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Hormone Replacement Therapy

Hormone Replacement Therapy

Description

Essentially, hormone replacement therapy is the substitution of an exogenous hormone when there is a deficiency state. Most commonly, hormone replacement therapy refers to the use of female hormones to ease the transition of menopause, due to either surgery or the natural aging process, as well as to reduce post-menopausal health risks, notably osteoporosis.

Hormone replacement therapy (HRT) has existed in some form for more than a century. Examples include: insulin, thyroid and corticosteroids.

Estrogen became available about fifty years ago although initial therapies with diethylstilbestrol (DES) may have had a negative impact upon the health of generations of children and their families. Both sons and daughters of women who took DES (usually to overcome a problem of infertility) have genital disorders and daughters have an increased susceptibility to cancer of their reproductive organs.

More recently, two forms of treatment have reached prominence: ERT (estrogen replacement therapy) and HRT.

ERT uses lower doses of estrogen and will generally be used for women who have undergone surgical menopause. The major benefit sought is to decrease complications of osteoporosis, namely hip and spine fractures.

For women who go through menopause, naturally, there is some concern that estrogen, by itself, will overstimulate the uterine lining, possibly causing endometrial hyperplasia which might lead to uterine cancer. Consequently, estrogen must be combined with progesterone. HRT, therefore, combines estrogen and progesterone.

Causes

In describing hormone replacement therapy (HRT), it was accepted that menopause is followed by a deficiency of female hormones.

Surgical procedures may remove the uterus and ovaries, or the ovaries can cease to function, naturally. There is some debate whether being menopausal requires the replacement of estrogen because there is a true deficiency.

There are arguments on both sides of this issue. Some women are happy to avoid many of the distressing symptoms associated with their "change of life" (the climacteric) and gain some immunity from long term consequences, notably osteoporosis.

However, other women are alarmed at now being subjected to hormonal drugs for most of their whole lives, either to protect them against conception, or against the ravages of time. Are women being betrayed by their natural hormonal cycles? Are women being exploited by doctors and the pharmaceutical industry?

Signs & Symptoms

The classic sign of menopause is the cessation of menstruation which usually takes place before 55 years of age, In Western countries a host of symptoms are now reported by the majority of women during this stage of their lives, including: 'crawly' skin sensations, depression, dizziness, fatigue, 'hot flashes' or 'flushes' (episodes of sudden skin flushing and perspiration in 70% of women, lasting between 1 and 5 years), insomnia, irritability, shortness of breath, strange pains and vaginal dryness.

These symptoms aren't serious, by themselves but certainly uncomfortable, even incapacitating. Of greater significance are the loss of bone mass and changes in the heart and blood vessels, both of which have high morbidity and mortality rates.

HRT has the potential to alleviate and, in many cases, eliminate these symptoms, as well as reducing the progression of the chronic diseases.

Estrogen improves the condition of the vagina and decreases the risk of heart disease and strokes. Overall, women taking HRT live longer than women who do not.

ERT may also play a role in the prevention of senile dementia.

On the other hand, HRT can increase breast density, making it more difficult to diagnose breast cancer by mammography. Some references report an increased incidence of breast and endometrial cancer in HRT populations studied. A recent study has reported a 2.5-fold increase in gallbladder disease in ERT populations.

There is also some breakthrough bleeding but most women have preferred to deal with this inconvenience than forego the other benefits.

Unraveling the precise risks and benefits for each woman is quite a complex issue for patients and their physicians. In an attempt to shed some light upon this, one study interviewed women physicians. In Britain, where this study was undertaken, the average use of HRT is quite low (1 5%) in the general population but increases within the younger set of postmenopausal women physicians to around 60%. The American rate is around one-third of all eligible women.

Some definite contraindications to HRT have also been established, including: acute liver disease, breast or cervical cancer, fluid retention, high blood fats, phlebitis, or uncontrolled hypertension.

Nutritional Supplements

---------------------------------
General Supplements
---------------------------------


Bioflavonoids*
Calcium1,500 mg
DHEA*
Magnesium*
Vitamin B-610 - 100 mg
Vitamin C1 - 5 gms
Vitamin D400 IU
Vitamin E800 - 1,200 IU
Indole 3 Carbinol*



* Where amounts are not specified please refer to the text.

Note: All amounts are in addition to those supplements having a Recommended Dietary Allowance (RDA). Due to individual needs, one must always be aware of a possible undetermined effect when taking nutritional supplements. If any disturbances from the use of a particular supplement should occur, stop its use immediately and seek the care of a qualified health care professional.

Nutrient Depletion

Long term, continuous use of "the Pill" is also associated with expansive vitamin and mineral depletion, notably:

Biotin, Choline, Folic acid, pyridoxine (vitamin B6), Niacin (vitamin B3), Riboflavin (vitamin B2), Vitamin B12 and Vitamin C; as well as minerals: Calcium, Magnesium, Manganese and Zinc.

Since it is most likely that a woman who has been on "the Pill" would switch to HRT, the same depletions might be anticipated.

Additional risk factors among patients using oral contraceptives include: malabsorption states (e.g. gluten-sensitive enteropathy) and inflammatory bowel disease. [Roe, 1994] In which case, Vitamin K deficiency is quite high in individuals with chronic gastrointestinal disorders or poor fat absorption.

Drug Interactions

Table: Benefits and Disadvantages of HRT

Positive EffectsNegative Effects
(Decreased)(Increased)
Bone lossVaginal bleeding, nausea, breast tenderness [estrogen]
Fracture rateFluid retention, weight gain, PMS [progestogen]
Menopausal symptomsBreast cancer
Heart disease mortalityVenous thromboembolism
Alzheimer's disease



Dietary Considerations

A healthful diet may provide a smoother menopausal transition. Indeed, the Japanese culture, apparently, has no term for "hot flash", which is credited to the predominance of phytoestrogens, notably in soy products.

Several foods may be contraindicated: notably caffeine, as well as highly spiced, or hot, foods. Alcohol should also be avoided and sugar, too, according to some authorities. Certainly, highly refined and sweetened processed products have little to contribute nutritionally.


Homeopathic Remedy

Kreosotum
Lachesis
Pulsatilla

Treatment Schedule

Over-the-counter homeopathic remedies may be single strength (of fairly weak potency e.g. 6X ) or a blend of several weaker strengths (6X, 8X, 1 OX).

This may comprise a single remedy, or several remedies.
Doses are administered on a 3 times daily (tid), between meals,schedule and continued for 3 days.
Liquid preparations usually use 8-1 0 drops per dose.
Solid preparations are usually 2 or 3 pellets per dose.
Children use 1/2 dose i.e. 1 pellet.
If there is aggravation of the symptoms, stop taking the remedy and consult a homeopath.

References

Murphy, R. Homeopathic Medical Repeftory. Hahneman Academy, Pagosa Springs, Colorado. 1993.
Murphy, R. Lotus Materia Medica. Hahneman Academy, Pagosa Springs, Colorado. 1995.
Pert, J.C.: Homeopathy for the Family. The Homoeopathic Development Foundation, London. 1985 edition.

Herbal Approaches

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Herbs
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Angelica (Dong Quai)
Black Cohosh
Chaste tree (berries)
Fenugreek
Ginseng
Horsetail
Licorice root
Red clover
Wild yam

Note: The misdirected use of an herb can produce severely adverse effects, especially in combination with prescription drugs. This Herbal information is for educational purposes and is not intended as a replacement for medical advice.

Discussion:

Phytoestrogens (also isoflavones) have not been associated with the side-effects of pharmaceutical preparations, usually synthetic hormones, derived from e.g. mare's urine. Licorice root, Red clover and Wild yam have been featured, while the accompanying list adds several more (although there are some 300 altogether).

Angelica (Dong Quai) is known as the "female ginseng", however, while Oriental women may not experience as many problems with menopause as their modern, Western counterparts, it has been found useful for "hot flashes".

Black cohosh is reputed to relieve hot flashes, insomnia and irritability. A Native American herb, the standardized extract has been in use in Germany since 1956 and this form is now gaining popularity in America. The Latin name is used: Cimicifuga racemosa, In 1994 over 6.5 million units were sold in Europe.

Chaste tree is deemed to be helpful to those who begin menopause early (in their early forties).

Horsetail is important for hair, nails and the skeleton as it is rich in silica.

Newall has compiled a list of hormonally Active Herbs:

HerbEffect
Agnus CastusHormonal imbalance disorders
AlfalfaEstrogenic, in vivo
AniseedEstrogenic
BayberryMineralocorticoid
Cohosh, BlackEstrogenic
FucusHyper-/hypothyroidism reported.
GinsengEstrogenic, human
HorseradishMay depress thyroid activity
LicoriceMineralocorticoid activity, human.
estrogenic in vivo, in vitro
Motherwortoxytocic
Pleurisy RootEstrogenic
Red CloverEstrogenic in vivo
Saw PalmettoEstrogenic and anti-androgenic in vivo,
human use in prostate cancer.
VervainInhibition of gonadotrophic activity
Wild CarrotEstrogenic



Zava has divided foods, herbs and spices between estrogen and progestin bioactivity:

EstrogenProgestin
SoyOregano
LicoriceVerbena
Red cloverTurmeric
ThymeThyme
TurmericRed clover
HopsDamiana
Verbena



References:

Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-care Professionals. London: The Pharmaceutical Press, 1996:21,45,63,282.

Walji, H: Natural Hormonal Therapies. Natural health Series, Kian Press, 1997.

Zava, DT: Estrogen and progetsin bioactivity of foods, herbs and spices. Proc. Soc. Exp. Biol. Med. 1998, 217:369-378.

Aromatherapy - Essential Oils

Angelica EssenceBasil Essence
Chamomile EssenceCardamom Essence
Clary Sage EssenceCypress Essence
Jasmine EssenceLavender Essence
Melissa EssenceRosemary Essence
Sage EssenceSandalwood Essence
Thyme Essence


Related Health Conditions

Aging
Atherosclerosis
Bleeding
Depression
Hot flash
Itching
Menopause
Menstruation


Abstracts

References

Andersson B et al., Estrogen replacement therapy decreases hyperandrogenicity and improves glucose homeostasis and plasma lipids in postmenopausal women with noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab, 1997 Feb, 82:2, 638-43.

Balogh A & Bettembuk P: Hormone replacement therapy and prevention of osteoporosis: risk assessment and practical advice. Eur J Obstet Gynecol Reprod Biol, 1997 Feb, 71:2, 189-91.

Bar-Hava I et al., Ovarian cysts and cyclic hormone replacement therapy: is there an association? Acta Obstet Gynecol Scand, 1997 Jul, 76:6, 563-6.

Barlow, D.H. Hormone replacement therapy. In Smith, R. (Ed.): Osteoporosis. RCP. London. 1990: 135 142.

Bergkvist, L. et al: The risk of breast cancer after estrogen and estrogen-progestin replacement. NEJM. 1989, 321: 293 - 297.

Brinton LA: Hormone replacement therapy and risk for breast cancer. Endocrinol Metab Clin North Am, 1997 Jun, 26:2, 361-78.

Brown M et l., Hormone replacement therapy does not augment gains in muscle strength or fat-free mass in response to weight-bearing exercise. J Gerontol A Biol Sci Med Sci, 1997 May, 52:3, B166-70.

Carranza-Lira S et al., Changes in symptomatology, hormones, lipids, and bone density after hysterectomy. Int J Fertil Womens Med, 1997 Jan-Feb, 42:1, 43-7.

Cicinelli, E. et al: Progesteron administration by nasal spray. Fertil. Steril. 1991, 56: 139 -141.

Cicinelli, E. et al: Effects of repetitive administration of progesterone by nasal spray in postmenopausal women. Feftil Steril. 1993, 60: 1,020 - 1,024.

Col NF et al., Patient-specific decisions about hormone replacement therapy in postmenopausal women. JAMA, 1997 Apr 9, 277:14, 1140-7.

Corson SL: A practical guide to prescribing estrogen replacement therapy. lnt J Feftil Menopausal Stud 1995 Sep-Oct;40(5):229-47.

Cumming RG & Mitchell P: Hormone replacement therapy, reproductive factors, and cataract. The Blue Mountains Eye Study. Am J Epidemiol, 1997 Feb 1, 145:3, 242-9.

Darj, E. et al: Natural micronized progesterone orally administered in postmenopausal hormonal replacement therapy. Eur. Menopause J. 1995, 2: 16 - 20.

Denke-MA: Effects of continuous combined hormone-replacement therapy on lipid levels in hypercholesterolemic postmenopausal women. Am-J-Med. 1995 Jul; 99(l): 29-35.

Ettinger B et al: Cyclic hormone replacement therapy using quarterly progestin. Obstet Gynecol 1994 May;83(5 Pt 1):693-700.

Fillit H: Future therapeutic developments of estrogen use. J Clin Pharmacol 1995 Sep;35(9 Suppi):25S28S.

Gelfand MM & Wiita B: Androgen and estrogen-androgen hormone replacement therapy: a review of the safety literature, 1941 to 1996. Clin Ther, 1997 May-Jun, 19:3, 383-404; discussion 367-8.

Hammond CB: Menopause and hormone replacement therapy: an overview. Obstet Gynecol 1996 Feb;87(2 Suppi):2S-15S.

Hartmann BW & Huber JC: The mythology of hormone replacement therapy. Br J Obstet Gynaecol, 1997 Feb, 104:2, 163-8.

Heikkinen AM et al., Biochemical bone markers and bone mineral density during postmenopausal hormone replacement therapy with and without vitamin D3: a prospective, controlled, randomized study. J Clin Endocrinol Metab, 1997 Aug, 82:8, 2476-82.

Hermens, W.A.J.J. et al: Nasal absorption enhancement of 17 b-estradiol by Dimethyl-b-Cyclodextrin in rabbits and rats. Pharm. Res. 1990, 7: 500 - 503.

Hermens, W.A.J.J. et al: Intranasal estradiol administration to oophorectomised women. Eur. J. Obst. Gyn. Reprod. Biol. 1991, 40: 35 - 41.

Hermens, W.A.J.J. et al: Intranasal administration of estradiol in combination with progesterone to oophorectomised women: a pilot study. Eur. J. Obst. Gyn. Reprod. Biol. 1992, 43: 65 - 70.

Isaacs, A.J. et al: Utilisation of hormone replacement therapy by women doctors. BMJ. 1995, 311: 1,399 - 1,401.

Kornhauser C et al., The effect of hormone replacement therapy on blood pressure and cardiovascular risk factors in menopausal women with moderate hypertension [see comments]. J Hum Hypertens, 1997 Jul, 11:7, 405-11.

Lewis, J.: Feminism, the menopause and hormone replacement therapy. Feminist Rvw. 1993, 43: 38 - 56.

Lignieres de B. et al: Influence of route of administration on progesterone metabolism. Maturitas, 1995, 21:
251 - 257.

Lippuner K et al., Prevention of postmenopausal bone loss using tibolone or conventional peroral or transdermal hormone replacement therapy with 17beta-estradiol and dydrogesterone. J Bone Miner Res, 1997 May, 12:5, 806-12.

Lochie, C.: HRT and menopause symposium: Introduction. The Practitioner, 1990, 234(8): 469.

MacLennan A: Osteoporosis. Menopause and beyond. Aust Fam Physician, 1997 Feb, 26:2, 123-5, 128-9, 131.

McCrea F.B. & Markle, G.E.: The estrogen replacement controversy in the USA and UK: different answers to the same questions. Social Studies of Science. 1984, 14(l): 1 - 26.

Merkus, J.W.M.W.: Hormone replacement via the nose, an option? Eur. Menopause J. 1995, 2(3): 18 - 19.

Mitshell, D.R. (Ed): Menopause, Physiology and Pharmacology. Year Book Medical, Chicago-London, 1987.

O'Brien T & Nguyen TT: Lipids and lipoproteins in women. Mayo Clin Proc, 1997 Mar, 72:3, 235-44.

Pearce J et al., Psychological effects of continuation versus discontinuation of hormone replacement therapy by estrogen implants: a placebo-controlled study. J Psychosom Res, 1997 Feb, 42:2, 177-86.

P?rez Gutthann S: Hormone replacement therapy and risk of venous thromboembolism: population based case-control study. BMJ, 1997 Mar 15, 314:7083, 796-800.

Perrone G et al: Hormonal and metabolic effects of transdermal estradiol/progestagen administration in postmenopausal women. Int J Fertil Menopausal Stud 1994 Jul-Aug;39(4):202-7.

Pham KT et al., Ovarian aging and hormone replacement therapy. Hormonal levels, symptoms, and attitudes of African-American and white women. J Gen Intern Med, 1997 Apr, 12:4, 230-6.

Phelps, R.L.: Alternatives to hormone replacement for menopause. Alternative Therapies in Health & Med. 1996, 2(2): (46) references.

Phillipov G et al., Initiation of hormone replacement therapy after diagnosis of osteoporosis by bone densitometry. Osteoporos Int, 1997, 7:2, 162-4.

Plushner SL: Lipoprotein disorders in women: which women are the best candidates for hormone replacement therapy? Ann Pharmacother, 1997 Jan, 31:1, 98-107.

Report: Effects of hormone replacement therapy on endometrial histology in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. The Writing Group for the PEPI Trial. JAMA 1996 Feb 7;275(5):370-5.

Rodgers M & Miller JE: Adequacy of hormone replacement therapy for osteoporosis prevention assessed by serum oestradiol measurement, and the degree of association with menopausal symptoms. Br J Gen Pract, 1997 Mar, 47:416, 161-5.

Siseles N. 0. et al: A comparative study of two hormone replacement therapy regimens on safety and efficacy variables. Maturitas l995 Apr; 21(3):201-10.

Slaven L & Lee C: Mood and symptom reporting among middle-aged women: the relationship between menopausal status, hormone replacement therapy, and exercise participation. Health Psychol, 1997 May, 16:3, 203-8.

Smith, D.C. et al: Association of erogenous estrogen and endometrial carcinoma. NEJM. 1975, 292: 1,164 1,170.

Soma MR et al., The menopause and lipid metabolism: strategies for cardiovascular disease prevention. Curr Opin Lipidol, 1997 Aug, 8:4, 229-35.

Sotelo MM & Johnson SR: The effects of hormone replacement therapy on coronary heart disease. Endocrinol Metab Clin North Am, 1997 Jun, 26:2, 313-28.

Taga M: Practical management of postmenopausal women with low bone mineral density. Source: J Obstet Gynaecol 1995 Feb;21(1):99-105.

Udoff L et al: Combined continuous hormone replacement therapy: a critical review [see comments]. Obstet Gynecol 1995 Aug;86(2):306-16. Comment in: Obstet Gynecol 1995 Nov;86(5):869-70.

Wardle PG: Managed care of hormone replacement therapy in the menopause. Curr Opin Obstet Gynecol, 1997 Aug, 9:4, 270-7.

Wen Y et al., The effect of hormone replacement therapy on vitamin E status in postmenopausal women. Maturitas, 1997 Mar, 26:2, 121-4.

Williams DB et al: Assessment of less than monthly progestin therapy in postmenopausal women given estrogen replacement. Obstet Gynecol 1994 Nov;84(5):787-93.

Ziel, H.K. & Finkle, W.D.: Increased risk of endometrial carcinoma among users of conjugated estrogens. NEJM. 1975, 293: 1,167 - 1,170.

Zweifel JE & O'Brien WH: A meta-analysis of the effect of hormone replacement therapy upon depressed mood. Psychoneuroendocrinology, 1997 Apr, 22:3, 189-212.

Further Reading:

Boston Women's Collective: The New Our Bodies, Ourselves. Touchstone, NY. 1992.

Cherry, S.H. & Runowicz, C.D.: The Menopause Book. MacMillan, NY. 1994.

Coney, S.: The Menopause Industry: How the Medical Establishment Exploits Women. Hunter House, CA. 1994.

Greenwood, S.: Menopause, Naturally: Preparing for the Second Half of Life. Volcano, CA. 1992.

Greer, G.: The Change: Women, Aging and the Menopause. Knopf. NY. 1992.

Landau, C., Cyr, M.G. & Moulton, Anne W.: The Complete Book of Menopause. Putnam, NY, 1994.

Perry, S. & O'Hanlan, K.: Natural Menopause. Addison Wesley, MA. 1992.

Worters, Paula B & Siegal, Dianna Laskin: The New Ourselves, Growing Older, Touchstone Press, NY, NY, 1994.


Resources

National Institute on Aging Information Center
P.O. Box 8057
Gaithersburg, MD 20898-8057
(800) 222-2225

National Women's Health Network
514 10th Street, NW Ste 400
Washington D.C. 20004
(202) 347-1140

National Women's Hotline: (800) 558 - 7046
National Women's Hotline (Consumer Line): (800) 222-4767
National Women's Hotline (Information): (800) 558-7046

North American Menopause Society (NAMS)
c/o University Hospitals Department of OB/GYN
11100 Euclid Avenue
Cleveland, OH 44106
(216) 844-8748
Fax: (216) 844-8708

Older Women's League (OWL)
666 11th Street NW Ste 700
Washington D.C. 20001.
(202) 783-6686.

Newsletters:

"A Friend Indeed"
P.O. Box 1710
Champlain, NY 12919-1710.

"Hot Flash"
Dr. Jane Porcino,
Box 816,
Stony Brook, NY 11790-0609.

"National Women's health Report",
National Women's Health Resource Center,
2425 L Street, NW THird Fl.
Washington D.C. 20037.
(202) 293-6045.

 


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