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W                  hen the Women’s Health Initiative (WHI) results came out in 2002, women dropped their hormone replacement (HRT) like a hot potato. Before you follow suit, some things must be put in perspective. “People’s interpretation was that all estrogen is bad,” says Dr. Kathy Maupin of BioBalance Health.

    She says there are two things women should know: first, all estrogens are not the same. The older Premarin hormone replacement is made from horse urine. Other estrogens are plant-based or synthetic. In addition, delivery system matters: How does the estrogen get into the body? It can be delivered orally via sublingual drops, or in skin sprays, gels, creams, vaginal tablets, patches, intramuscular injections and pellet injections into fatty tissue.

     “The type of estrogen and how it gets into the body determine how dangerous or safe it is, and whether it helps the worst menopause symptoms,” Maupin says. “The delivery system and type of estrogen that most closely mimic our own body produce the lowest risk of breast cancer. The safest estrogen is non-oral and bioidentical,” she says.

    Maupin says the most dangerous hormones are taken orally. “These preparations go into the stomach and then to the liver before the rest of the body,” she says. “In the liver, they are broken down into other products with a completely different composition and function than what the ovaries put out. They are not what your body recognizes as its own.” One of the main byproducts of this liver metabolism, she says, is a form of estrogen called estrone, which causes belly fat and breast pain. The youthful estrogen, estradiol, is what the ovaries put out directly to the rest of the body. Breast cancer risk comes from estrone. Keeping estradiol levels high and estrone levels low greatly reduces that risk, says Maupin. Any non-oral estrogen is safer than oral, Maupin cautions. Pellets, she says, are the safest and create the least estrone of any delivery system. Giving testosterone along with the estrogen in the pellets also increases T-cell activity to bolster the immune system against cancer.

    Dr. Teresa Knight of Women’s Health Specialists of Saint Louis, advises keeping menopausal estrogen use in perspective: “Throughout history and as women have become over-nourished, the age of puberty has become younger,” she says. “The age of menopause, however, has stayed the same, on average about 52. With the average age of death for women 78 to 80, we live nearly half our lives past menopause.” When scientists discovered hormone replacement, she says, it offered women improved cognition, less arthritis, better sleep and better sex. Then the WHI study came out in 2002 and scared everyone.

    Knight doesn’t believe estrogen causes breast cancer cells. If they are already there, and they have positive estrogen receptors, estrogen can cause them to grow, she says, so you may get breast cancer earlier. For those opting to take supplemental estrogen, she also recommends bioidentical, non-oral estrogen. Bioidentical hormones are made in the lab, she says. She prefers transdermal creams that bypass the liver. Objectively, HRT is the best way to protect bones, she adds. “The morbidity and mortality caused by osteoporosis are unbelievable. Osteoporosis treatment is only second-best because while it increases the density of bones, it makes them very brittle.”

    The average age of the women in a recent update study on HRT was 63, more than 10 years past menopause. By that age, permanent changes from estrogen deprivation, such as hardening of the arteries, had already occurred. Giving HRT at that point, Knight points out, is too late to prevent heart disease and can actually make it worse, which is exacly what the study showed. “HRT can help with heart disease if you start supplementing early, in the mid-40s when menopausal symptoms first start. Then it can prevent heart disease,” says Knight.

    So before you decide to suffer silently without estrogen, think about this: The recent increased concern about HRT is from following women who were, on average, 10-plus years beyond menopause, taking oral HRT for at least 15 years, in higher doses than prescribed today, and taking a combination of estrogen and progestin. So check with your physician, and do your homework before making big decisions about HRT.