bleeding should be evaluated by a doctor.
Some women have vaginal dryness despite taking HRT, because estrogen in the blood simply does not adequately reach the vaginal tissue. Dr. Altman has had good results using the new vaginal ring, Estring®, a low- dose time-release estrogen application.
Dr. Altman depends more on what patients report about their symptoms than on blood test results. He doesn't do a lot of hormone blood levels, although he does some when it seems useful.
A Hormone SpecialistDr. Carolyn Shaak, a gynecologist in Needham (Massachusetts), calls herself a "Hormone Specialist". Several years ago Dr. Shaak responded to her patients' complaints about the few choices available in HRT by devoting herself to finding a better way. Now she believes she has found it, with "bio-identical natural hormones" mixed into creams by her pharmacist collaborators at Bird Hill Compounding Pharmacy.
Dr. Shaak now has over 1000 women in her practice using her hormone creams, which are individualized combinations of estradiol, progesterone and testosterone. She is applying for a patent for her formulations, which she will simplify into 5 different commercial products.
I asked Dr. Shaak why she prefers to use the transdermal (through the skin) method of taking hormones. Studies have shown that women are more compliant with hormone regimes that use pills.
"We are not trying to corral women like sheep into compliance," said Dr. Shaak. "Women know whether they feel better or worse taking hormones, and they will not take a pill that causes uncomfortable side effects. I have had tremendous success with women who have tried other hormone regimes and couldn't tolerate them."
"When women understand the benefits of transdermal hormones," added Dr. Shaak, "they gladly use the cream. Some have tried the patch [which also provides natural estradiol] and were allergic to the adhesives. Many women who do not like wearing a plastic patch prefer a cream to taking a pill. They use creams anyway for moisturizing. It seems more natural and less medical than taking a pill for the rest of your life when you consider yourself a healthy person. After all, menopause is not a disease.
"Women also like the creams because it makes them an active participant in their treatment and gives them some control over the dose," she said. "Unlike pills, cream dosage can be adjusted easily. For perimenopausal women who still experience their own bodies' hormone ups and downs, with breasts that are sometimes tender and swollen, the dosage can be cut back for a few days until the tenderness passes."
Dr. Shaak's patients use their cream in twice daily applications to thighs, hips, abdomen--areas where there is body fat to absorb the cream and slowly release the hormones into the blood just as the ovaries do. Most hormones taken in pill form do not reach the bloodstream. They are broken down in the digestive system. Those that make it through the liver are changed molecules, metabolites of the original hormones. According to Dr. Shaak, that is the cause of many side effects women experience in taking hormones in pills. Pills also result in an uneven release of hormones into the blood, peaking shortly after taking the pill and dropping off greatly later in the day. Peaks and falls of hormone levels can cause headaches or nausea.
Dr. Shaak asks all of her patients to read Natural Woman, Natural Menopause by Dr. Marcus Laux N.D. and Christine Conrad (Harper Collins, 1997). This book explains the concepts of hormone balance and the benefits of natural hormones. Natural, when it comes to hormones, means hormones that are an exact molecular copy of human hormones. Usually natural hormones are produced in a lab from a substance in soy or wild Mexican yam called diosgenin. (Premarin®, the most common form of oral estrogen prescribed, could be called "natural" because it is extracted from mare's urine, but is not 100% natural to the human body. It is composed of 11 different estrogens most of which the human body cannot use.)
Bio-identical natural hormones have all the same actions in the cells as our own hormones. Synthetic hormones are different molecules, and do not have all the same actions. Synthetic progesterones such as Provera®, for example, will act more strongly than natural progesterone on the uterus to prevent hyperplasia (excessive cell growth). It will not, however, have all the same good effects as natural progesterone on metabolism and mood.
It wasn't commonly believed, even five years ago, said Dr. Shaak, that all three sex hormones could be effectively absorbed through the skin. Her work has demonstrated, by checking blood levels before and after treatment, that satisfactory levels of hormones can be achieved using her prescription creams.
Her goal is to supplement a woman's own hormones to the levels of Day 17 of a normal menstrual cycle. This puts estradiol at 60-90 pg/ml, progesterone at 3.5-5 ng/ml, and free testosterone at 0.8-1.8 pg/ml. She admits that the targets are somewhat arbitrary in that we do not know what optimal postmenopausal hormone levels are. But she has found these levels, which duplicate average hormone levels before menopause, to be where most women feel comfortable and do not experience side effects, bleeding or hyperplasia. Her office does perform endometrial biopsies to confirm the effectiveness of natural progesterone treatments in preventing hyperplasia.
Finding the right prescriptionThe physician is on the front lines of treatment, faced daily by patients who are in distress now. Using current knowledge and tools, he or she often has to go beyond what has been studied and proven, to try to solve complex problems. The two specialists described in this article have done so, courageously I might add, in an area like Boston, which is dominated by conservative, by the book, treatment. They have helped many patients, myself among them, to cope with a very difficult time in our lives.
In seeking the prescription that is right for you, look for a specialist with the expertise and information about menopause that you need. Find someone who will work with you to problem solve and try different approaches, if necessary. Remember that there are many different kinds of hormones and ways of using them, as well as complementary therapies. Don't lose hope!
And remember too, you are paying for your health care, whether directly, through insurance or through your taxes. If you are not happy with your service, seek out another doctor. Ask your friends for recommendations, network, interview doctors over the phone if possible. Do research on your own or with the help of a librarian or friend. Don't be passive; find what you need. It makes the system better for all of us.