Bioidentical Hormone Therapy for Menopause
Why Do Women Fear Menopause?
Many women dread the thought of menopause because they have "bought into" two common misapprehensions. The first is believing the "horror stories" they heard from their mothers and friends about the awful symptoms women must endure when they go through the "changes". Fortunately, not every woman will suffer with menopausal symptoms and many women pass through menopause without more than a few hot flashes.
The second misconception is that there is no safe and effective treatment for menopausal symptoms should the symptoms become so intolerable that they interfere with the quality of life.
I am happy to say that there is both effective and safe hormonal replacement therapy to alleviate suffering during menopause. The form of hormones and the details of how they are administered are the critical determining factors of safety and efficacy.
What is Menopause and When Does It Actually Start?
Menopause occurs naturally in all women as their ovaries gradually cease functioning. This happens over a five to ten year time span, typically starting between the mid thirties to the mid forties. Symptoms are caused by a deficiency in the production of the two major ovarian hormones-Estrogen and Testosterone-normally produced by a woman’s ovaries from the time of the first menstrual period to the time that menstruation ceases.
Although menopause is officially defined as beginning when a woman goes without a menstrual period for one year, women may experience menopausal symptoms, often intense, for 5-10 years prior to the end of menstruation. A woman should be eligible for treatment whenever needed rather than delaying treatment until she has not had a period for one year.
The Biologic Effects of Hormone Replacement Therapy
It is well known that the female hormone, estrogen, in any of its various forms, is a successful treatment that eliminates many symptoms of menopause. Hot flushes stop in a matter of a few days, mood swings resolve in a matter of weeks and vaginal symptoms show improvement in a month or two.
Testosterone’s effect is more subtle. Sex drive may take several months to return, but return it will. Other benefits, such as the reversal of muscle flabbiness, increased muscular strength, weight loss and the return of mental clarity may take somewhat longer to be noticed. The prevention and reversal of osteoporosis is a result of both estrogen and testosterone therapy. Evidence also exists that testosterone may prevent the development of age related cognitive impairment.
Testosterone’s role in the treatment of menopause is less well known, but is of equal importance to that of estrogen. Testosterone is often omitted from the treatment of menopause because of difficulties in finding an effective method of administration that will minimize potential side effects. Fortunately, a solution is now available in the form of tiny pellets containing bioidentical testosterone and estrogen that are implanted under the skin.
Hormone Therapy Reborn: Bioidentical Hormone Pellet Therapy
For hormone therapy to be both safe and effective the circulating levels of Estrogen and Testosterone must be similar to those found in a woman’s body during the prime of her life. If the dose of hormones is too high, there will be side effects. Should the dose be too low, the treatment will not be effective and a woman will continue to experience symptoms.
The problem is that the usual ways of administering hormonal medication- by pill, by injection or through the skin with patches or creams cannot deliver and maintain the constant levels of hormones required to be effective and safe.
A totally different approach to menopausal hormone replacement therapy bypasses the problems inherent in the hormonal medication delivery systems most commonly in use today.
It is called "Pelleting", which is the insertion of tiny time-released pellets of bioidentical hormonal medication under the skin.
The Rebirth of Hormone Pellet Therapy
First described in the medical literature in the 1940’s, the technique has been updated incorporating surgical and pharmacologic advancements developed over the last 80 years.
When placed under the skin the pellets produce a constant level of circulating hormones, avoiding the fluctuations in hormone levels produced by other methods of hormone delivery. The hormones are an exact molecular carbon copy of Estrogen and Testosterone made by a woman’s ovaries, hence they are totally natural because they are bioidentical.
In an area that has been numbed with local anesthesia, the pellets are inserted under the skin in an area of the buttocks. The insertion of the pellets is virtually painless and takes only about 15-20 minutes to complete. There is some local tenderness in the area of insertion for 3-5 days after the procedure.
The pellet supply of hormones lasts for approximately 3 months and must be replaced regularly as long as therapy is required.
Complications are rare. In a series of 376,000 patients published in the Journal of Therapeutic Advances in Endocrinology and Metabolism, the complication rate was less than 1%. Complications reported were bleeding, infection and pellet expulsion.
The Thyroid Gland and Menopause
It’s a fact that defies explanation, but Hypothyroidism most often presents itself at the three most biologically significant times in a woman’s life: at puberty, after childbirth and at the time of menopause. Since Hypothyroidism, a deficiency in the production of Thyroid hormones, often appears at the same time as the symptoms of Estrogen and Testosterone deficiencies during peri-menopause, comprehensive Thyroid blood testing is an important part of the endocrinologic evaluation of menopausal women. A thorough clinical evaluation of perimenopausal women for symptoms of Hypothyroidism is also crucial. The presence of clinical symptoms are of equal diagnostic importance as are the results of blood tests.
In addition to the symptoms of Estrogen and Testosterone deficiencies, Menopausal women frequently have the hallmark symptoms of Hypothyroidism such as fatigue, brain fog, weight gain without an increase in caloric intake, development of abdominal fat, hair loss, anxiety, panic attacks and depression. These symptoms must be addressed and treated along with the deficiencies of Estrogen and Testosterone.
My preference for the treatment of Hypothyroidism is with natural desiccated thyroid (NDT) medications such as Armour or NP Thyroid. Studies have shown that patients have superior symptomatic relief when treated with NDT medication as compared to treatment with synthetic thyroid medications, such as Synthroid. Furthermore, just like the human Thyroid gland, NDT contains Thyrocalcitonin, a hormone that causes the formation of new bone. NDT is an effective preventative and restorative therapy for osteopenia and osteoporosis, common menopausal conditions that cause the spontaneous fracture of bones in women who have gone for years without the benefit of adequate Estrogen and Testosterone.
Why are Relatively Few Symptomatic Women Treated with Hormone Replacement Therapy?
Twenty years ago a highly publicized study (The Women’s Health Initiative) on the safety of hormone replacement therapy was stopped prematurely because the authors claimed that there was a higher than expected incidence of breast cancer in a group of women who were treated with hormones.
The dramatic termination of the study was quite unusual and the media immediately spread the word that treatment with estrogen caused breast cancer. The association of the words breast cancer and hormonal therapy was the kiss of death for the hormonal treatment of the menopause. There was an instantaneous drop of 60% in the number of women taking hormonal treatments for menopausal symptoms. Although the women in the WHI study were treated with artificial hormones that were quite different from natural bioidentical hormones in use today, all types of female hormones were stigmatized. A huge number of women went "cold turkey" off their hormones and suffered through menopause without hormone replacement therapy.
Years later, the WHI authors repudiated the results of their own study. They admitted to serious flaws in their study’s design that led them to draw totally erroneous conclusions about the dangers of hormonal therapy.
Years after all the damage was done, the authors admitted that hormonal therapy was not as dangerous as they had originally stated and there was no proof that estrogen actually caused cancer.
There are certain critical pieces of information that a woman must be aware of when she reaches perimenopause.
- If symptoms are not debilitating and do not interfere with the quality of life, hormonal therapy may not be necessary.
- In the case of severe menopausal symptoms, a relatively short period of hormone replacement therapy of 1-2 years can be used safely to eliminate intense menopausal symptoms that prevent a good quality of life.
- Long term treatment with hormones as a preventative measure against hormonally dependent medical conditions such as osteoporosis, heart disease, cognitive decline and loss of sexual functioning is relatively safe with proper medical oversight. It may delay the progression of some hormonally related medical conditions but will not prevent them entirely.
- Natural estrogen therapy does not cause cancer but may cause the spread of certain pre existing cancers.
- Testosterone, when given with Estrogen, may actually be protective against the incidence of certain cancers.
- In most cases, when a woman having a uterus is treated with Estrogen, Progesterone must be taken to prevent the development of premalignant or malignant changes in the lining of the uterus.
- If indicated, hormone replacement therapy should be started whenever symptoms begin and before the age of 60. There is no advantage of waiting to start hormone replacement therapy until the periods stop completely.