The Hormone Replacement Question Florence first came into my office at the age of fifty-one for her annual visit. She was having hot flashes, but they weren't really bothering her. She didn't want to take estrogen. On the other hand, she was concerned because she had read that women need to be on hormone replacement to prevent heart disease, Alzheimer's, and osteoporosis. Florence hadn't had a period in three months, exercised regularly, had a healthy percentage of body fat, and had had a salivary hormone profile several months before that showed that her estrogen was on the low side, but her testosterone levels were high normal. Her progesterone was a little low. She had no family history of heart disease, osteoporosis, or Alzheimer's, and her sex life was fine. Her mother was seventy-five and ramrod straight, played tennis every day in the summer, and skied all winter; her maternal grandmother was sharp as a tack mentally, lived alone, and still did all her own gardening at the age of ninety-two. Neither of these women had ever taken hormones. When a woman such as Florence seeks my advice on hormone replacement, my recommendations are quite simple. She should use the least amount of intervention that will provide symptomatic relief. In this case, I'd recommend taking 400 to 1,200 IU per day of vitamin E, plus some bioflavonoids. And I might have her try a 2% progesterone cream daily on her skin three weeks out of every month. Then I'd see how she was doing in three to six months and make adjustments as needed. Because her testosterone level is naturally high, she will probably do well without estrogen. I would also suggest to her that we revisit the hormone question each year when she comes in for her checkup-or earlier, if she is having any problems. However, most women today aren't given an individualized menopausal evaluation and prescription. Instead, the vast majority are given a standard prescription for Premarin, a collection of over twenty different conjugated equine estrogens made from the urine of pregnant horses. (Premarin is an acronym derived from the phrase "pregnant mares' urine." If you doubt this, just put a drop of water on a tablet of Premarin and smell it.) Women who have not had a hysterectomy are also given a synthetic progestin, usually Provera (medroxyprogesterone), a hormone produced in the laboratory that is quite different from naturally occurring progesterone. The purpose of the synthetic progestin is to prevent the Premarin from causing excessive buildup of tissue inside the uterus, which over time can lead to an increased risk for uterine cancer. Natural progesterone will do the same thing without the PMS-like side effects of Provera. Premarin was introduced in 1949, and for historical and economic reasons it continues to be the standard against which all other menopausal hormone treatments are measured. It is also the estrogen employed in most major studies. Though it has been shown to relieve the menopausal symptoms of many women and has been associated with a decreased risk for heart disease, osteoporosis, and Alzheimer's disease, I no longer recommend it. First of all, many women simply don't feel good on it, which is why so many discontinue taking it. All too often, they develop sore breasts, headache, and bloating. And many don't like getting their periods again, which are sometimes heavy and crampy. What I have learned from salivary tests is that many women on standard doses of Premarin have levels that are far too high. They are, in fact, being overdosed, thus needlessly increasing the risks associated with hormone replacement. But even on a lower dose, a woman still won't be getting what I consider the best treatment. Here's why: Premarin doesn't contain hormones that match those in the human body. As Dr. Joel Hatgrove, a pioneer in the use of natural hormones and medical director of the Menopause Center at Vanderbilt University Medical Center, quips, "Premarin is a natural hormone if your native food is hay." (Occasionally, a woman will feel best on Premarin compared to other choices, for reasons that are still unclear. These women sometimes experience dizziness on other preparations.) In view of the concerns regarding breast cancer associated with estrogen replacement therapy (ERT), the use of synthetic sex compounds with which the human body is not designed to cope would appear to be the equivalent of conducting a vast experiment on the human female population. It is ironic, in this light, that treatment using natural hormones bioidentical to those in a woman's body is designated as "alternative" medicine. The Individualized Hormone Solution For those women who require hormone replacement by virtue of their symptoms or other risk factors, there is very good news. The field of individualized natural hormone support has positively blossomed since the first edition of this book was published. And instead of reducing the entire hormone question simply to estrogen, we now know that replacement of hormones may require the two other classes of hormones that the ovaries also produce: progesterone and androgens. First, a word about that confusing and much-debated word natural. The hormone components of Premarin are indeed natural for horses, but the word is more commonly applied to plant hormones (phytohormones) found in foods such as soybeans and wild yams. The human body utilizes plant hormones better than equine hormones, because we have been ingesting them for millions of years, but they are still not the same as those made in the human body. The natural hormones I will be talking about fall into another category. They are derived from the hormones found in soybeans and yams, but their molecular structure is modified in the laboratory to match those found in the human body exactly. That is why they are also referred to as bioidentical hormones. The natural estrogens, progesterone, and testosterone available from formulary pharmacies for hormone replacement are produced in this way. The amount of hormone is also standardized, so that its effects are measurable and predictable. The issue is not whether or not a hormone is produced in a laboratory; if it matches the hormones found in the human body, then it's a natural hormone. PROFILE OF A HIGH-RISK WOMAN: HRT RECOMMENDED Premature menopause (age 40 or earlier) Artificial menopause before age 45, induced by surgery, chemotherapy, drugs, or radiation) Diagnosed cardiovascular disease Very strong family history of early cardiovascular disease High umbilical-to-hip ratio (apple-shaped figure) Smoker Strong family history of Alzheimer's dementia Sedentary Nutrient-poor refined-foods diet Perception that there is nothing much to live for Source: Northrup, Christiane, M.D. Women's Bodies, Women's Wisdom. Bantam Books, 1994 (p. 536-39).