By Dr. John Alevizos
Specializing in Integrative Medicine & Anti-Aging
In my day to day life, I am never happier than when my wife is happy, energetic, and feeling upbeat, and is not suffering from chronic pain. Having a wife in this state is very achievable and desirable for her, and is twice as desirable for her husband.
Modern medicine seems to be uninterested in women beyond the reproductive years. For example, we age because our hormones decline, not the other way around. We have learned to accept aging as “natural” and we throw up our arms and say we are genetically determined to develop certain diseases at certain ages, so we should just accept it because that’s the way it has always been.
If one took the hormone level of a woman at age 50 and compared it to a woman at ages 18, 19 or 20, doctors would say that the young woman is sick due to a lack of hormones, and that she is in desperate need of treatment. However, when women lose their hormones at a later age, there seems to be confusion about what to do about it when wrinkles occur, when osteoporosis develops and when all of the diseases of aging impact activities of daily living.
Replacing bioidentical estrogen, progesterone and testosterone is a powerful tool in patients’ lives in order to decrease the chronic inflammation that occurs due to the lack of hormones, as I will explain in this article. There is some controversy, however, that I would like to dispel before going any further. First, a bioidentical hormone, molecule for molecule and atom for atom, is identical to what a woman’s ovaries were producing during the energetic and more productive part of her life. The most popular hormones available by drug companies are, in fact, not human, and can cause a great deal of harm.
The Women’s Health Initiative was a government-sponsored study to evaluate hormone replacement therapy and used conjugated estrogens (Premarin). Premarin is an equine (horse) conjugated estrogen that is composed mainly of equillin and some estradiol. This is a horse estrogen and should not be given to the human species when bioidentical hormones are available. The study also used progestins (Provera), which is not bioidentical, and in medical school, I was taught that progesterone and progestin are interchangeable. However, when I started practicing anti-aging medicine, in order to prove it to myself, I would draw a progesterone level from women on Provera. You guessed it, their progesterone level was zero. This study was halted onJuly 9, 2002, three years early, due to the findings of increased breast cancer in women taking combined hormones. They also noted the increased risk of heart attack in this group.
As a card carrying Board certified family physician, I had my mother on Prempro and when these results came out, I became very confused. When the study came out, multiple female patients of mine stated that they saw this on the news and wanted to know what to do. At that point, the information was not released to the medical community yet and it was difficult to advise patients before I had the opportunity to review the study and before the medical community in general had a chance to review the study.
The study showed that the stroke rate was 41 percent higher, blood clots were 100 percent higher and breast cancer was 26 percent higher. However, colorectal cancer was 30 percent lower, hip fracture was 33 percent lower and total fractures were 24 percent lower. In real numbers, this means that for every 10,000 women, there were eight more cases of breast cancer, seven more cardiac events, eight more strokes, 23 more cases of dementia, six fewer colon cancers and five fewer hip fractures.
With respect to heart disease, the Women’s Health Initiative showed seven cases more per 10,000 people, but we know that they were using oral equine estrogen. Oral estrogen increases sex hormone binding globulin and increases clotting factors because of its first pass effect through the liver. Transdermal estrogens with a patch, cream or gel do not do this. Therefore, transdermal estrogens do not cause an increased risk of blood clotting. They also used Provera (a progestin, not progesterone), which causes increases in clotting cells and heart artery vasoconstriction (narrowing of the heart arteries). Therefore, if you give a bunch of women with the average age of 63 years who have a lot of risk factors for heart disease two agents (both that increase clotting factors and one that causes constriction of the heart arteries), what could be expected to happen? We cannot take these results and think that they are equal to bioidentical hormones.
In the Journal of the American Medical Association, March 2, 2004, the estrogen-only arm of the world health initiative was continued and showed a decreased incidence of breast cancer, a decreased incidence of heart disease, and an increased incidence of stroke and dementia. This was equine estrogen without the progestin. In the estrogen-only arm, there was neither an increase nor a decrease in mortality between estrogen only and placebo. The global risk index for estrogen only was zero and the risk ratio was 1.0. The difference between the estrogen-only arm and the estrogen-progestin for heart disease patients was taking away the progestin. In the Journal of the American Medical Association, 2001, 285…906-913 states that the first-year risk for coronary artery disease events due to hypertension and increased thrombosis were increased with estrogen. However, if one made it through the first year, the World Health Initiative and the HERS secondary studies showed statistically significant risk reduction over time.
So, for those of you taking Premarin, if you are concerned about heart disease, the WHI and HERS showed a reduction in long-term risk and the WHI estrogen-only arm showed no risk for coronary heart disease. This would have to be women who have undergone a hysterectomy who do not need to take progesterone in order not to have menses. However, this is not the ideal way, as I will explain later. To further prove that progestin (Provera) is not good for women, if you look at the Physician’s Desk Reference, more than 60 percent of the text is devoted to contraindications, the main one being birth defects if taken when pregnant. Any woman who has ever been pregnant and any OB/GYN or family practitioner can tell you that women produce boatloads of progesterone when they are pregnant. Thus progestin is not progesterone bioidentical or not.
The American Journal of Epidemiology 114:2009-217 wrote about a 1981 Johns Hopkins University study that was done on 1,000 infertile women for 13 to 33 years. These women were divided into two groups – the progesterone-deficient women and those with other causes of infertility. They found that the progesterone-deficient women had five times more breast cancer and 10 times higher overall cancer mortality than the other group. Therefore, progesterone protects against breast cancer and it is also a precursor to many other hormones, and you have to wonder how many other positive effects it has in the rest of the body. Women should be aware that every cell in their bodies has a progesterone receptor. Doctors tend not to give women progesterone who have had a hysterectomy because progesterone is not necessary to stabilize the endometrium so that a woman does not have a period while taking estrogen. However, as you will see later, even women without uteruses need to take progesterone for multiple reasons. We must remember that hormones are like a spider web in that they all depend on each other to balance one another for optimal health.
A French study of 54,548 postmenopausal women put on different forms of hormone replacement therapy for 2.8 years showed no increased risk (actually, a 10 percent decrease in risk) with oral or transdermal estrogen use alone or combined with oral progesterone. There was a 40-percent increased risk of breast cancer when either form of estrogen was combined with synthetic progestins. The conclusion of the study was that the association between hormone replacement therapy and breast cancer risk most likely varies according to the type of progesterone used. Once again, there was no increased risk with the use of bioidentical progesterone.
Enough of the technical information. Let’s go forward so I can give you some information that you can use. In my practice, I have noticed that women are much more intricate and complicated than men. The men just do what I tell them, but women are more in tune with their bodies, emotions and feelings. What I am about to describe is not just for women who are no longer having periods and are postmenopausal. Several years before a woman goes through menopause, she is perimenopausal. Women in their late 30’s and early 40’s can have mild hormone deficiencies that once corrected, can dramatically improve their quality of life.
Let me say this a different way. If you look at a young girl who is 5’4” tall and 180 pounds in a bathing suit at age 18, 19 or 20 years, you will notice that the back of her legs are quite smooth. Look at the same woman at 5’4” tall and 180 pounds at 40 years of age and you will notice that the back of her legs look like cottage cheese. When women are younger, their hormones are brimming in anticipation of childbirth. They can work at a job, take care of their husbands and children at home, and still have enough energy to do that every day. I am not here to advocate giving everybody hormones as the ultimate fountain of youth. I am advocating treating a deficiency; this is for people who actually need to have some supplementation in order to be in the optimal range. Those of us who are still making hormones naturally must remember that we have to have cholesterol in order to make hormones. Cholesterol goes through a chemical pathway in the body where it has a choice – whether to go into the three female hormones of estrogen, progesterone and testosterone, or to go to cortisol, which is a stress hormone. For women who are under a lot of stress, their chemical reaction chain gets hijacked and goes into making cortisol rather than making the three aforementioned hormones.
At the end of every article I write, I encourage people to obtain more information and once they do, I am confident that they will follow my suggestions. There is no disclaimer here. Entire books have been written on every topic that I briefly touch on. Your very reliable OB/GYN or family physician who has delivered your children, performed minor surgeries and has treated you very well for years may be a very qualified doctor. However, anti-aging medicine is its own specialty. You don’t necessarily need an anti-aging doctor to get information, as it is readily available on the internet.
It is important to know that laboratory values get us in the ballpark. However, the reference ranges are vast. What is in the bloodstream does not 100 percent accurately reflect what isin the tissues. The most accurate way to test hormones is by saliva. I strive to get patients to the upper one-third of the reference range, which should be close to what is ideal. If the laboratory values and the patient disagree, I will side with the patient.
In plain English, this means that I treat the patient clinically and listen to their symptoms and do not treat only the laboratory value. The laboratory values help me confirm a diagnosis, not make a diagnosis. Most of my postmenopausal patients need to have an estrogen level of 200 to 300 in order not to have hot flashes. However, I have patients who feel great with a blood estrogen level of 100. This type of medicine is not an exact for every individual, and this is why it is best to present yourself to somebody who will take multiple factors into consideration.
Let’s now go on to talk about the individual female hormones. A woman, during her normal menstrual cycle, once she releases an egg during ovulation, a corpus luteum cyst is formed and the cyst makes progesterone. For women who are perimenopausal and are not ovulating regularly, a corpus luteum cyst is not produced regularly, and therefore, they are progesterone-deficient. Progesterone is known as the hormone of pregnancy and it prepares the lining of the woman’s uterus for endometrium and supports the baby. It balances estrogen in the uterus and in the brain, as estrogen has sympathetic properties (fight or flight) while progesterone has parasympathetic properties (calming). One of the main effects of progesterone is that it is anti-inflammatory. I use oral bioidentical progesterone commonly to treat women with migraines in and around their menstrual periods. The most dramatic effect that my patients get from bioidentical progesterone is having a good night of sleep and staying asleep.
I give oral Prometrium to some patients, which is bioidentical progesterone, mainly to release melatonin at nighttime. When a woman takes this one hour to one-half hour before going to bed, she will fall asleep and notice the effects of the progesterone immediately, the first night (in general hormones take a few weeks to have a noticible affect) The standard dose is anywhere from 100 to 400 mg at bedtime. I start my patients at 100 mg and titrate up if needed. Some patients, even at 100 mg, wake up too groggy in the morning and therefore, they have to be given less. Not only does progesterone help the body make melatonin, it also makes serotonin, the same thing that Prozac, Zoloft, Paxil, etc. increase in the body, and therefore, it helps patients produce natural anti-anxiety and antidepressant hormones.
Please remember what I stated previously, that during times of stress, cholesterol that gooes to pregninolone then to progesterone is converted to cortisol, the stress hormone, and the cortisol competes for progesterone receptors and helps produce progesterone deficiency since the cells are bound to cortisol and cannot absorb the progesterone, and there is also less progesterone to go around. Needless to say, all kinds of stress can cause progesterone deficiency and cause estrogen dominance (please look up estrogen dominance). Because of this effect, many young women can complain of symptoms of menopause such as irritability, a lack of ability to sleep well, hot flashes and irregular periods. Most doctors would look at those women and say “You’re crazy. You’re not of age yet.” I see this mainly in business women who are trying to juggle their third child, a flourishing career and many different demands on their time. They are not producing the calming hormone. In this case, it is perfectly acceptable to supplement with oral Prometrium (progesterone) or have a compound pharmacist make a bioidentical gel or cream. However, oral bioidentical progesterone works better than the cream for sleep. All women must remember that hot flashes do not only mean estrogen. Fortunately, progesterone has a wide margin of safety and when I give too much, women complain of being a bit sleepy and a little too relaxed. Also, medically speaking, too much progesterone will cause insulin resistance (this is what noninsulin-dependent diabetics get, mainly due to obesity).
Now let’s talk about estrogens. The different functions of estrogen increase deep sleep, maintain muscle mass, regulate body temperature, increase metabolic rate, maintain arterial elasticity and decrease arterial plaque accumulation. Having stated the above, women who have difficulty falling asleep generally have more of a progesterone issue. However, if they have difficulty staying asleep, they tend to have more of an estrogen issue. Estrogen also improves insulin sensitivity and along with increasing metabolic rate, women who get older tend to get more belly fat and no matter how much they exercise, some of them still have trouble. Estrogen reduces the overall risk of heart disease by 40 to 50 percent, decreases bad cholesterol, increases good cholesterol, decreases blood pressure, and along with testosterone, increases water content of the skin and is responsible for skin thickness and maintaining collagen. Estrogen also aids in serotonin increase in the brain, which decreases depression, anxiety, pain sensitivity and irritability. It enhances energy, improves mood and increases concentration. You need progesterone to lay down bone, you need testosterone to make it thick, and you need estrogen to maintain it. Along with testosterone, estrogen also increases sexual interest.
I would bet that most people are not aware that a woman actually has three different estrogens. The first, estrone (E1), is the predominant estrogen after menopause. It is made from some adrenal hormones and estrone (E1) can go to estradiol (E2). Thus, postmenopausal women tend to have some estrogen. Therefore, estrogen does not necessarily have to come from the ovaries. Estradiol (E2) is the most potent estrogen and is 12 times more potent than estrone and 80 times more potent than estriol (E3). This is where most of the action is for a premenopausal woman. Estradiol can come from E1 and from testosterone. It assists in the functions of female reproduction, bone health, nervous system protection, sexual development, etc. If your doctor does not subscribe to or understand how to prescribe bioidentical hormones, there are some estradiol patches available that I would highly recommend over horse estrogen. Estriol (E3) is quite high during pregnancy. This causes some researchers to assert that the more babies a woman has, the lower the risk of breast cancer. When I prescribe bioidentical hormones to my female patients, I place estradiol and estriol (not estrone) in a cream, gel or drops.
Testosterone is necessary for strength, especially in the upper body, a sense of well-being, energy, nipple and genital sensitivity, sex drive, body composition and bone density. It should be noted that obese women produce testosterone in their fat cells. This is one of the reasons that they tend not to get osteoporosis and be hunched over when they are older. By increasing body composition, we know that there are more testosterone receptors in our fat cells (thus testosterone helps with belly fat) than there are in many other places in our bodies, so testosterone in women is necessary in order to build muscle. It is a connective tissue hormone and results in a stronger collagen layer, fuller lips, tighter skin, more lean muscle mass and less fat. Remember that during stress in a younger woman, cortisol hijacks the progesterone down that pathway so testosterone is not being produced. In my practice, I have placed several dozen premenopausal women on testosterone, and sometimes I have to argue with them and tell them I cannot give them any more, as I do not want to turn them into men.
It should be noted that these are the side effects of too much testosterone in decreasing order: 1) oily skin, 2) acne, 3) genital enlargement, 4) hair production in places women don’t want it, and 5) deepening of the voice. When I am replacing testosterone in women, I back off the dose if they start to get acne. Most women try to get the oily skin, as they feel the look younger. With testosterone deficiency in women, they will have abdominal fat, a lack of muscle and bone, fatigue, memory loss, weight gain, a lack of self confidence, and general malaise.
The women who are not quite sure about any of what I have said can try the following: The women who are premenopausal (still having regular periods) can get DHEA 25 mg at a local health food store. The women who are past menopause should get DHEA 50 mg. Take one a day every morning. DHEA will be converted into testosterone in a woman, but not in a man. DHEA is an adrenal hormone that, during times of stress, gets depleted. If you are going to take this, keep in mind the side effects that I stated above. In about a week or so, you should notice increased energy and a slight increase in sex drive. You will notice the full effect of the hormones after several weeks to months.
In summary, some of the symptoms of menopause include hot flashes, urinary tract infections, painful intercourse, vaginal dryness, vaginal itching, night sweats, mood swings, palpitations, panic attacks, depression, bloating, migraine headaches, and even gastrointestinal symptoms. I would encourage every woman reading this article to get more information by looking up progesterone in women, estrogen in women and testosterone in women on the internet. There you will find a lot more detail about the individual hormones, which might help you make an informed decision.
Dr. John Alevizos is Board Certified in Family Practice and an Anti-Aging Specialist. His areas of practice includes Integrative Medicine, Anti-Aging, Bioidentical Hormone Replacement Therapy & PRP Therapy. Alevizos Medical is located in Irvine, Calif. Visit us at www.AlevizosMedical.com or call us at (949) 916-3600.