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  Estrogen Replacement  
 
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Women have several choices for estrogen replacement therapy today. They can go the synthetic or natural route and can choose an oral or transdermal (patch/cream) preparation. The liver can use estrogens for the production of hepatic enzymes. This means the liver can metabolize estrogens into other substances, in this case enzymes the liver produces. Oral estrogens are effective, but to some degree their effectiveness is diminished by passing through the liver before being available in the blood stream. On the other hand, transdermal estrogens enter the bloodstream directly, bypassing the liver. Transdermal estrogens are probably more effective in achieving their effects then oral estrogens.

Natural estrogen replacement therapies often combine different forms of estrogen. This means that depending on what conditions are being treated and what your own levels of these are, you can have a formula compounded just for your needs. These formulas are called Triest (containing 3 estrogens) and Biest (contain 2 estrogens). These preparations mimic the 3 natural estrogens in your body, estriol, estrone, and estradiol. Most synthetic oral estrogens are made from horse's urine and horse's estrogens, which are not the same as those naturally occurring in your body.

Supplemental estrogens are typically used on all days of a woman's cycle except during menstruation. They can be used continuously during and after menopause, but most natural doctors recommend a break of 1 week per month if tolerated.

Transdermal delivery of estrogen therapy available by prescription "seems not to alter" the risk of venous thromboembolism (VTE), or blood clotting, in postmenopausal patients when compared to oral delivery, a new study suggests. The study was conducted by researchers at NYU Langone Medical Center and was published in the latest issue of Menopause: The Journal of the North American Menopause Society, March 2009.

Please keep in mind that there are three forms of estrogen - estradiol, estrone and estriol. Estradiol is the most potent, but also associated with increasing breast cancer risk. Estriol, a weaker form, may have protective effects against estrogen sensitive breast cancer. So when recommending or avoiding 'estrogens', it is necessary to specifiy which estrogen is being referred to.
 

 
 

Estrogen Replacement can help with the following:
 
 
Autoimmune  Multiple Sclerosis / Risk
 In a small-scale, early-phase trial of the hormone estriol, a form of estrogen, women with relapsing-remitting multiple sclerosis showed decreases in MRI-detected brain lesion activity and immune responses during treatment.The six participants with relapsing-remitting MS experienced significant decreases in brain lesion numbers and volume, as well as a reduction in levels of immune proteins indicative of inflammation. When estriol treatment was stopped, lesion numbers returned to pre-treatment levels, and then decreased again when estriol treatment was resumed. During treatment, cognitive function scores improved significantly in women with relapsing-remitting MS. Women with secondary-progressive MS did not improve significantly during the course of the trial. [Annals of Neurology 2002;52: pp.421-428]

Hormones

  Low Estrogen Levels
  Low SHBG
 The use of estrogen to increase SHBG and hence reduce biologically free testosterone may lessen acne and hirsutism. This mechanism is commonly operative in women with Polycystic Ovarian Syndrome. With estrogen replacement, estrogen levels are higher and liver production of SHBG increases. With pregnancy or some birth control pills, you will have high SHBG, and you will have high levels of circulating hormones, but they will be mostly bound (including testosterone).

  Elevated Testosterone Level, Female
 Low estrogens allow the circulating androgens and testosterone to be more freely available and thus stimulate cells more. Increasing the circulating estrogen in the blood, by taking estrogens, will increase the proteins that bind the androgens and help decrease the effects of all androgens, whether the levels are normal or excessive.

Infections

  Cystitis, Bacterial Bladder Infection
 Further evidence that estriol is effective in counteracting the symptoms of the menopause comes from studies with estriol intravaginal creams. One such study, conducted by scientists from the Technion Faculty of Medicine in Haifa, Israel, looked at urinary tract infections, a common affliction in post-menopausal women who suffer from an atrophying vagina characterized by elevated pH and a disrupted flora caused by lack of estrogen.

In this study, 93 postmenopausal women with a history of recurrent urinary tract infections were enrolled in a randomized, double-blind trial of a topically applied intravaginal 0.5 estriol cream. One group received 0.5 mg. of estriol every night for two weeks, followed by twice-weekly applications of the cream for eight months, and the other group received a placebo cream in the same manner.

The results of the study showed a dramatic reduction in urinary tract infections in the women receiving the estriol cream compared to those receiving the placebo cream. The incidence of infection was almost 12 times greater in the placebo group (5.9 per patient year) compared to the estriol group (0.5 per patient year). According to the Israeli scientists, "The intravaginal administration of estriol prevents recurrent urinary tract infections in postmenopausal women, probably by modifying the vaginal flora."

Risks

  Increased Risk of Breast Cancer
 Exposure to HRT was associated with an increased risk of invasive breast cancer. [JAMA Vol. 281 No. 22, June 9, 1999]

ScienceDaily (May 30, 2008) — If hormone replacement therapy is taken over a period of more than five years, the risk of breast cancer will increase. While this risk is considerably elevated during use of hormone medication, it drops back to the original level within about five years after a woman has stopped taking hormones. These new findings from Germany fit with earlier findings in the U.S.

ScienceDaily (Feb. 5, 2004) — A Swedish study established to assess the effect of hormone replacement therapy (HRT) for women with a history of breast cancer has been stopped early after preliminary results show 'unacceptably high' risks of breast cancer recurrence for HRT users. The results are published online by THE LANCET (3 February 2004) and appeared in the February 7 print edition.

HOWEVER, the use of estriol, one of the forms of estrogen, is thought to reduce the risk of breast cancer recurrence, and should be considered as part of a treatment package to prevent recurrence.

  Increased Risk of Alzheimer's / Dementia
 Estrogen replacement therapy may help reduce risk or delay its occurrence, but does not help once disease is established. One reason for the confusion is the use of synthetic estrogens: natural estrogens should exert a protective effect. One study found that the risk of Alzheimer's disease and related dementia for women who had used estrogen was found to be about one third below that of women who had never used estrogen. The risk also decreased with increasing dosage and duration of estrogen therapy. The lowest risk was observed in long-term users taking high doses.

Suggestions that the decline in estrogen levels in women at menopause might somehow make them more vulnerable to the disease have prompted interest in the hormone as a possible treatment and research has suggested that women who take estrogen are less likely to develop Alzheimer’s.

However, a new study found that once the mind-robbing disease sets in, the female hormone offers no benefit. A year of estrogen did nothing to slow the progression of the disease or improve mental functioning in 120 older women with mild to moderate Alzheimer’s. Overall, the results of this study do not support the role of estrogen in the treatment.

In another study, women aged 60 and older were given either a low estrogen dose, a high dose or a placebo every day for a year. Instead of showing any improvement, those taking estrogen in fact fared worse than the placebo group in a rating of dementia. [JAMA February 23, 1999 283: pp.1007-1015]

[One of our doctors comments: I am really surprised that this study did not receive more widespread news coverage. When the drug companies had the initial studies published suggesting that estrogen will help protect against Alzheimer's it was all over the news. I was immediately confronted by many patients who felt my recommendation to avoid estrogens was unwise. Now the evidence is in that estrogen does NOT help Alzheimer's but actually worsens it. I am delighted that JAMA continues to take a leadership role in publishing these landmark articles which refute the drug companies' position. Unfortunately, the conventional media still appears to be sold out - hence the lack of notification of the results of this study.

There are times when estrogen is necessary. I believe if phytoestrogens are unable to stop the hot flashes then it would be wise to use small amounts of estrogens to stop them. Waking up every night with hot flashes is a surefire prescription for depression and increased risk of disease. Thus in this case the estrogen is the lesser of two evils. It should be used for the shortest time possible and always with the intent of weaning oneself off of it.
]

Tumors, Benign

Not recommended for:
  Fibroids
 Supplemental estrogens should generally be avoided when fibroids are present, as estrogen stimulates fibroid growth.

Tumors, Malignant

  Breast Cancer
 Great caution should be exercised in exposing women who have had breast cancer to supplemental estrogens.

However, estriol, one of the estrogens produced by the ovaries, is considered a safe estrogen in that it has been shown to inhibit breast cancer. Dr. Henry Lemon and his colleagues conducted a study in women who already had breast cancer that had spread to other areas of the body. One group was given Estriol and another not. At the end of the study, 37 per cent of those women who received estriol had either a remission or an arrest of their cancer. Might not estriol, a natural, safe hormone with almost no side-effects, be able to accomplish what tamoxifen does but without the toxic side-effects?

Uro-Genital

  Vaginal Dryness
 Systemic hormone replacement can provide relief, as can a plant-derived safe estriol cream used locally.

  Susceptibility To Miscarriages
 Estrogen supplementation may be used following uterine surgery for adhesions to stimulate the regrowth of the uterine lining.

  Vulvodynia / Vestibulitis
 Topical estrogen creams may provide relief. Estrogen thickens or toughens the skin and increases blood supply. It may help you even if you have not reached menopause or do not have estrogen deficiency. If you find vaginal creams painful (possibly from the additives such as alcohol or parabens), your physician may mix 5-10% solution in a petroleum gel base or mineral oil instead of using the standard base.


Not recommended for:
  Endometriosis
 The use of supplemental estrogen may make the symptoms of endometriosis worsen.
 
 


KEY
Likely to help
Highly recommended
May have adverse consequences
Reasonably likely to cause problems







GLOSSARY

Cancer:  Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.

Enzymes:  Specific protein catalysts produced by the cells that are crucial in chemical reactions and in building up or synthesizing most compounds in the body. Each enzyme performs a specific function without itself being consumed. For example, the digestive enzyme amylase acts on carbohydrates in foods to break them down.

Estrogen:  One of the female sex hormones produced by the ovaries.

Menopause:  The cessation of menstruation (usually not official until 12 months have passed without periods), occurring at the average age of 52. As commonly used, the word denotes the time of a woman's life, usually between the ages of 45 and 54, when periods cease and any symptoms of low estrogen levels persist, including hot flashes, insomnia, anxiety, mood swings, loss of libido and vaginal dryness. When these early menopausal symptoms subside, a woman becomes postmenopausal.

Metabolism:  The chemical processes of living cells in which energy is produced in order to replace and repair tissues and maintain a healthy body. Responsible for the production of energy, biosynthesis of important substances, and degradation of various compounds.

Postmenopause:  The postmenopausal phase of a woman's life begins when 12 full months have passed since the last menstrual period and any menopausal symptoms have become milder and/or less frequent.