Women's Bodies, Women's Wisdom (122 page)

The bottom line is that estriol seems very promising as an estrogen for those women who are worried about breast cancer. Not only does estriol not cause excessive cell growth in the uterine lining
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or breast tissue, but it’s good at helping hot flashes
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and preventing vaginal dryness, and it has an equal benefit on the skin collagen layer as the other estrogens.
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But very high doses (12 mg or more per day) are required to affect bone density. Such doses generally cause nausea and are therefore not clinically appropriate. It is also worth noting that es triol has been linked with otosclerosis in some women, a genetically linked condition in which the three small bones in the middle ear fuse together and thus fail to transmit sound to the brain. The usual oral dose is 2 mg per day.

Progesterone

During perimenopause, estrogen levels often rise, while progesterone is the first hormone to fall. This situation is known as “estrogen dominance” and it is largely responsible for many of the PMS-like symptoms so common in perimenopause. Giving estrogen to a woman with estrogen dominance is like putting a match to gasoline. What she really needs is progesterone. The voluminous research of Jerilynn Prior, M.D., coauthor of
The Estrogen Errors
(Praeger, 2009), clearly shows that progesterone therapy, not estrogen, should be given first to symptomatic perimenopausal women. Progesterone is a precursor molecule that the body can use to produce both estrogens and androgens. For example, the body may be able to make adequate DHEA from natural progesterone, which is why a common finding with natural progesterone supplementation is increased sex drive. (Alas, this doesn’t work for everyone.)

As already mentioned, bioidentical progesterone is very different from the synthetic progestins, such as medroxyprogesterone acetate (Provera). Unlike Provera—which increases the risk of fatal coronary artery spasm (see section later in this chapter on heart disease) and is also known to cause bloating, headaches, depression, and weight gain—bioidentical progesterone has no serious side effects at the usual doses and has no adverse effects on blood lipids.
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Although there are circumstances in which a woman may need the strong pharmacologic effect of Provera, as in cases of heavy bleeding, for most purposes of symptom relief, bioidentical progesterone is far superior, with the additional advantage of a lack of side effects.

For clinical purposes, the usual conversion is 5 mg of Provera equals 100 mg of natural progesterone if a woman is using oral doses. In general, a significant amount of progesterone must be given to down-regulate estrogen receptors in breast tissue and the uterine lining in order to inhibit the growth-hormone effect of estrogen replacement.
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Transdermal 2 percent progesterone cream at a dose of one-quarter teaspoon (about 20 mg) has also been shown to result in physiologic levels of progesterone, and this is often all that a woman needs to counteract the effects of estrogen, though this must be individ ualized.

Many doctors believe that 2 percent progesterone creams such as Emerita don’t work because they don’t result in increased blood levels. But a 2005 study showed that small amounts of progesterone skin cream do indeed get absorbed into the bloodstream.
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Serum levels of progesterone are often low when a woman is on progesterone creams because when progesterone is absorbed into the blood stream, 80 percent of it will be bound to the plasma membranes of the red blood cells—the part that is thrown out when serum levels are checked. This is also the reason why salivary levels of hormones often measure higher than serum levels. Ideally, hormone levels will be monitored by a physician in a clinical setting. Most clinicians agree that how a patient feels on hormones is, ultimately, a far better measure of effectiveness than a blood or salivary hormone level. This has certainly been my experience.

For effectiveness, transdermal cream should contain a minimum of 375 mg progesterone per ounce. The following creams meet or surpass the standard: Emerita, PhytoGest, BioBalance, Ostaderm, Progonol, ProBalance, and Serenity. The usual dose of these standardized progesterone creams is one-quarter to one-half teaspoon on the skin one or two times per day. There is virtually no danger of overdose, and many women use 375 to 400 mg, or the equivalent of an entire tube or jar, per week with no ill effects. Bioidentical progesterone is also available in regular pharmacies in two forms: oral micronized progesterone under the brand name Prometrium and vaginal progesterone under the brand names Crinone 4% and 8% and Prochieve 4% and 8%.

Many preparations sold as wild yam
(Dioscorea)
creams may con tain little or no progesterone. Although wild yams are one ingredient used in laboratory manufacture of progesterone and other sex hor mones, there are no data to indicate that a yam cream will help a woman in the same manner as standardized formulas. Wild yam may have benefits as a phytohormone (plant hormone); it’s just that it doesn’t have the same measurable effects.

Androgens

As I pointed out in the section on adrenal function, the androgenic hormones DHEA and testosterone are associated with energy, vitality, and sex drive. However, it’s also true that the female brain is the biggest sex organ in the body and optimal libido is critically linked with one’s thoughts and emotions. Hence some women with low androgen lev els have good libido and some with normal androgen levels have low libido. Androgen levels may drop following hysterectomy even when the ovaries are spared; they may also drop following tubal ligation be cause of the change in blood supply to the ovary. Many women who don’t feel their best even on estrogen and progesterone find that taking a small amount of DHEA or testosterone is all they need to feel like their old selves. DHEA is a precursor for testosterone, so I prefer trying this first.

If you think you might benefit from increased androgen levels, first try transdermal magnesium and/or transdermal progesterone; as I’ve noted, these can help the body produce its own DHEA. If symptoms persist, try oral or transdermal DHEA at a starting dose of 5 mg twice per day. It’s rare that a woman will need to increase this much beyond 10 mg twice per day. A 2009 study in the journal
Menopause
reported that daily doses of DHEA intervaginally improved sexual functioning, including desire, arousal, orgasm, and lubrication.
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Some women, however, will need testosterone supplementation directly, which can be given in pill form or as a cream. Many women find that natural testosterone at 1 or 2 mg every other day given as a vaginal cream clears up both vaginal dryness and libido problems. A formulary pharmacist can compound either testosterone or DHEA cream for either transdermal or oral use with a prescription.

SYMPTOMS OF MENOPAUSE

What you’re likely to experience in menopause has a lot to do with your beliefs, your culture, and your expectations. Given the culture of medicine, it’s no surprise that the vast majority of studies through the years have been on women who were experiencing health problems during menopause. The medical system (which is simply a reflection of the larger culture) has only very recently begun to study the menopausal experience of healthy women who exercise regularly, don’t smoke, eat a good diet, and lead a healthy lifestyle. And just as one might suspect, these studies are showing that many healthy women have no problems with bone loss, sex drive, cardiovascular disease, or depression.

The research on traditional cultures in which women’s experiences are quite different is fascinating. For example, medical anthropologist Anne Wright, Ph.D., studied menopausal symptoms in both traditional and accultur ated Navajo women. She found that traditional Navajos exhibited fewer menopausal symptoms than acculturated Navajos, and that economic ranking and social status were clearly related to women’s experience of symptoms. Her study sug gested that menopausal symptoms are caused by psychological stress rather than physical stress.
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A study of !Kung women in southern Africa showed that their so cial status increased after menopause. Moreover, there is no word for “hot flash” in the !Kung language. This points to the possibility that !Kung women either do not experience this symptom or experience it in a manner different from Western women and do not view it in a negative light.
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By contrast, 80 to 90 percent of women in our culture experience hot flashes, and a significant number have vaginal dryness and loss of libido.

HOT FLASHES

Hot flashes, or vasomotor flushes, are characterized by a feeling of heat and sweating, particularly around the head and neck. They affect anywhere from 50 to 85 percent of women at some time during their climacteric years. For most women, hot flashes are simply an occa sional sensation of warmth and slight sweating, but about 10 to 15 percent of women experience hourly waves of heat and drenching sweats that disrupt daily activities and can result in sleep disturbance and sub sequent depression. Hot flashes usually subside in a year or so, but some women have them for anywhere from ten to forty years.
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The actual cause of hot flashes is not known; it is thought to be related to neurotransmitter changes that are poorly understood. Women may experience hot flashes during their adolescence and reproductive years, after having a baby, and premenstrually for reasons other than estrogen deficiency. Hot flashes have also been shown to increase when a woman is anxious or tense. This is because the stress hormones, adrenaline and cortisol, adversely affect the way other hormones are metabolized. Excess stress hormones from worry, depression, sleep deprivation, and nutritional deficiency are often the root cause of hot flashes that go on for years or that do not respond well to standard treatments.

Treatment

Nutritional Treatments

Many, many women notice vast improvements in sleep and hot flashes when they reduce their glycemic stress. (See
chapter 17
, “Eat to Flourish.”) Hot flashes almost always improve when you stop wine, sugar, white flour products, and coffee. (Sorry.) The reason for this is that these substances can raise blood sugar and adrenaline levels, thus resulting in imbalances of neurotransmitters. Take vitamin E (d-alpha-tocopherol), 100 to 400 IU two times per day,
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and citrus bioflavonoids with ascorbic acid, 200 mg four to six times daily.
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Omega-3 fats such as those found in flaxseed and fish oil are also very helpful.

Phytoestrogens

Phytoestrogens (also known as isoflavones) are naturally occurring estrogen-like substances found in more than three hundred plants, including soybeans and flaxseed (two particularly rich sources). Significant amounts of phyto estrogens are also found in cashews, peanuts, oats, corn, wheat, apples, and almonds.
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Phytoestrogens contain isoflavonoids, which are chemically similar to the estrogens found in the hu man body (although not identical). These substances prevent free-radical damage (the number one cause of premature tissue aging) and appear to block the effects of excess estrogen stimulation of the breast and uterus. (The genistein in soy products shows promise for decreasing cancer risk as well.) Phytoestrogens also decrease menopausal symptoms and modulate es trogen levels. It is hypothesized that Japanese women have a lower incidence of hot flashes and other symptoms in part because of their high intake of soy-based products.
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Soy protein, when taken in high enough dosages, has been shown to improve hair, skin, and nails; cool hot flashes; increase vaginal moisture; help with weight loss; and also improve quality of life. A 2009 double-blind, randomized, placebo-controlled study of ninety-three postmenopausal women done at Johns Hopkins University School of Medicine in Baltimore showed that daily consumption of soy protein (in the form of Revival products) reduced hot flashes and night sweats as well as improved the quality of life for the women in the study.
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Many women have personally told me how much this high-dose soy product has helped them. One wrote, “Revival has transformed my life! This last summer, my days were plagued by hot sweats, broken nails, and limp hair, plus I was overweight. Now, after four months of using Revival daily, I am twenty-four pounds lighter, my hair and nails are not brittle, and my sweats are completely gone. I am now in a new relationship. I feel like a new woman, young and vital, and without the symptoms of menopause I look and feel wonderful. I know I do not look fifty-two years old.” (See Resources.)

Botanicals

A wide variety of herbs has been used to alleviate menopausal symptoms since antiquity. One of the most studied is an extract of black cohosh
(Cimicifuga racemosa),
sold under the name Remifemin, and available in pharmacies and natural food stores. It has been shown to improve vaginal lubrication and to reduce depression, headache, and hot flashes. The usual dose is two tablets twice daily.
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A new form of black cohosh known as BNO 1055, contained in the preparations Menopret (formerly Klimadynon) and Menofem, was shown to calm hot flashes in breast cancer survivors as well as conjugated estrogens did, completely eliminating hot flashes in 47 percent of the women in the study.
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Other herbs that have been shown to be helpful are
Vitex agnus-castus,
Siberian ginseng, dong quai, fo-ti, red clover, and wild yam.
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Tinctures and oral combinations of these are widely available in natural food stores. They must be used for four to six weeks before improvement in symptoms is noted. Chinese herbal remedies have also been shown to reduce menopausal symptoms. Several excellent formulations are available, or consult an indi-vidual practitioner. (See Resources.) Note that botanicals and all other natural treatments for hot flashes tend to take longer to work than es trogen. Recent studies show that while all women improved on black cohosh and red clover, both of which were found to be safe, they didn’t improve significantly more than the placebo group.
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Even so, the botanicals didn’t have an adverse affect on cognitive function the way synthetic estrogen did.
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Moreover, many individual women do very well on these herbs.