May
14
2016

Hormone Replacement Therapy In Menopause

By | Cancer, Cardiovascular disease, heart attack, Hormones, Menopause, Mortality, Osteoporosis, Stroke

Back in the 1980’s many physicians were hopeful that hormone replacement therapy in menopause (HRT) could extend the lives of postmenopausal women by approximately 10 years, if HRT would be started early enough. But the HERS study (Heart and Estrogen/progestin Replacement Study) in 1998 and the WHI study (Women’s Health Initiative) of 2002 changed things dramatically.

The HERS study did not show any benefit with regard to prevention of heart disease. Instead it showed more gallbladder disease (1.38-fold) and blood clots (2.89-fold) develop in the experimental group versus the placebo.

The WHI study was complex and had several arms. There also were some methodological errors in the study as pointed out here.

Instead of a decrease in heart attacks, there was an increase, when estrogen and progestin was combined. There were more cases of colon cancer, more blood clots and heart attacks in the placebo groups compared to the experimental groups. It seems that something went wrong with these trials.

Unknown facts about hormone replacement therapy in menopause

Premarin is not bioidentical to human estrogens

Both clinical trials used the wrong hormones to do the trials. If you use the wrong hormones in a trial, you would expect to get the wrong test results. Horse derived estrogen (equine estrogen) is hardly a match for bioidentical, human estrogen in women. But decades ago the drug manufacturer had decided that estrogen was easiest to manufacture on a large scale when urine from pregnant mares was used. The product contains conjugated horse estrogen and is known by the name Premarin. Premarin is not bioidentical to human estrogens.

Synthetic progesterone causes heart attacks

The other hormone, medroxy progesterone (MPA) is a progestin, a bad copy of the bioidentical progesterone that a woman’s corpus luteum of one of her ovaries produces. This is in the second half of her menstrual cycle. During pregnancy the placenta produces lots of progesterone to protect the pregnancy. As Dr. Masley, a cardiologist stated synthetic progestins cause heart attacks, while progesterone does not. Masley said: “Medroxy progesterone (MPA) increases the risk for heart disease and for breast cancer. I can’t understand why any physician would recommend medroxy progesterone during menopause, but it is still in use.”

Don’t use estrogen orally, but only by estrogen patch or estrogen cream

Next there is the question whether the liver changes the composition of an oral hormone tablet metabolically or not. The answer is: yes! Dr. Masley stated in the link above that oral estradiol, when compared to estrogen rubbed onto the skin, increases levels of inflammation by 192%. The C-reactive protein (CRP) can be measured with a blood test. The risk for a blood clot increases by 400%. A woman using estrogen should always use the estrogen patch or an estrogen cream with bioidentical estrogen to avoid these complications.

Measure hormones, don’t estimate

Measure hormones – don’t estimate: Hormones are constantly changing and if you don’t measure, you don’t know what you are dealing with. Dr. John Lee showed a long time ago that you should measure hormones and identify those women who are truly hormone deficient. These are the ones who need hormone replacement. However, you use only bioidentical hormones to replace and you replace only as much as is needed to normalize the levels. This is also the level where postmenopausal symptoms disappear. Lee noted: “A 10-year French study of HRT using a low-dose estradiol patch plus oral progesterone shows no increased risk of breast cancer, strokes or heart attacks.”

Measure progesterone hormone levels only in saliva

The elusive progesterone: when the physician measures progesterone as a blood test, it may come back as high while it can be low in a saliva hormone test in the same woman. Dr. Lee has pointed out that studies have shown that progesterone levels in tissue are usually higher by several factors when compared to blood levels and that blood levels are not reliable predictors of tissue levels (Ref.1). On the other hand he found that saliva levels have a good correlation with tissue levels in organs like the ovaries or the uterus. Dr. Lee preferred saliva hormone tests for this reason. When it comes to progesterone levels you can trust saliva test, but you cannot trust blood tests. Many physicians ignore that fact and strictly order blood progesterone levels coming to false conclusions.

Progesterone to estradiol ratio

We know that estrogen and progesterone must be balanced to avoid troubles of developing heart attacks or cancer. The link of Dr. Lee above stated that women without breast cancer have saliva progesterone hormone levels that are more than 200-fold higher than the saliva estradiol levels. On the other hand women with breast cancer have a ratio of less than 200 to 1 with respect to progesterone to estradiol saliva levels. There is a similar ratio in men. Here the ratio of testosterone to estradiol must be larger than 20 to 1. If this is not the case, he is at a higher risk of developing prostate cancer. Unfortunately many older men, when overweight or obese, have high estrogen levels and the ratio is less than 20 to 1.

Bioidentical hormones can prevent heart attacks and strokes

Masley has mentioned that in the first 6 years after menopause using a topical form of estrogen and micronized progesterone as tablets can minimize the risk of future heart attacks and strokes. But after 10 years it is less obvious what is the best solution. The question is what type of estrogen application is used. Is it estradiol or is it Bi-Est or Tri-Est, which are other topical estrogen applications. Tri-Est is 80% estriol, 10% estrone, and 10% estradiol while Bi-Est is 80% estriol and 20% estradiol. Tri-Est in particular would be very close to the natural composition of estrogens in a woman’s body.

What to do after 10 years of hormone replacement therapy in menopause

Given the insecurity what to do after 10 years of menopause, my suspicion is that there are other factors that play a role with respect to hormone replacement. A lot of women have extra pounds accumulated. Fatty tissue contains an enzyme called aromatase.

This makes estrogen from androgenic hormones including testosterone. The adrenal glands situated above the kidneys produce these hormones in menopause. The more overweight or obese a postmenopausal woman is, the higher the estrogen levels in her blood because of the action of the aromatase. Most physicians have not measured hormones in the past, but just replaced hormones monitoring only postmenopausal symptoms. This is changing. What I said under point 4 above is happening more.

Bioidentical hormone replacement practiced by naturopaths

Naturopaths tend to be more comfortable with bioidentical hormone replacement the way I have described it. If you did hormone tests (preferably saliva hormone tests) you would pick up higher estrogen levels and low progesterone levels with unfavorable progesterone to estrogen ratios as mentioned. These women do not need estrogen (they have it already in their systems). They need progesterone replacement only. A woman can take progesterone by mouth as micronized bioidentical progesterone capsules at night. It also  comes as bioidentical progesterone cream for application to the skin. Here is another take on the use of bioidentical hormones.

Hormone Replacement Therapy In Menopause

Hormone Replacement Therapy In Menopause

Conclusion

Bioidentical hormone replacement is complex. It requires some basic knowledge of the facts mentioned above. I find it surprising that two separate research groups could not free themselves of the Big Pharma grip. In not doing so they unwillingly produced studies showing all of the undesirable side effects of using artificial hormones. When manufacturers modify natural hormones with unnatural side-chains, the end products are synthetic hormones. These do not fit the appropriate natural hormone receptors. The anti-aging community as represented by the A4M group (American Academy Of Anti-Aging Medicine) with more than 25,000 physicians worldwide has been saying this all along. Now we know that it is really true. Use hormone replacement knowledgeably and use bioidentical hormones!

References

  1. Dr. John R. Lee: “Natural Progesterone – The remarkable roles of a remarkable hormone”, Jon Carpenter Publishing, 2nd edition, 1999, Bristol, England.
Dec
06
2014

Regrets Following Holiday Foods

By | Abdominal Pain, Angina, gout, heart attack, High Blood Pressure, Nutrition

Countless blogs have been written about gaining pounds with holiday food. This is not my topic in this blog. I am looking at the medical evidence of what is happening to our bodies, some of which is permanent. I like to focus on the gallbladder, blood pressure, heart function and gout. I will provide little clinical vignettes that make my points clear.

Gallbladder disease

Many patients are unaware that their gallbladder has developed stones that accumulate over several years, perhaps even several decades. But, if infection sets in there is an acute flare-up of gallbladder pain, which can be excruciating. Also, when one of the stones is transported into the gallbladder duct, there is a sudden colicky pain similar to labor pains. In cases where the migrating stone blocks the common bile duct, the patient can get jaundiced and the pancreatic juice can get backed up leading to an acute pancreatitis.

What does that have to do with overindulging during a Thanksgiving meal? Fatty sauces, ham, and gravy can all lead to more cholesterol deposits in the gallbladder and make stones larger. Add to this a rich dessert with ice cream and a dollop of whipped cream and you’ve got yourself a fairly fatty feast. So, this one fatty meal can make a difference by bringing on symptoms of a previously undiagnosed condition, and you spend hours in an emergency room of a hospital.

The scenario could look like this case:

Fred is a 40-year-old teacher, somewhat overweight who enjoyed a holiday meal at his parent’s place for Thanksgiving. His health has been good with no surgeries. Following the turkey dinner, which he enjoyed he noticed right upper abdominal pain, and he started to vomit. As the pain did not improve, his parents called an ambulance that brought him to a hospital. The emergency physician said that he was concerned about Fred’s gallbladder. He ordered a CT scan and this showed multiple stones with one of the stones being stuck in the cystic duct. Despite pain medication and bed rest the situation did not resolve (the stone did not pass). A surgeon was called in and a laparoscopic cholecystectomy was performed. Fred recovered within only 3 days and could return to teaching. The fatty food of the Thanksgiving dinner was only the tip of the iceberg in this case. The fact that there have been many pre-existing gallbladder stones tells us that this patient had the chronic habit to eat foods with too much fat and cholesterol.

High blood pressure

Extra salt intake leads to an elevation of blood pressure. If a person has borderline high blood pressure, the extra salt intake from holiday meals can get the blood pressure out of control and this in turn can cause a stroke (typically a hemorrhagic stroke) or is a strain to the heart leading to a heart attack or to congestive heart failure.

Janice is a 50-year-old janitor who has had problems with borderline high blood pressure readings. Normally her blood pressure was 140 over 90, and when she watched her salt intake it would go down to 125 over 80. She bought a blood pressure monitoring device, just so she could measure her own blood pressure at home. Following the Thanksgiving turkey dinner she noticed that she developed fullness in her head and a headache and her face looked flushed. She took her blood pressure with a reading of 160 over 100. It had never been that high. When she saw her doctor he asked her what she had for Thanksgiving dinner: they sat together with friends and had potato chips with dip and drank some red wine with it. Next for the meal she enjoyed the roasted, brined turkey and ham. Yes, she did add some more salt to the mashed potatoes too.

The doctor found her blood pressure to be 165 over 100. He explained to her that she needs to go on a DASH diet, which is low in salt. He also started her on blood pressure pills. Here is another link for a low salt diet.

Heart attack following turkey dinner

When working as an intern in teaching hospitals of McMaster University of Hamilton/Ont. during my training in 1975 to 1978 I noticed a strange correlation between holidays like Thanksgiving and Christmas and intensive care unit admissions with acute heart attacks. Later a formal study was published that there is indeed such a correlation between consuming a big meal with fat, salt and refined carbohydrates and the development of a heart attack.

This likely does not develop without prior silent conditions of high triglycerides, high cholesterol and insulin resistance leading to inflammatory substances circulating in the blood. The C-reactive protein is one of the substances that has emerged as a useful monitoring device and a fasting insulin level. Both should be low or the person is at a higher risk of developing a heart attack.

Add to this a festive, large meal and you got troubles at your hand like in the next case:

Joan is a 62-year-old high school principal who developed chest pain within 2 hours of having enjoyed her Christmas dinner. She was known to have high cholesterol levels for about 5 years and she had been taking statins for 4 years as diet alone could not control it. But she loved food in general and was about 20 pounds overweight. The doctor had discussed exercise with her, but she felt too busy doing other things. Now all of this came back to her as she was recovering in a hospital bed from an emergency stent procedure. They had to insert two stents to overcome narrowing of the coronary arteries. She was now pain free and felt that she needed to do something about her lifestyle. She would see a dietician and record her weights daily. She wanted to loose 20 pounds and yes, she wanted to start mild exercise when her doctor allowed it and gradually build it up to a maintenance program.

Regrets Following Holiday Foods (Gout Patient)

Regrets Following Holiday Foods (Gout Patient)

Gout attack following rich meal

It is known since the Middle Ages that feasting on a large meal of beef combined with lots of beer or wine can cause a gout attack. Gout at this time was known as a disease of the affluent. The poor obviously could not afford big feasts. Today we know that purines are the end product of meats and this gets excreted in the kidneys. However, alcohol prevents the purines to be excreted in the urine so that uric acid levels exceed a certain limit beyond which uric acid crystals are precipitated in soft tissues like around joints, which is very painful.

The following case will illustrate this:

Carl, a 45-year-old sales person suddenly developed excruciating pain and swelling in his left big toe. He went to the emergency room of the closest hospital. After some tests he was told that he had come down with acute gout. His blood tests showed a high uric acid level and biopsy samples from the left toes also revealed uric acid crystals. With the help of colchicine and allopurinol things turned back to normal within 3 days.

The gout episode occurred just 4 hours after his holiday meal consisting of a few beers and copious amounts of turkey meat. He also seems to be addicted to soft drinks which are sweetened with high fructose corn syrup which he consumes freely all day long.

It is known that sugar from soft drinks make a person 85% more prone to develop gout than a person who uses diet drinks or water.

Here is a diet sheet for Carl to prevent his next gout attack.

Conclusion

Who would have thought in the past that food could be a dangerous substance with the potential of making us sick? But this is exactly what I wanted to point out in this blog. Of course, it does not stop at holidays where we tend to eat more of what we normally eat. It pays dividends watching what we consume even in the days between feasts. For instance a DASH diet is a good idea for those of us who may have developed borderline high blood pressure. Avoiding excessive red meat is a good idea for prevention of heart attacks and strokes, as your cholesterol stays lower. Avoiding soft drinks with sugar and fructose is good prevention for avoiding obesity, cancer, heart attacks and strokes. Get the greens going (vegetables, salads etc.) to live longer without disabilities.

Last edited Dec. 6, 2014