Hormone Replacement Therapy

Over the last 18 years in holistic medicine, I’ve seen the paradigm shift regarding the treatment of menopause and andropause, “male menopause”.  The famous Premarin Provera study was released in 2003. Which showed clearly the increased risk for breast cancer and heart disease for women who were put on Premarin and Provera. To the point that the study was stopped before the conclusion, since the numbers showed categorically the increased risk for women who are taking these kind of hormones.  When you look at Premarin and Provera, you realize that Premarin is an estrogen which is derived from pregnant horses, and does not belong in the human female. The Provera on the other hand, is a progesterone that is altered by the pharmaceutical companies so they can write a patent on it.

Both of these products alleviate some symptoms of menopause. However, the side effects of these prescriptions – as mentioned before, increases the risk for breast cancer and uterine cancer. So immediately after the release of that study, a “panic” occurred in the medical community and within the patient population. And doctors stopped writing prescription for these drugs.  However, instead of exploring more natural ways, they continued to listen to the pharmaceutical companies. And slowly but surely, with marketing techniques of changing the dose a bit, doctors were slowly returning to their habit of prescribing these drugs; because they did not have any other alternative to help patients who complained about menopausal symptoms.  So today, 13 years past the release of this study, the Premarin Provera combination are back on the market, and being prescribed to many patients. It seems that the “memory” of these doctors, is short. And they’re back to the old ways of prescribing these, “tried and true” prescriptions.

Women, on the other hand, are still very concerned about taking these drugs, and rightfully so. So when I see patients that need hormone support, they are convinced and afraid that any bioidentical, and they’re afraid and convinced that using hormone replacement therapy will pose risk of increased cancer and heart disease.  It usually takes me quite a bit of explaining to do, to show them that using bio-identical hormone replacement therapy is totally different than using the prescription drugs that was meant, that were mentioned before. In fact, according to research that can be found in books like, “Stay Young and Sexy with Hormone Replacement Therapy,” by Doctor Jonathan Wright.  It is evident then that women who take estrogen progesterone combination in correct manner and correct doses, will actually have less breast cancer and ovarian and uterine cancer than women who take no replacement at all. So the question comes to mind is, why the differences between bioidentical hormone replacement therapy and conventional pharmaceutical replacement therapy?

The answer is not complicated at all. Bio-identical hormones are the same as the ovaries have been producing before menopause in the female body. Estrogen being manufactured mainly the first 2 weeks of a cycle. Ovulation or carrying at day 14, causing an increase in production of progesterone to the point of having a ratio of progesterone 100, 200 times more than estrogen on day 24 of cycle.  Supplying these hormones in menopause will be welcomed by the body, and will prevent premature aging, dementia, Alzheimer’s, heart disease, vaginal dryness, improved libido and help prevent depression. There are various ways to administer these bio-identical hormone. They can be administered via creams. They can be administered by mouth. They can be also delivered via sublingual troches and or subcutaneous pellets.  The majority of my patients prefer the cream delivery modality, because it’s easy and convenient. It bypasses the liver because when we take hormones orally, they do pass the liver first, before they get to the receptors to cause their action. And therefore being removed to a certain degree. But when delivered through skin application, these hormones are being absorbed directly into the circulation. They go into the receptor sites, causing the action necessary. And then relieved or delivered, being removed from the system, rather by the liver.

That is not to say that some women will prefer – take it, the oral route. And they still can get excellent results, as long as we adjust the dose according to their individual needs. So the important point to take from that, is that no one dose fits all patients. It has to be individualized; mainly according to their clinical presentation.  If you ask the question of what about synchronizing hormone replacement relying on blood tests? The answer to that is a bit complex. Because blood test results obviously serve a purpose. To see that we are not under delivering or over delivering the amount of hormones necessary for good physiological response.  However, the pitfall of blood testing lies in the fact that the “normal’s,” are pretty wide. And since none of us take a baseline of hormones at the age of 20, it’s hard for us to determine what is normal for that specific person. So I like to look at blood tests as they correlate. As a broad guideline, but I mainly rely on patient’s clinical response.  For instance, if they come in with the complaint of hot flashes, did the dose that I gave to the patient, Improves or eliminates completely the hot flashes. The same goes for vaginal dryness, low libido, muscle loss, abdominal weight gain etc. Other tests should be considered as a follow-up and safety for patients on bio-identical hormone replacement.

For instance, for women I recommend yearly ultrasound, vaginal ultrasounds to visualize the ovaries. Visualize the thickness of the lining of the endometrium to see that we are not overstimulating the growth of the endometrium. Yearly breast thermography, and yearly breast ultrasound, to ensure breast health.  In practice, women – after educating themselves about the modality of bio-identical hormone replacement therapy. The large majority will decide to take the hormone therapy, because they see and understand the benefits and would like to achieve the benefits. Like prevention osteoporosis, dementia, vaginal dryness, low libido, muscle loss etc.   With correct application of these natural hormones and correct follow up at least on the early basis, ensures that women get the protection they need without exposing them to any increased risk for breast cancer and or heart disease. When it comes to male usage of bio-identical hormones, we need to consider the simple fact that men lose about 1 to 2% of testosterone level from the age of 25 – per year.  So by the time a man reaches 50 or 60 years of age, we may be looking at 50 to 60% of loss of testosterone in that period of time. The loss of testosterone affects men’s health in a profound manner. It is the number 1 cause of men’s depression over the age of 50 is low testosterone level. Yet conventional medicine is very hesitant to give these men testosterone supplementation to address these issues. In fact, they very eagerly would give antidepressant prescription drug instead of prescribing a natural hormone to these patients.

The reason why testosterone is so important is for men’s state of mind is the fact that the male brain has more receptor sites for testosterone than the genitals. So in order for a man to feel effective in their life, productive, getting up in the morning and looking forward to their job and being productive, instead they feel like something is missing in their life.  So when most men go to see their conventional doctor, and they request to have their testosterone level checked because they see the continuous commercials about “low T,” and they get the lab results, which fall between 200 to 1100. They are considered to be in a normal range. And again, the problem is that nobody checks males testosterone level at the young age of 20 or 30. So how do we know what is normal for that patient? Is 201 normal for a 60 or 50 year old male that most likely had a level of 1000 when they were 20 or 30?  Other symptoms of low testosterone for males are low libido, loss of muscle mass, and erectile dysfunction. Also males will complain of decreased ability to perform at the gym. There are various ways to restore testosterone level to the aging male. Even though aging – quote unquote – is not exactly the adjective that I would like to use. Because I do have patients in my practice that are 30 and 40 years of age, who need testosterone supplementation. And I see this trend is going upwards.

One of the ways to deliver testosterone is via cream applied on a daily basis in the morning. The basic dose would be 100 milligrams per day. And then according to the clinical response, one would adjust that upwards if needed. Another way would be to deliver via injections. Injections can be done intramuscularly – IM, or subcutaneously into the fat tissue. The testosterone being delivered in that manner is testosterone cypionate usually. And it’s usually delivered once a week to avoid decrease of the testosterone by delivery to the point of being too low.  Few patients will need a twice a week injections. Depending on their clinical response. I explain to my male patients that the first improvement they’re going to feel is usually an increase in their mood, in their ability to perform their job. Their libido is going to be next. And usually takes about 6 to 8 weeks to have actually a response to the erectile functionality of their sex life.  Men who take testosterone replacement need to be followed up for the following items. We need to check their hematocrit, which means what is the ratio between the liquid part of the blood to the red blood cell part of the blood? And you would like to keep it below 50%. That means that the cell component, the red blood cell component of a volume of blood, would be less than 50%.  The reason for that is that if it increases above 50% – the blood becomes more sluggish, and therefore decrease in movement. Increasing the possibility of having a blood clot. Also it increases the workload on the heart. Both of which are not desirable. I will say that about 10 to 20% of men experience increase in volume of red blood cells. And this is because testosterone simulates the bone marrow to make those red blood cells. And they need to go to the Red Cross about twice a year to donate a pint of blood, and that will take care of the problem.  Another issue that needs to be followed is the level of estrogen. Some men will convert testosterone to estrogen in a higher in a higher manner than others. Higher testosterone will increase prostate size, increase men’s breast size, and also decrease libido. These men will need an aromatase inhibitor, and can be delivered as a natural product called chrysin. And or a prescription drug called anastrozole or arimidex.

So as you can see, for both men and women it is not too complicated to improve quality of life, slow down the aging process. It’s all a matter of the right education for the patients, so they can make a decision from knowledge and understanding, rather than from fear.