| Submitted by: Elizabeth W.
Q: There is a lot of
press about HRT [Hormone Replacement Therapy] lately. They
discuss all the bad stuff but don't really discuss any clear
alternatives. What do you suggest?
A: On July 9, 2002,
the National Institutes of Health (NIH) announced that the
Women's Health Initiative (WHI) study of hormone replacement
therapy was halted due to increased risk of breast cancer,
heart attack, stroke, and blood clots. The federally funded
study was supposed to run for eight years, but the five-year
results were so striking that the researchers cut it short
and urged the 16,000 postmenopausal participants to stop taking
their drugs. We have been saying this for a long time but
it is satisfying to see that research has caught up with clinical
experience and the results of such a large study are necessarily
reported on every news station and in all the consumer magazines.
As some of you may remember we recently reported that the
National Toxicology Program of the US Public Health Service
recently added conjugated estrogen's to the known to be human
carcinogens list. Prempro, the drug administered in this WHI
study contains conjugated equine estrogen's and medroxyprogesterone
acetate (a synthetic form of progesterone). This synthetic
form of progesterone also called progestin should not be confused
with natural forms of progesterone which are identical to
the progesterone our own body's make.
The current generation of women who will be or are going
through perimenopause and menopause may be the first generation
that lives nearly half their lives without menstruation. So,
the western medical philosophy of treatment for perimenopausal
and menopausal women will be obsolete. There is now a lot
of widespread confusion because last year US pharmacists filled
close to 70 million prescriptions of drugs containing these
conjugated estrogen's under the brand names Premarin (so named
because it comes from the urine of pregnant mares) and Prempro.
I will offer some general and some specific recommendations
for the relief of symptoms associated with perimenopause and
menopause and more importantly shed some light on why these
symptoms may occur in the first place.
The Western view would have us believe that menopause is
an estrogen-deficiency disease that needs to be treated with
estrogen to compensate for the normal decline of estrogen
levels with aging. This philosophical thought process probably
began with the unfortunate release the book Feminine Forever
written by Robert A. Wilson, M.D., in 1966. He introduced
the theory that menopause is an estrogen-deficiency disease
that needs to be treated with estrogen to compensate for the
normal decline of estrogen levels with aging. According to
Wilson, without estrogen replacement therapy women are destined
to become sexless "caricatures of their former selves...the
equivalent of a eunuch." Contrary to popular belief,
perimenopause is not a hormonal transition associated with
the lowest levels of estrogen. The fact is that hormonal levels
are fluctuating wildly and estrogen levels may peak to a point
equal to that of when the woman was twenty years old and then
as quickly as it went up, estrogen levels may then rapidly
plummet.
Perimenopause, therefore, is difficult to define because
follicle stimulating hormone (FSH) and estradiol (the two
most common markers used to determine menopause status) can
appear in the postmenopause range one day and in the premenopause
range a few days later.
The most common complaint of early perimenopause is the temperature
variant called a hot flash (or flush). Other common complaints
are menstrual irregularities, breast tenderness, increased
fibrocystic changes, growth of uterine fibroids, flare-ups
of endometriosis, emotional stress, and weight gain.
There are three main families by which the body metabolizes
estrogen. These families are the 2-H estrogen's, the 4-H estrogen's,
and the 16-H estrogen's The 4-H and 16-H estrogen's are believed
to the more carcinogenic. The 2-H estrogen's are believed
to be anticarcinogenic. Interestingly, last year in the Journal
of the American Medical Association, it was reported that
estrogen replacement therapy (ERT) increases the exposure
of the highly estrogenic 4- and 16- hydroxylated estrogen's
Also, ERT increases breast density, making early detection
by mammography difficult. Density decreases when ERT is discontinued.
Isoflavones (often referred to as phytoestrogens) from soybeans
are considered adaptogens for managing estrogen balance. In
other words, they help increase estrogen in individuals with
a low-estrogen imbalance and they decrease estrogen in those
with a high-estrogen imbalance. The soy isoflavones genistein
and daidzein are the most studied estrogen-modulating compounds
from plants.2-4 Isoflavones from red clover and the Kudzu
vine have also been shown to have estrogen activity-modulating
effects. In addition to soy, red clover, and the Kudzu vine;
chasteberry (Vitex agnus-castus L.), black cohosh (cimicifuga
racemosa), and essential fatty acids (such as flax and fish
oil), have been demonstrated historically to have hormone
activity-modulating affects.
Another way to promote the "friendly" 2-H pathway
by lowering the more carcinogenic 16-H pathway is administration
of the phytonutrient indole-3-carbinol
(I3C).7-8 Now found in capsule form this nutrient is derived
from the cruciferous family of vegetables, mostly notably
broccoli and to a lessor degree Brussels' sprouts, cauliflower,
and cabbage.
Another important and common finding that warrants consideration
for perimenopause is low levels of progesterone.
This is especially important because, among other reactions
in the body, low progesterone is related to a short luteal
phase (the part of the menstrual cycle where ovulation occurs)
and a short luteal phase is associated with increased bone
loss. This is a very important situation to consider because
bone mineral density studies are usually not ordered until
after menopause but the average age of perimenopause is 47
and bone mineral loss begins at around the age of 40 - 10
or 15 years before it is usually even tested for. And as with
many situations in the body, the earlier an imbalance is detected
the better the prognosis. As I indicated in a previous article
on osteoporosis, it is the number one bone condition in the
United States. Eight million women have osteoporosis, over
a million with fractures, many of which were potentially preventable.
There are over 70,000 deaths related to preventable hip fractures
and over 50,000 requiring long term care.9
Another important aspect to recognize is that hyperinsulinemia
(high levels of insulin in the blood) influences estrogen
synthesis and overall hormone balance or imbalance. A number
of nutritional, diet, and lifestyle interventions can improve
insulin sensitivity and reduce symptoms associated with these
hormone imbalances in women. The dietary program needs to
include low glycemic index foods, such as most fruits, berries,
nuts, a variety of vegetables, whole grains (not refined grains),
fish, eggs, soy products, and lamb. Also consider the following
specific nutrients: D-chiro-inositol, chromium, antioxidants,
omega-3 fatty acids, and magnesium.
Thyroid function is another important area that appears to
change in the perimenopausal period. Many of the common symptoms
of perimenopause may be attributed to thyroid dysfunction
such as weight gain, depression, anxiety, fatigue, cold intolerance,
loss of libido, and abnormal menses. As part of the perimenopausal
evaluation, I would, therefore, recommend a comprehensive
thyroid panel. If hypothroidism is evident, I may suggest
the following: elimination of dietary sources of gluten-containing
grains such as wheat, and casein-containing products from
dairy, such as milk, cheese, etc. These potential food antigens
could induce antibodies that cross-react with the thyroid
gland. I will also recommend organic iodine from fucus (seaweed),
selenium, zinc, omega-3 fatty acids, and antioxidants (including
vitamins A, C, and E).
One major underlying issue to consider is that a stress hormone
called cortisol plays a major factor in disrupting the orchestrated
symphony of the body that is the endocrine hormonal system.
Among other lifestyle factors exercise has been proven time
and again to have direct positive benefits on stress and on
the hormone imbalances related to menopause. Recent studies
indicate that moderate physical exercise in menstruating women
increases 2-hydroxyestrogen formation.
In another study, the frequency of moderate and severe hot
flashes was investigated in postmenopausal women who took
part in physical exercise on a regular basis and was compared
to that in a control group. The study clearly demonstrated
that regular physical exercise (average of 3.5 hours per week)
decreased the frequency and severity of hot flashes.
Some other benefits include decreased blood cholesterol levels,
decreased bone loss, decreased fat storage, improved ability
to deal with stress, improved circulation, improved heart
function, increased endurance and energy, increased self-esteem
and mood, reduced blood pressure, and relief from hot flashes.
In summary, treatment for symptoms associated with perimenopause
needs to be centered around balancing estrogen, raising progesterone
levels, controlling insulin and blood sugar, and correcting
thyroid imbalances.
In addition to previously mentioned nutrients, I would consider
standardized botanical medicines. Black cohosh (Cimicifuga
racemosa) helps to reduce hot flashes. Chasteberry (Vitex
agnus-castus) used for symptoms of perimenopause. Dong Quai
(Angelica sinensis) and licorice (Glycyrrhiza glabra) have
also been shown to decrease symptoms associated with perimenopause
and menopause. Also consider gamma oryzanol for hot flashes
and soy protein isoflavones. Certain individuals may benefit
from natural micronized progesterone augmentation.
|
Dr. Chad Larson
The dietary supplements below may be very helpful:
