Clarity and Confidence
There have been several additional news reports about hormones in the past couple of months catching my attention, and probably yours, too. They may raise questions such as: Does this apply to me? Am I doing the right thing? Are there aspects of this that I have not considered?
It is good to stop and look with an open mind at such new reports. But, is also important to do so critically to discover what the report is really telling us and what it isn't. That requires looking closely at the details and taking into account what we already know.
"Health Outcomes After Stopping Conjugated Equine Estrogens Among Postmenopausal Women With Prior Hysterectomy"
One of the news reports was based on this article that was published recently in the Journal of the American Medical Association, (JAMA. 2011:305(13):1305-1314. It studied women with hysterectomies who started taking oral equine estrogen between ages 50 and 79 and continued taking it for an average of 5.9 years. These women were part of the initial Women's Health Initiative study, discontinued in 2002 due to increased risk of breast cancer, blood clots, strokes, heart attacks.
The authors concluded:
"Among postmenopausal women with prior hysterectomy followed up for 10.7 years, CEE (conjugated equine estrogens) use for a median of 5.9 years was not associated with an increased or decreased risk of CHD (coronary heart disease), deep vein thrombosis, stroke, hip fracture, colorectal cancer, or total mortality. A decreased risk of breast cancer persisted."
A few important facts about this study. First, this study, like the original Women's Health Initiative study, was based exclusively on equine estrogen and progestins. Unlike bio-identical estrogen, equine estrogen is not the same molecules as those produced by the human body, and has been shown in many studies not to have the same risk profile as the physiologic use of bio-identical hormones. Also, progestins are synthetic substitutes for progesterone and have very different chemical structures, once again creating different risk outcomes for the body.
Second, the method of administration is important. Whenever estrogens (and testosterone) are taken orally as in this study, they go through what is called the "first pass of the liver." This means that they are absorbed through the digestive system and go through the liver before being released into circulation to the cells to do their job as a hormone. The liver is notorious for making changes to molecules, and we cannot always predict that the outcome will be benign. In the case of oral estrogens, these changes by the liver are the probable cause of increased incidence of blood clots, strokes, and heart attacks as seen in the Women's Health Initiative study.
In contrast, bio-identical hormone therapy administers estrogen and testosterone in a similar way that the ovaries release them into the body, which is directly into the circulation to avoid the digestion and liver processes. By the way, this does not seem to be a problem with progesterone, which appears to go through the liver without molecular changes. Nonetheless, I use other forms of progesterone before resorting to oral progesterone.
A third issue regarding this study is the age of the participants when they started using hormones. Our risks for many diseases increase with age. So, the longer we wait to start preventative or curative measures, the lower the likely success rate. Any woman or man who wants to begin bio-identical hormone therapy must weigh the risks and benefits, and these are best discussed with a knowledgeable provider. What we do see in the literature, however, is that there can be benefits to using bio-identical hormones at almost any age and that these risks do not correlate with the risks seen with equine estrogens and progestins or synthetic testosterone.
I believe that it would be tragic if the public or certain clinicians should conclude from this study that the use of unopposed estrogen (i.e., without being balanced with natural progesterone) is appropriate and would recommended that for post-menopausal women whether they have or have not had a hysterectomy. Every cell in our body has receptors for progesterone, and a failure to provide a balance of the three hormones women need after menopause (estrogen, progesterone, and testosterone) would carry definite health risks. In addition, the risks of some patients are different from those of others based on life style, genetics, and previous health issues - all variables that need to be assessed for each individual patient.
My conclusion is that the results of this study do not meaningfully contribute to our understanding of the risks and benefits from the use of bio-identical hormones. More studies are always needed, but they need to be based upon state-of-the-art bio-identical hormone therapy and to reflect the findings of years of clinical practice.
"Progesterone Gel Reduces Rate of Premature Birth by 45 Percent"
In this article by David Brown in the Washington Post (WashingtonPost.com, Thursday, April 7, 10:20 am) the distinction was made between progestins (the synthetic substitute for progesterone) and human equivalent progesterone - what a breath of fresh air!
The article reports on an NIH study of high-risk women who applied naturally-derived progesterone gel vaginally. NIH found that this reduced the rate of preterm birth by 45 percent in women with a short cervix, one of many risk factors for premature delivery. It also reduced the rate of complications for the babies.
This study is clear on the type of progesterone that was used and shows the beneficial effects of this bio-identical hormone in helping to maintain viable pregnancies in this specific population. Great, clear reporting! And wonderful news for those women who are in this risk category.
The more you understand bio-identical hormone therapy, the easier it becomes to look at research and news reports and find what is and is not helpful. And kudos to my savvy patients who read these articles and evaluated them for what they in fact have to offer!
If you are interested in more research on bio-identical hormones, I highly recommend the new book by Pam Smith, MD, "What You Must Know About Women's Hormones." The last 45 pages of the book provide an extensive reference list of published scientific articles on bio-identical hormones and related research. The book is available on Amazon or most likely also from your local bookstore.
Let's continue to have our eyes and ears open to keep learning what is the best way to optimize bio-identical hormone therapy with the least risk and the most benefits for everyone.
To your health with balanced hormones!
Jane Kennedy
Nurse Practitioner
Gordon Medical Associates
Please send your comments or questions to me at: jane@gordonmedical.com
