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"I have more energy now that I am sleeping through the night again. I am now exercising again and losing weight."
"AWESOME!: Dr. Bruice was able to pinpoint my HRT needs and also identified that I was hypothyroid (something other physicians had missed in my case). His diagnoses and treatment have been perfect and my menopausal symptoms have nearly vanished. I am so pleased and relieved. I would highly recommend Dr. Bruice and bioidentical hormone therapy."
"GREAT AT BIOIDENTICAL HRT: Dr. Bruice's Rx for bioidentical HRT has been the best thing I've done in years. Love his approach of testing my blood levels and adjusting dosage to get the levels at which women feel the best."
"Just what I needed."
"He has given me "my life" back. I have more energy and even my co-workers have noticed that I am "much happier" and less "cheerful with an edge". I am definitely in my "happy place". Would and have recommended him to every female I care about."
"BEST HORMONAL REPLACEMENT DOCTOR IN DENVER/ASPEN: Dr. Bruice is a caring and competent doctor. He will listen to all your problems and concerns and address them accordingly. He will work with your hormonal levels until he gets them just right to make you feel your best. His follow up emails are done in a timely manner. I think that he is the best hormonal doctor in the Denver Metro area."
"I am getting compliments on how much younger I look."
"I have gone to Dr. Bruice for more than 5 years. He is always very professional and asks lots of questions and listens to your answers. I appreciate the fact that he is working with bioidentical hormones when it is so hard to find someone who offers this service. His follow up is prompt and his services have helped me tremendously."
"I can remember names again and my short-term memory is back. I no longer feel that I have brain fog."
"Dr. Bruice is very professional. I had good friends recommend him. I felt like I had the flu for a year and a half. Within a week I was feeling much better. I was having 5 to 8 hot flashes per hour. It was so exhausting. I was waking up 4 to 5 times a night. What a good educated Doctor. Thanks Doc."
"Thank you for your help. Since I have been seeing you and started this cream I feel better than I did in my 20's and 30's. I never enjoyed sex before – that’s changed. My husband says thank you too."
"I am GREAT on the bio-identical hormones! I have more energy now that I’m sleeping though the night again. Many thanks!"
"I went to 5 different doctors for my migraine headaches and after one month on my hormones my migraines were completely gone."
"I am less irritable, nicer, and sleeping very well."
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"I am doing wonderfully with my hormones! The little things are no longer bothering me and my family likes me again. Again, thank you, thank you for all you have done for me."
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"Please express our appreciation to Dr. Bruice for his consideration, patience and kind nature. He has always proven to be one of great integrity all along the way."
"I am feeling much better and I do attribute that to the Rx's I've been taking. Thank you so very much for helping me."
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"I started the prescription and I am feeling so much better. Thank you for your prompt response to my needs."
"I have used the cream and sublingual pill for 1 1/2 days and feel like Wonder Woman. I guess this is a positive result."
"I have been seeing Dr. Bruice for quite awhile and have been very happy with the results. He is very knowledgeable and sees a vast array of patients. I feel that I benefit from his exposure to many different women and their individual needs."
"Very knowledgeable. The treatment given has helped a lot, I have a lot more energy and not as many mood changes. I am very pleased with the results."
More than half of Dr. Bruice’s new patients are referrals:
"I've recommended Dr. Bruice to many of my friends and family. He listened with genuine concern, asked questions, promptly corresponded with me and my appointments always start at the scheduled time. I feel great and it's because of him."
"I have a friend that has been using your cream and taking the pills you prescribed for about two months. She says she's never felt better and encouraged me to contact you."
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The menstrual cycle is, on average, 28 days and basically
involves fluctuating estrogen and progesterone levels. Day one of
the cycle is the first day of menstruation when estrogen and
progesterone are at their lowest levels. I have never understood
why doctors check hormone levels on day 1-5 because they are
supposed to be low at this time. The first half of the cycle is
known as the follicular phase, and it is the estrogen dominant part
of the cycle. Estrogen peaks at approximately day 11-12 and this
sharp increase in estrogen is what triggers the leutenizing hormone
(LH) surge from the pituitary gland within the brain. Estrogen is
responsible for building up the endometrial tissue in the uterus,
so it is impossible to menstruate without estrogen production.
Estrogen also causes one of the follicles in the ovary to become
dominant and ready for ovulation. The rise in LH at approximately
day 13 is what triggers ovulation. After ovulation, on
approximately day 14, the corpus luteum starts producing
progesterone. The corpus luteum is the remainder of the egg left
behind in the ovary.
The second half of the cycle is thus called the luteal phase and
it the progesterone dominant phase of the menstrual cycle.
Progesterone levels peak approximately 6-8 days prior to the next
menses and this peak occurs around day 21-22, when estrogen has
their second peak in the cycle. Progesterone is responsible for
stabilizing the thickened endometrial lining in the uterus. The
purpose of the menstrual cycle is to ovulate and prepare the uterus
for a pregnancy after conception takes place. If conception occurs,
the corpus luteum continues to produce progesterone until 6 weeks
after conception. The placenta then takes over the production of
progesterone. If conception does not occur, the corpus luteum
regresses, causing the progesterone level to fall. When the
progesterone level gets back to its initial baseline, menstruation
sets in and a new cycle is started. The only purpose of
menstruation is to generate a healthy endometrial lining for
implantation of an embryo.
A woman's life can be broken down into four phases; premenarche,
reproductive, perimenopause, and menopause. The average occurance
of menarche, a woman's first menstruation, is at 12.8 years of age.
For the first year or two, the menstrual cycles are usually an
ovulatory. Young women are producing estrogen, but not enough to
produce the aggressive peak on day 11-12. As a result, the LH surge
does not occur, resulting in an ovulation. If there is no
ovulation, a corpus luteum is not produced, and thus progesterone
is not made. These are estrogen dominant cycles, because even
though estrogen levels are too low to ovulate, there is no
progesterone to counterbalance the estrogen. An ovulatory cycles
can result in amenorrhea or irregular menstrual cycles.
Progesterone deficiency in young girls can result in mood changes
that we see in perimenopausal women.
The cause of perimenopause is progressive follicular depletion.
The age at which follicular depletion accelerates is estimated to
be 37. Perimenopausal cycles behave exactly like the an ovulatory
cycle described above. Just like in young women, they can have
cycles of ovulation with episodes of an ovulation. The ironic thing
is that a lot of perimenopausal women have 12-14 year old daughters
who are experiencing the same cycle patterns. Perimenopause usually
starts in the mid forties and lasts until menopause. Perimenopause
is characterized by a decrease in the number of functional ovarian
follicles and significant fluctuations in hormone levels. These
fluctuations can be very dramatic from one cycle to the next and
from day to day.
The decline in estrogen results in limited egg production,
resulting in an ovulation and diminished progesterone production.
An ovulation can result in irregular menses. Irregular menstrual
cycles can consist of more frequent menses, longer or shorter
menses, and heavier or lighter menstruation. It is common to have
two or more menstruations per month, followed by skipping
menstruations. Most gynecologists prescribe birth control pills,
which will make the cycles regular again, but they will not
alleviate the other symptoms of perimenopause, and often will make
these symptoms worse. I believe in replacing the exact bioidentical
hormones that are lacking.
Not only can women have irregular menstrual cycles, they can
have other symptoms from lack of progesterone. The most common
symptoms of perimenopause are mood disorders like depression and
anxiety. These symptoms closely resemble symptoms of PMS, and the
diagnosis of perimenopause is often made after women start to
experience symptoms of PMS, which they may never have had before.
This is a period of estrogen dominance, so the first line of
treatment is to replace the missing progesterone. Not only can this
regulate the menstrual cycle, but many of the mood changes like
depression, irritability, anxiety and nervousness are alleviated as
well. It is important to take only natural progesterone and not
synthetic progestins, like Provera. Provera will regulate the
menstrual cycle like birth control pills, but it will not help with
the symptoms of PMS.
Estrogen levels are very unpredictable during perimenopause.
They fluctuate dramatically throughout the day and they lack the
predictable levels seen in a reproductive woman. To make matters
worse, each cycle is vastly different from the previous cycles.
Women may have no signs of estrogen deficiency one day and then be
symptomatic the next day. Though perimenopause is a period of
estrogen dominance, most women are also estrogen deficient.
Perimenopausal women are still making estrogen, but not nearly what
they were making in years past. The most common symptoms of
estrogen deficiency are hot flashes, sleeping difficulties, and
vaginal dryness. If these symptoms are present, estrogen
supplementation is warranted.
Estradiol and progesterone should be checked via blood levels. The
optimal time is 6-8 days prior to the next menses when progesterone
is peaking and estradiol is at its second peak. It is important
that your physician is able to interpret these levels because the
laboratory will often give too wide a range of normal findings. I
have found that symptoms will not improve until the progesterone is
at least 10ng/ml. If the labs are normal and the patient is having
symptoms, I will still treat them because it is ludicrous to treat
lab values and not symptoms. A woman in perimenopause can still get
pregnant, though it is more difficult than when she is in her
twenties and thirties. The mean age of sterility is estimated to be
The average age of menopause is 51. Approximately
42 million women in the U.S. are menopausal. Because ours is an
aging population, each year a higher percentage of the population
is menopausal. Approximately 4900 U.S. women enter menopause each
day. The age of menopause is not influenced by socioeconomic
factors and has been relatively constant. The average life
expectancy for a woman in 1900 was 48 years, now it is 79
While life expectancy has increased, the age at menopause has
remained constant. The increasing life span means that the average
woman is menopausal for greater than one third of her life. The
medical definition of menopause is for a woman to be menstruation
free for twelve straight months. Menopausal symptoms often start
prior to this because of fluctuating levels of estrogen. A better
definition of menopause would be to have persistent symptoms of
The most common symptoms of estrogen deficiency are hot flashes,
vaginal dryness, and sleeping difficulties. Menopause occurs when
there are fewer than 1000 follicles left in the ovaries. Follicle
stimulating hormone (FSH) and estradiol levels are not reliable
predictors of menopause, but persistently elevated FSH and low
estradiol is suggestive of menopause. The hypothalamus sends
gonadotropin releasing hormone (GnRH) to the pituitary gland, which
then releases FSH to act on the ovary. In menopause the ovary
becomes less capable of producing estrogen but the hypothalamus and
pituitary gland are not aware of this. So they continue to make
GnRH and FSH respectively, trying to tell the ovary that the body
is lacking estrogen. This is why FSH is elevated in menopause. In
early menopause, moderate estrogen production can still occur,
keeping the FSH level low. If a practitioner is relying on only the
FSH level, and not symptoms to diagnose menopause, the diagnosis
will be missed.
The hypothalamus is the temperature-regulating organ. Because it is
working in overdrive, releasing GnRH, hot flashes occur. In early
menopause, estrogen fluctuations are still occurring, leading to
more menopausal symptoms. Later in menopause, the symptoms can
disappear, and women consider themselves to be post-menopausal.
There is no such thing as being post-menopausal; one is menopausal
for life. Smokers reach menopause on average two years earlier than
nonsmokers. Symptoms of menopause are hot flashes, night sweats,
sleeping problems, vaginal dryness, mood swings, and memory loss.
Hormone replacement therapy (HRT) can alleviate these symptoms, and
Hormone Replacement Therapy is most likely the safest form of treatment. Only
10% of women have abrupt cessation of menstruation with no
menopause related symptoms. There is a 30% drop in estrogen by age
50, with a sharp decline after menopause. There is 75% loss of
progesterone between 35-50, and progesterone is almost nonexistent
after menopause. Today, fewer than 30% of menopausal women are on
Prevention of disease is the goal for everyone.
Women account for two-thirds of all health care expenses. Women
need an annual exam yearly. This exam includes a breast exam, PAP
smear, and a bimanual exam to evaluate the size of the uterus and
ovaries. Blood pressure and weight should be measured yearly. The
thyroid should be palpated for nodules and the heart auscultated
for irregular beats and murmurs. A complete examination of the skin
should be performed looking for abnormal skin growths. A rectal
exam checking for fecal occult blood should be performed yearly
starting at age 40. A colonoscopy is the gold standard for
screening for colon cancer and should be done every 5-10 years
starting at age 50. A mammogram should be done yearly starting at
age 40. A blood test should be performed every five years
evaluating cholesterol, thyroid function, fasting glucose, kidney
and liver function, and complete blood count (CBC). A
tetnus-diphtheria shot should be given every 10 years and an
influenza vaccine should be given yearly after age 55. The American
College of Obstetrics and Gynecology recommends not screening for
ovarian cancer because nothing has been proven to be cost
effective. A pelvic ultrasound is the best screening test. A Ca125
blood test is commonly used but it can have a lot of false positive
and false negative results. Lately full-body scans are the rage.
There are two huge problems with this procedure. This procedure
often detects abnormalities that are benign normal findings such as
scar tissue. Additionally the radiation exposure is 100 times that
of a mammogram.
Lack of sleep can affect your health, just like lack of exercise
and unhealthy eating. The body rejuvenates, repairs cells, and
produces natural killer cells in deep stages of sleep. The body
produces antibodies during sleep, which enable us to fight off
infections. Lack of sleep makes one prone to obesity, hypertension,
heart attacks, and diabetes. Sleep derivation affects metabolism
and hormone balance. As a result, the body ages more rapidly when
it does not get the proper amount of sleep. Studies have shown that
people over 60, who do not sleep well, have twice the risk of dying
early when compared with those over 60 who sleep well.
Unfortunately as we age, we tend to sleep less. It is not that less
sleep is needed later in life, but sleep patterns are interrupted
by anxiety, pain, heartburn, and needing to empty the bladder.
Proper sleep not only improves alertness and concentration, but
memory improves as well. Memory recall is significantly better
after a good nights sleep.
Insomnia is much more common in women than in men. Approximately
20% of the population suffers from chronic insomnia. It is also
much more common when hormone levels are changing in perimenopause
and menopause. Insomnia is not only a frustrating condition, but
results in irritability, fatigue, mental confusion, and headaches.
Insomnia can either be transient or chronic. Transient insomnia
lasts less than two weeks in duration, and can result from jet lag,
acute life stresses, or grief. Insomnia can lead to depression. 90%
of people who suffer from insomnia for at least six weeks are
depressed. Chronic insomnia can usually be broken down into a
psychological or biological diagnosis leading to sleeping problems.
There are greater than sixty diagnoses that result in sleeping
disorders. Common psychological causes of insomnia are depression,
anxiety, and drug or medication abuse. The most common biological
cause of sleeping disorders is sleep apnea. Sleep apnea accounts
for 30% of all insomnia and effects 2-5% of fifty year old women.
Sleep apnea usually affects people with larger neck sizes; during
sleep they self obstruct their airway, resulting in hypoxia,
causing them to awaken. People with apnea can wake up multiple
times throughout the night, interrupting sleep. Other biological or
medical causes for sleeping disorders consist of cardiovascular,
pulmonary, neurologic, endocrine, or gastrointestinal conditions.
Primary insomnia is often genetically linked; these people have a
history of never sleeping well. Menopausal insomnia is one of the
leading causes of sleeping problems in women. It can usually be
cured by estrogen and progesterone supplementation.
There are multiple ways to eliminate insomnia. Appropriate diet
and exercise is the first line of treatment. Eliminating caffeine
from the diet is extremely important. Caffeine has a half-life of
six hours, so the stimulant is in the body for hours after intake.
It is also important to limit nicotine and alcohol in the evening.
Many people end up abusing alcohol, using it as a sleep aid.
Alcohol will help initiate sleep, but it causes poor sleep by
suppressing rapid eye movement (REM) sleep. Research has shown that
lack of REM sleep is equivalent to no sleep at all. For obvious
reasons it is important to avoid sugar in the evening. The most
important cure is to eradicate the underlying diagnosis causing
insomnia. Most sleeping disorders are secondary to stress and
anxiety. Cognitive behavior therapy (CBT) aims at eliminating
anxiety and is usually more effective than traditional medicines.
Maintaining a regular sleep schedule is an important component of
Valerian is an herb that has been used for insomnia for two
thousand years. Studies have shown that it is more effective for
long-term improvement in sleep instead of initiating sleep acutely.
Kava is another herb used for insomnia, but it is not as effective
as valerian, and there have been questions concerning it causing
liver damage. The pineal gland naturally produces melatonin,
controlling the sleep-wake cycle. The production of melatonin is
stopped in response to sunlight, causing us to waken in the
morning. Melatonin naturally peaks at three o'clock in the morning,
and darkness is responsible for this peak. The invention of
electricity has affected our melatonin production. We now rely on
artificial light after the sun goes down, affecting our circadian
rhythm. Supplemental melatonin is used for insomnia, but most
studies have only evaluated its usefulness for eliminating jet lag.
To learn more about melatonin, see the chapter on other
supplements. Antihistamines, such as Benadryl, have been used with
success but tolerance easily builds and hangovers from the medicine
are common. Halcion, the antipsychotic, has been used for years but
it is no longer recommended because studies have shown it causes
holes in ones memory the following day. Antidepressants are also
commonly used and can be helpful, mainly because depression is a
common cause of insomnia. Trazadone, an antidepressant, is commonly
used for insomnia but it can cause residual sedation secondary to a
long half-life of the drug. Anxiolytics, such as Xanax and Valium
are widely used, but they are terribly physically addictive
medicines. Ambien is the most common prescription medicine used for
insomnia because it is so effective. It is not addictive like the
anxiolytics, and it usually does not cause a hang over because of
its short half-life. The problem with Ambien is that rebound
insomnia can result from long-term use. What this means is that it
becomes very difficult to naturally sleep after withdrawing from
Ambien. Studies are currently underway evaluating the safety of
taking sleeping pills every night. Any remedy used for insomnia can
have a psychological addictive effect.
Approximately 60% of Americans are overweight. If body weight is
10% over ideal weight, one is overweight; if body weight is 20%
over ideal weight, one is obese. Diseases that are associated with
obesity are cancer, heart disease, hypercholesteremia, high blood
pressure, diabetes, and kidney failure. Public health costs from
treating obesity related illness is more than 100 billion dollars a
year. There are more than 400,000 deaths a year secondary to
obesity. There are many over the counter and prescription remedies
available, but few actually work and many are dangerous. The best
medicine is proper nutrition and exercise. Weight gain is the
result of caloric intake being greater than caloric burning.
Instead of temporary diets, it is better to make permanent changes
to eating habits. See the chapter on nutrition. Unfortunately,
metabolism is greatly controlled by our genes and aging, two things
we cannot change. If medication is needed to help with weight loss,
I prefer natural remedies.
There are many natural remedies that have been shown to be
helpful with weight loss. Adequate intake of water is the most
important thing other than a proper diet and exercise for losing
weight. Green tea has been shown to increase fat oxidation and
energy expenditure. It decreases lipolysis of triglycerides,
resulting in reduced fat absorption. The active ingredients in
green tea that help with weight loss are epigallocatechin-3-gallate
and caffeine. Green tea also has antioxidants, protecting the body
from cancer. Chromium is important in helping regulate blood
glucose levels. Chromium is part of glucose tolerance factor (GTF)
and is necessary to produce insulin. Studies have shown that taking
chromium increases weight loss, especially fat weight. Most
Americans are deficient in chromium. Chromium lowers triglycerides
and probably lowers cholesterol levels. 5-hydroxytryptophan (5-HTP)
is another natural remedy that aids in weight loss. 5-HTP increases
serotonin levels. Adequate serotonin levels have been shown to
decrease appetite, whereas low serotonin levels can cause
carbohydrate cravings and binge eating. Tryptophan is either
converted to serotonin or 5-HTP, so consuming 5-HTP causes
tryptophan to be converted to serotonin. Calcium has also shown to
be helpful in weight loss. Calcium decreases fat production and
increases the metabolism of fat.
Proper will power is also very important. It is natural for us
to crave foods high in fat and sugar. These are comforting foods,
which is why we often eat them during times of stress. They cause
us to relax by calming the brain. These foods cause the release of
dopamine which temporarily counteracts the stress hormone,
cortisol. It is imperative to fight these cravings because over
time the desire for these foods diminishes. Unfortunately these
foods often taste better when they have been avoided, so if one
falls off the wagon, it becomes that much harder to get back
Prescription and over-the-counter medicines for weight loss are
either classified as central-acting appetite suppressants, bulk
forming drugs, or fat absorption blocking drugs. The
over-the-counter central-acting appetite suppressants either have
ephedra, ma huang, and/or caffeine. These drugs are stimulants and
can have adverse effects on the cardiovascular system. Ephedra
contains ephedrine and pseudoephedrine. Their stimulant effect on
the central nervous system can result in decreased appetite.
Recently the Food and Drug Administration (FDA) banned ephedra
secondary to complications from the drug leading to more than 150
deaths. Ephedra caused sudden death secondary to heart attacks and
The most popular prescription stimulants are dexafenfluramine
(Redux), fenfluramine (Pondimin), phentermine, and sibutramine
(Meridia). Redux and Pondimin were banned by the FDA in 1997.
Fen-phen, a combination of fenfluramine and phentermine, was found
to cause damage to heart valves. Phentermine was not implicated in
the damage to the heart so it is still available. Phentermine acts
like amphetamine so it is no different than speed. The danger with
phentermine and Meridia is they both can raise blood pressure.
Meridia inhibits the reuptake of the neurotransmitters, serotonin
and norepinepherine. Redux and Pondimin also worked by increasing
the same neurotransmitters. Meridia works in a similar fashion as
the SSRIs; see the chapter on depression. The risk of these drugs
outweighs the possible benefit.
The most commonly used bulk forming drug is methylcellulose. The
purpose of the drug is to give a feeling of satiety, so less food
is consumed. Side effects can be abdominal distension and
flatulence. Xenical is a prescription medicine that blocks an
enzyme involved in fat absorption. As a result fat is not digested
and fat is excreted in the stool resulting in symptoms of gas and
steatorrhea (fat diarrhea). Olestra, a fat substitute, is a fat
that cannot be digested and is now found in fat free chips, can
give the same symptoms. Diuretics are often abused and they can
result in electrolyte imbalances. Laxatives are also commonly used
and if abused severe swelling and constipation can result when the
medication is stopped.
Recently scientists have discovered a protein, YY3-36, which is
produced in the stomach. This particular protein is what gives us a
sense of fullness after we eat. It has been shown that obese people
make less of this protein than thin people. When people are
injected with YY3-36, they have been found to eat 67% fewer
calories. As of this publication, YY3-36 suppressants are currently
in the research phase and are unavailable to the general public.
Leptin is a hormone that partially controls hunger and metabolism.
Leptin levels increase as people gain weight causing a decrease in
appetite. Leptin levels fall when people start to burn fat, which
is why it difficult to keep the weight off after dieting.
Researchers are currently evaluating the efficacy of injecting
people with leptin after losing weight. Researchers are also
studying drugs that destroy blood vessels that supply fat cells,
causing the cells to die. These drugs are still in the experimental
Procedures such as bariatric surgery (stomach stapling) and
liposuction should be reserved when diet, exercise, and supplements
have failed. Liposuction is for cosmetic reasons not for health
benefits. Liposuction removes only the superficial fat, not the
internal fat that promotes heart disease. Bariatric surgery shrinks
the size of the stomach from two quarts to one ounce. Secondary to
weight loss there was also a drastic reduction in cholesterol
levels, hypertension, and diabetes. Bariatric surgery should never
be done for cosmetic reasons because of the high risk of
complications associated with the procedure. More than 10% of
people have a serious complication such as internal bleeding or
blood clots. Malnutrition secondary to rapid weight loss can cause
peripheral nerve damage so these patients need to be monitored
closely. Over 100,000 people undergo the procedure yearly.
Heart disease is the number one cause of death in
women. More women die secondary to heart disease than all forms of
cancer combined. One out of every three women will develop heart
disease and half of a million women will die from it annually. In
comparison, forty thousand women die of breast cancer yearly. Fifty
percent of women die during their first heart attack, whereas only
thirty percent of men die. Women are also more likely to have
another heart attack within a year. Heart disease is much more
common in men in their fifties, but women catch up to men by their
sixties. One theory is that a woman’s natural hormones protect her
from heart disease, which she no longer produces after fifty.
Numerous observational studies have shown that both estrogens and
progesterone are protective to the cardiovascular system. After a
women reaches menopause she no longer produces these hormones. She
is often given synthetic hormones, which are possibly harmful to
the heart. See the chapter on hormones and research on hormone
replacement therapy. Women can continue to have protection from
heart disease if they take
bio-identical hormones. Bio-identical
hormones are identical to the protective hormones a woman produced
Women’s bodies are much different from men’s bodies
and heart disease behaves differently between the sexes. Women have
smaller hearts and smaller blood vessels. Men usually develop heart
attacks when an atherosclerotic plaque in the coronary aterery
dislodges and blocks the blood vessel downstream. Heart attacks
also result from enlargement of the plaque to the point where it
occludes the entire vessel. Oxygen can no longer reach this part of
the heart causing pain (angina), irregular heartbeats (arrhythmia),
or heart failure. Artherosclerosis is when fatty deposits,
cholesterol, and calcium collect on the lining of artery walls,
forming a plaque. The most common form of heart attacks in women is
secondary to artherosclerosis as well. But women are more prone to
developing artherosclerosis in a more diffuse manner. Instead of
the plaque gathering in one part of the vessel, artherosclerosis is
spread more evenly throughout the vessel. Additionally women who
suffer from heart attacks often do not have artherosclerosis. It is
felt that women may instead suffer from vasospasm of the major
heart vessels. When an artery has spasms, especially in a smaller
female blood vessel, it cuts off the ability of blood to pass
through the artery. Studies have shown that women with smaller
coronary arteries suffer more from heart disease than women with
larger blood vessels. The size of arteries in men did not show the
same findings. Secondary to different etiologies of heart attacks
between men and women, there symptoms are often much different. Men
will often have the classic symptoms of a heart attack; pain in the
chest radiating to the left arm or jaw associated with shortness of
breath. Women, on the other hand, often have atypical symptoms such
as nausea, indigestion, fatigue, dizziness, or pain in the upper
back. Heart attacks are often misdiagnosed in women because of
this. Misdiagnosis could also be attributed to the thought of heart
disease as a disease that primarily affects men. 45% of physicians
surveyed did not realize that heart disease is the leading cause of
mortality in women over 50. Mortality secondary to heart disease is
falling in men but continues to rise in women. Now more women die
secondary to heart disease each year than men.
The most basic test to evaluate heart disease is
the electrocardiogram (EKG). It measures electrical activity within
the heart. Breast tissue can distort the findings, making the test
less accurate in women. An EKG is also used during a stress test,
where the heart is evaluated during exercise. A more accurate test
is the echocardiogram. An echocardiogram assesses blood flow
through the chambers of the heart under ultrasound guidance.
Angiogram is the best test to diagnose heart disease. It is an
invasive test that involves threading a catheter from the femoral
vein in the leg to the heart. Dye is then injected into the
coronary vessels looking for blockages. Complications, such as
strokes, can be caused by this procedure. Women with heart disease
often have normal angiograms because their disease presents
differently from men, as described above. This is also why women
have not benefited as much as men from angioplasty. Angioplasty is
a procedure treating artherosclerosis by dilating the affected
artery with a balloon catheter and then a synthetic stent is placed
in this area. The stent enables blood to pass unobstructed through
the affected artery. A newer noninvasive test for heart disease is
electron beam computed tomography (EBCT). Artherosclerotic plaques
contain calcium, and an EBCT evaluates how much calcium has
accumulated in the coronary vessels. Unfortunatey if the calcium
count is high, an angiogram is often needed to see which blood
vessels are affected and how severely they are affected.
Like all diseases, prevention is the best modality.
Risks for heart disease are smoking, obesity, high cholesterol,
high blood pressure (hypertension), inactivity, stress, and a
family history. Laboratory values can also determine who is at more
risk for heart disease. Elevated total cholesterol, LDL
cholesterol, triglycerides, homocysteine, fibrinogen, C-reactive
protein (CRP), and lipoprotein (a) levels are associated with heart
disease. Smoking increases heart disease by three-fold over the
general population. Smoking not only increases artherosclerosis but
causes the plaques within the arteries to become unstable. Smoking
also increases fibrinogen, a blood clotting protein produced by the
liver. An excess of fibrinogen can cause hardening of the arterial
walls, leading to loss of elasticity. Being overweight, especially
at the waist, increases the risk for heart disease substantially.
Women usually do not start to gain weight in their abdomen until
after menopause. Prior to menopause, women are more prone to
storing excess weight below the waist. Obesity also increases the
chance of developing diabetes, which is another risk factor for
heart disease. Fifty percent of women over the age of 45 have
hypertension. Hypertension makes it harder for the heart to pump
blood into the increased pressure within the arteries. Keeping
total cholesterol, LDL cholesterol, and triglycerides low and HDL
cholesterol high is very important. Low HDL cholesterol is more of
an indicator for developing heart disease in women than in men.
Homocysteine is an amino acid that rapidly rises after a woman
reaches menopause. Elevation of homocysteine is correlated with
arterial wall damage. Folate, vitamin B6, and vitamin B12 can
reduce homocysteine levels. Inflammation has recently been shown to
increase heart disease. CRP is an indicator of inflammation and
people with higher CRP levels have been found to have more
artherosclerosis. Research has shown that women with the highest
levels of CRP were four times as likely to develop cardiovascular
disease. Lipoprotein (a) is composed of apolipoprotein A and an
LDL-C-like particle. Elevation of lipoprotein (a) is an indicator
for possible artherosclerosis and coronary heart disease. Estrogen
has been found to lower lipoprotein (a). See the chapter on
estrogen to find out how estrogen is protective to the heart.
Stress plays a role in heart disease and women have more stress
related angina than men. Additionally depression increases the risk
for heart disease and women have a higher incidence of depression.
Unfortunately we cannot control our genes, but we can be aware of
our risks and seek treatment for abnormal lab values and
hypertension and maintain a healthy lifestyle.
Aspirin prevents platelets from clumping together
to form blood clots. If symptoms of a heart attack occur, taking an
aspirin immediately can save your life. Aspirin thins the blood
enabling it to pass easier through the clogged blood vessel.
Aspirin also reduces inflammation. C-reactive protein and
interleukin-6 are substances associated with inflammation and are
markers for cardiovascular disease. In January 2002 the U.S.
Preventative Task Force concluded that aspirin could reduce the
risk of heart attacks and strokes. Researchers showed that aspirin
could prevent heart attacks by 28% when compared with a placebo.
The side effects from aspirin are bleeding problems that usually
occur in the gastrointestinal system. If there is no history of
bleeding problems, all menopausal women should take a baby aspirin
Cholesterol is essential to the body. The sex hormones are
originally derived from cholesterol. The body naturally produces
all the cholesterol it needs, so it is not required in the diet.
Though cholesterol levels can rise secondary to our diets,
cholesterol levels are mainly determined by heredity. Plants do not
produce cholesterol, so no fruits or vegetables can increase our
cholesterol intake. Animals, fish, and birds produce cholesterol so
it is found in meats, egg yolks, and milk products. Saturated fats
increase cholesterol levels. Low-density lipoprotein (LDL)
cholesterol is commonly referred to as the “bad” cholesterol. LDL
cholesterol is responsible for transporting cholesterol within the
bloodstream. It then deposits the cholesterol on the lining of
vessels forming cholesterol plaques. High-density lipoprotein (HDL)
cholesterol is commonly referred to as the “good” cholesterol
because it rids the body of cholesterol by transporting it to the
liver. A high LDL/HDL ratio is more of an indicator for heart
disease than high total cholesterol. The American Heart Association
recommends keeping LDL cholesterol below 130, but newer evidence is
showing that LDL should be kept even lower than this. The higher
the HDL, the more protection you have. Cholesterol levels have been
found to fluctuate and levels are often higher in the winter
compared to the summer.
The first line of treatment for high cholesterol is
lifestyle changes. It has been proven that cholesterol can be
lowered with proper diet and exercise. Unfortunately some people
only can lower their cholesterol slightly with lifestyle
modifications and some people refuse to change. In 1987 the
“statin” drugs were introduced, and they are now the leading class
of prescription drug used in the U.S. They work by slowing the
production of cholesterol in the liver and thus can substantially
lower total cholesterol levels. They also work by removing LDL
cholesterol from the blood, resulting in lower LDL cholesterol.
They have also been shown to reduce C-reactive protein (CRP), which
causes inflammation in blood vessels and other organs. In addition
they increase HDL cholesterol and lower triglyceride levels. This
class of drugs significanty reduces artherosclerosis, resulting in
less coronary artery disease and less peripheral vascular disease.
As a result they have decreased the risk of heart attacks and
strokes by approximately 25%. Limited research has also shown that
the “statins” may reduce the risk of Alzheimer’s disease,
osteoporosis, rheumatoid arthritis, glaucoma, macular degeneration,
and multiple sclerosis. The decrease in these diseases is probably
secondary to the anti-inflammatory aspect of the “statins”. Some
“statins” are more effective than others because have the ability
to reduce inflammation more. The “statin” drugs have been shown to
be very safe as well as effective, but they are expensive. Liver
enzymes should be checked periodically since the drug works within
the liver and1% of people will get liver problems. Other side
effects are muscle pain and body aches. ApoA-1 Milano is a rare
type of HDL cholesterol originally discovered in people living in
Milan, Italy. ApoA-1 Milano has been found to significantly reduce
the size of arthersclerotic plaques in a very short time period. A
synthetic version of this HDL has been developed and has shown
promising results when injected into patients. A new drug,
Torcetrapid, has been found to increase HDL levels by nearly
Numerous natural remedies are used to treat
hypercholesteremia. A recent study has shown that a diet rich in
plant sterols, oats, barley, almonds, and soy proteins was just as
effective as “statin” drugs at lowering cholesterol. Niacin
(vitamin B3) has been used with success to lower cholesterol. It
has been shown to lower LDL cholesterol by 20%, raise HDL
cholesterol by 20%, and lower triglycerides. The main side effect
from niacin is flushing. In multiple studies, garlic has been shown
to reduce total cholesterol by 10%.
Breast cancer is the most common cancer among women,
representing 32% of the cancers in women. One in eight women in
their lifetime will develop breast cancer. In the U.S. there are
180,000 new cases of breast cancer annually. Fortunately the
five-year survival rate is 86%. But unfortunately breast cancer is
becoming more common. One in fourteen women developed breast cancer
in 1960. Between 1950 and 1987 the incidence of breast cancer rose
approximately 1% per year. It might be secondary to a longer
lifespan or it may be secondary to using synthetic hormones. See
chapter on estrogen. Increasing age is the greatest risk factor for
breast cancer. Other risks include smoking, obesity, alcohol, a
strong family history, not giving birth or giving birth late in
life, and lack of breastfeeding. 80% of women with breast cancer
have none of these risks. Most benign growths, such fibroadenomas,
do not increase the risk of breast cancer.
Breast tissue cells are very responsive to estrogen and
progesterone. Estrogen causes breast cells to proliferate, whereas
progesterone counterbalances the aggressive effects of estrogen.
Many breast cancers have estrogen receptors. It is believed that
these cancerous cells will grow more rapidly if estrogen is in the
body. A recent study showed that women on
bioidentical hormonesafter breast cancer diagnosis had a 50% lower recurrence rate.
Indole-3-carbinol (I3C), derived from broccoli, inhibits the growth
and proliferation of breast cancer cells. Aspirin has been shown to
decrease the risk of breast cancer by 30% because of its
The biggest fear that women have when taking estrogen is the
possibility of developing breast cancer. Among women surveyed, 40%
felt that the leading cause of death in women is breast cancer,
when in reality it is 4%. Whether or not estrogen causes breast
cancer is still not known. Prior to the WHI study there were more
than fifty case control and cohort studies with mixed findings,
thus the findings have been inconclusive. If there is an increased
risk, the risk must be small. See the chapter on research on
hormone replacement therapy. The largest cohort study
retrospectively looked at 46,355 women who were evaluated for 15
years in the Breast Cancer Demonstration Project. There were 2082
incidents of breast cancer. Women taking estrogen alone had a 1.2
fold increase in breast cancer, whereas women taking estrogen and a
progestin had a 1.4fold increase in breast cancer. These risks are
shown to decrease after stopping HRT, and are almost nonexistent
five years after stopping. These studies only looked at synthetic
hormones, so the hormones a woman naturally produces have not been
properly evaluated. Synthetic estrogens have been shown to increase
density and mitotic activity in breast tissue. Synthetic estrogens
are not only foreign to the body, but many are more aggressive than
bioidentical estrogens. The use of synthetic estrogens, including
birth control pills, could account for the recent increase in
Progesterone is cancer protective. Progesterone reduces the
mitotic change in endometrial and breast tissue. It reduces cell
proliferation and it enhances natural killer cells, interleukin-2,
and the p53 molecule. Natural killer cells and interleukin-2 are
important components of the immune system. Molecule p53 coordinates
the actions of more than 60 genes that prevent damaged cells from
turning cancerous. Progesterone increases apoptosis (cell
destruction) before damaged cells convert to malignancies. Several
studies have shown that the higher a woman's progesterone, the less
likely she is of developing cancer. Synthetic progestins have been
shown to increase the incidence of breast cancer. The recent
increase in breast cancer could very well be secondary to the lack
of progesterone. Progesterone becomes deficient in a woman's
forties and it is completely absent by menopause. Women continue to
produce some estrogen and they often take synthetic estrogens and
progestins. There is strong evidence that this causes the breast to
become estrogen dominant. Unless natural progesterone is in her
body, she is most likely increasing her risk of breast cancer.
Studies have shown that women who take HRT have a greater chance
of surviving breast cancer. The breast cancer in women who use HRT
are more localized, lower grade, smaller tumors, and more likely to
be lobular in origin. Ductal carcinomas of the breast are more
ominous than lobular carcinomas. As a result there is a 40-60%
reduction in mortality when compared with women who developed
breast cancer without a history of HRT.
bioidentical hormones are limited regarding breast
cancer. Estriol has been postulated to be protective but doctors
are not using it so studies will continue to be limited. Every baby
a woman has lowers her chance of breast cancer by 7%. This is
ironic because when a woman is pregnant she is exposed to more than
ten times the amount of estrogen and progesterone than any other
time in her life. It very well could be the high levels of estriol
during pregnancy that is responsible for this protection. Early
pregnancies are protective against breast cancer not only because
of the early exposure to estriol, but also because the p53 gene is
upregulated in early pregnancies.
Breast cancer can occur secondary to an inherited gene mutation.
BRCAI and BRCAII gene abnormalities have been shown to increase the
risk of both ovarian and breast cancer. BRCAI and BRCAII are tumor
suppressor genes that have a particular importance in breast and
ovarian cells. The general risk for carrying a mutation in either
BRCA genes is between 1 in 400 and 1 in 800. Jewish women of
Eastern European decent have a 1 in 40 risk of a BRCA gene
mutation. If an inherited mutation in the gene is discovered, women
have an 87% lifetime risk of developing breast cancer. If there is
a strong family history of breast and/or ovarian cancer BRCA
testing should be performed. It is a blood test and the test is
very expensive. If the test is positive, women should be counseled
concerning their options.
There are many different treatment protocols for breast cancer.
Options change with the type of cancer, nodal involvement, and the
estrogen receptor status of the tumor. The decision should be made
by the patient with input from the surgeon and the oncologist.
Treatment usually consists of a combination of two or more of the
following: mastectomy, lumpectomy, axillary node dissection,
radiation, and/or chemotherapy. After this, five years of Tamoxifen
is usually recommended; see the chapter on SERMs. Tamoxifen works
by binding to estrogen receptors within the breast, preventing
estrogen from binding to those receptors. After five years, the
estrogen receptors become resistant to Tamoxifen, and it is no
longer effective. A new drug called Femara is now being used after
Tamoxifen. Femara is an aromatase inhibitor that works by
decreasing the amount of estrogen production in the body. Studies
have shown that Femara decreases the recurrence of breast cancer by
43%. Other aromatase inhibitors are Aromasin and Arimidex.
Mammography is the best screening test for the detection of breast
cancer. A mammogram is an X-ray of the breasts. Despite what you
have seen in the news, there is no controversy with screening
mammography. Early detection of cancer is crucial, because the
quicker a cancer is diagnosed, the better the survivability. The
five-year survival rate for breast cancers detected and treated at
an early stage is 95%. Women should get annual mammograms starting
at age 40. The controversy with mammography stems from the exposure
to radiation secondary to the procedure. Radiation can cause cells
to become damaged, which can ultimately lead to cancer. We are
unfortunately exposed to radiation daily. A woman gets just as much
radiation from flying across the country as she gets from a
mammogram. The newer mammography machines not only are able to
identify smaller lesions but they also give the patient less
radiation. The main problem with mammography is false-positive
findings. Not only does this give women anxiety, but it leads to
further tests such as spot compressions, ultrasounds, and breast
biopsies. Women under the age of 50 have denser breast tissue
secondary to estrogen exposure. Denser breasts are more difficult
to evaluate with mammography so there are more false-positive
readings in younger women. Women who are at high risk for
developing beast cancer should also get an MRI of their breasts.
MRIs are ten times more costly than a mammogram but they are more
accurate at detecting cancers. Unfortunately they have more
false-positive findings, so more unnecessary biopsies are
performed. If a woman or her physician is able to palpate a lesion,
an ultrasound should be ordered. For palpable lesions, this is the
best test. It can determine if the mass is solid or cystic. The
problem with routine screening breast ultrasounds is that there are
too many false-positive findings leading to unnecessary biopsies.
Thermography is another widely used screening test. Thermography
detects heat within the breast. When there is a cancerous growth,
the cancer recruits new blood vessels; this new blood supply
results in increased heat within the breast. The problem with this
test is that by the time there is a positive thermography reading,
the cancer is usually quite large. Thermography cannot pick up
early cancers, like ductal carcinoma in situ, whereas mammography
is able to detect these early cancers. There are a lot of
false-positive findings with thermography as well. False-positive
findings lead to more extensive workups. Monthly selfbreast exams
are the most important preventative measure against fatal breast
cancer. More breast cancers are discovered by selfbreast exams than
mammography and physicians combined.
Osteoporosis literally means “porous bones”. Osteoporosis is
when the holes within the honeycomb matrix of the inner bone become
larger, making the bone fragile. The world Health Organization
defines osteoporosis as bone density that is 2.5 standard
deviations below an average 35 year old. 10 million Americans have
osteoporosis and 1.5 million succumb to bone fractures each year.
When bone density is between 1.0 and 2.5 standard deviations below
an average 35 year old, one has osteopenia. Approximately 20-30
million Americans have osteopenia. Do not be alarmed if your bone
density is slightly low because you are being compared to bone at
its maximum density. Women reach maximum bone density at age 35.
Older bone is constantly being replaced by newer bone tissue. After
age 35, bone is broken down faster than it can be rebuilt. Bone
loss is a consequence of advancing age, but it is much more rapid
in women after menopause. The loss of estrogen and progesterone at
menopause is responsible for the majority of the disease. Women
lose the majority of their bone in the first five years after
menopause if they are not taking supplemental estrogen and
progesterone. This is why 80% of all people with osteoporosis are
women. The most common area for an osteoporotic fracture is within
the vertebral bodies in the spine. This can result in curvature of
the spine, loss of height, chronic back pain, and leads to further
fractures in the vertebra. The second most frequent place of a
fracture is in the hip. Hip fractures are so serious that
approximately 25% of women hospitalized secondary to a hip fracture
will die within a year.
There are no symptoms of osteoporosis. Besides being a woman,
there are many other risk factors for osteoporosis. Uncontrollable
risks include an early menopause, having a family history of
osteoporosis, having a small frame, and fair skin (Caucasian,
Asian). Medical and nutritional risks include hyperthyroidism,
calcium deficiency, alcohol, smoking, and corticosteroid use. The
national Osteoporosis Foundation recommends that women over the age
of 65 get a bone density test. I think it is important to get one
at the age of 50 so a baseline is established prior to menopause.
Any woman with a documented vertebral, hip, wrist, or rib fracture,
should get a bone density test right away. The best test is called
a dual x-ray absorptiometry (DEXA) scan. This test accurately
measures the density of the bone at the three most common areas of
fractures; the spine, hip and wrist.
Non-medical prevention and treatment of osteoporosis involves
adequate calcium (1000-1500 mg daily), vitamin D (400-800 U daily),
and weight bearing exercise. Vitamin D enables calcium to be
absorbed by the bones. The most common source of vitamin D is from
direct sunlight. Adequate magnesium intake is critical because
magnesium helps the body absorb calcium. Even with adequate
magnesium, the stomach can only absorb 500mg of calcium at a time,
so calcium should be taken three times a day. There is nothing
better than adequate estrogen and other hormones in the prevention
of osteoporosis. Estrogen helps prevent osteoporosis by inhibiting
bone resorption. Progesterone, on the other hand, stimulates bone
formation. Testosterone also stimulates the formation of new bone
and aids in the absorption of calcium. DHEA both inhibits bone
resorption and stimulates bone formation. Raloxifene (Evista) is
also used for osteoporosis but it has only been shown to prevent
fractures in the spine. Alendronate (Fosamax) and risedronate
(Actonel) are biphosphonates and have been shown to rebuild bone by
preventing bone resorption. It has to be taken on an empty stomach
because food inhibits its absorption. Calcitonin is another drug
that inhibits bone resorption. It is not as effective as estrogen
or the bisphosphonates. Calcitonin reduces the risk of spinal
fractures but does not have much of an effect on the hip. It is
available as an injection or a nasal spray. Teriparatide, recently
approved by the FDA, stimulates the growth of new bone by
increasing the number of osteoblasts (bone-forming cells). Taking
folic acid may one day prove to be beneficial because folic acid
decreases homocysteine levels. Two recent studies showed that
people with high homocysteine levels were at much greater risk for
Women are diagnosed with depression twice as often as men are.
Women have been taught from an early age to express their feelings,
whereas men are taught to deal with their feelings internally.
Possibly depression is just as prevalent in both sexes, but women
are the ones seeking help. Underweight women have twice the
incidence of depression compared to overweight women; the reason
for this is unknown. Depression could also be hormonally related.
Depression is commonly seen in early teenagers and perimenopausal
women, when their hormones are fluctuating drastically. Depression
is also common in menopause, during the second half of the
menstrual cycle (luteal phase), and postpartum, when there are
drastic hormone changes. There also could be some anatomical
differences between men and women. Research has shown that women
store both emotion and memory in the same parts of their brain,
whereas men store them in separate areas.
It is unclear what exactly causes depression, but research shows
that it is most likely related to our inherited genes plus a
triggering environmental effect. It is felt that heredity may
account for as much as 80% of the risk for depression. Researchers
have isolated a gene that is responsible for regulating serotonin
function. People with the short arm of the gene are twice as likely
to develop depression after a triggering environmental effect.
Symptoms of depression are prolonged sadness, inability to feel
pleasure, sleeping too much or too little, difficulty eating and
suicidal thoughts. Approximately twenty million Americans are
affected, with 30,000 committing suicide each year.
Brain cells communicate with one another via neurotransmitters.
A deficiency of the neurotransmitters, serotonin, dopamine,
norepinephrine, and glutamate is involved in depression. Signs of
serotonin deficiency are depression, over eating, and being
overwhelmed. An excess of dopamine causes excitement, whereas low
dopamine causes fatigue. Newer evidence is pointing towards
unhealthy nerves in the part of our brains that control emotion,
not the lack of neurotransmitters, is what is causing us to be
depressed. The stress hormone, cortisol, is elevated in people with
depression. Overexposure to cortisol has been shown to inhibit the
growth of nerve cells in the brain. Part of the reason why
antidepressants work is that they stimulate the growth of new nerve
cells. Drugs in the future will probably focus on repairing damaged
nerves in the part of the brain that controls emotion. Drugs that
diminish the stress response are currently being studied. From what
we learned about cortisol in the last chapter, it is apparent that
depression can have serious effects on our health. Depression is a
serious risk factor for heart disease.
The treatment of depression is centered upon making the
neurotransmitters, especially serotonin, available for use.
Neurotransmitters are mostly made from amino acids, the building
blocks of proteins. Tryptophan, an amino acid, is a direct
precursor of serotonin. Tryptophan is available by prescription
only, but supplemental 5-hydroxytrptophan will increase serotonin
levels as well. The amino acids phenylalanine and tyrosine are
precursors of dopamine, epinephrine, and norepinephrine. Brain
chemistry is still not completely understood, but it is believed
that by increasing individual amino acids in the diet, levels of
neurotransmitters will increase as well, preventing or relieving
depression. There are some theories indicating that the longer one
is depressed, the harder one is to treat. It is important to seek
treatment sooner than later. There is some evidence that prolonged
severe depression can result in early ovarian decline.
Initially the treatment of depression was with psychoanalysis
thanks to the work performed by Sigmund Freud. Ever since the
tricyclic antidepressant drugs became available in the 1960's,
psychoanalysis has been used less and less. The tricyclics increase
the activity of serotonin and norepinephrine, thus increasing
euphoria. The side effects are blurred vision, dizziness, and
sleepiness. In 1987 Prozac was the first selective serotonin
reuptake inhibitor (SSRI) available in the U.S. SSRIs only increase
the availability of serotonin and not norepinephrine, so side
effects were less severe. The SSRI's include Prozac, Celexa, Luvox,
Paxil, and Zoloft. Side effects from these medicines include
insomnia, loss of sex drive, nausea, and restlessness. Lexapro is
the newest SSRI and it has been touted to relieve anxiety as well
as depression. The monoamine oxidase inhibitors (MAOIs) are less
commonly used than the SSRIs because they have more dangerous side
effects. Marplan, Nardil, and Parnate are MAOIs and they can cause
a hypertensive crisis, dizziness, weight gain, constipation, and
headaches. MAOIs cannot be used with other medications to treat
depression and people must eliminate the amino acid, tyramine from
their diet. The use of MAOIs might be back on the rise, because the
FDA just approved an MAOI patch. This will result in fewer side
effects because most of the serious side effects from MAOIs were
secondary to oral administration. Wellbutrin is another commonly
prescribed drug for depression, but its exact mechanism of action
is unknown. There seems to be less sexual dysfunction on
Wellbutrin, and Wellbutrin SR (sustained release) is the same drug
as Zyban, used for smoking cessation. Some of the above
antidepressants have increased suicidal thoughts in teenagers, as
well as adults. It is important to watch for signs of increased
irritability, anxiety, hostility, or restlessness, especially in
the first few weeks of treatment. When antidepressants are stopped
it is important to decrease the medication slowly. Stopping cold
turkey can cause dizziness, fatigue, nausea, headaches, anxiety,
There are also natural agents which are used for depression. St.
John's Wort has been used for hundreds of years and it is one of
the most studied herbs. The studies show that it is as effective as
standard drugs for treating mild depression. Omega-3 fatty acids
are being extensively studied. The nervous system cannot grow and
regenerate without omega-3 fatty acids. Docosahexaenoic acid (DHA),
an omega-3 fatty acid, is the main component of cell membranes in
the brain. GABA and glutamate are natural occurring molecules,
which can also be taken as a supplement. They are the primary
neurotransmitters in the brain, and as a result they can affect all
activities in the brain. Testosterone supplementation has been
shown to improve mood in a study involving men, so the same hormone
may have the same effect on women. DHEA, an over the counter
hormone, has been used for depression and mood elevation as well.
SAMe, ginkgo biloba, phenylalanine, and 5-HTP are also used to
treat mild depression. Adequate levels of vitamin B12 have been
shown to be important in treating depression. People who respond
best to medical treatment have higher concentrations of vitamin
B12. Exercise is also important because of the release of natural
endorphins, which elevate mood.
When the above treatments are unsuccessful the next step would be
electroshock therapy. It involves using a small electrical current
to induce a mild seizure, resetting the electrical state of the
brain. Though the exact mechanism of action is poorly understood,
it is a very effective treatment for depression. More recently,
magnetic resonance imaging (MRI) is being looked at as a possible
cure for depression. Small studies have shown that moods improved
following an MRI of the brain.
Unfortunately stress is a big part of a women's life and it can
have negative effects on health. Like depression, women suffer from
anxiety much more than men. In addition to having a career, women
are usually responsible for taking care of the children, cooking
and cleaning, which leaves little time for other interests. It is
very important to find time to channel this stress out of your
body. In a stressful situation cortisol and epinephrine
(adrenaline) are secreted from the adrenal glands and secreted into
the bloodstream. Epinephrine causes the heart to pump faster and
stronger, getting ready for the “fight or flight” response. Too
much epinephrine over time can lead to hypertension and damage to
arteries. After the stressful situation is resolved, cortisol
remains elevated, which is responsible for an increased appetite
for sugar. This results in impulse eating and is responsible for
the majority of diet breakdowns. Cortisol also increases insulin
levels, causing fat storage, especially in the abdomen. Chronic
exposure to cortisol has multiple deleterious effects. It can be
responsible for heart disease, hypertension, stomach ulcers,
overeating, impaired immune response, sleep impairment, memory
impairment, and depression. High levels of cortisol can lead to
osteoporosis because cortisol interferes with the bones' ability to
absorb calcium. Cortisol levels naturally increase with age, and as
a result it is the hormone that is strongly implicated in the aging
process. Hostility and impatience has shown to double the risk of
hypertension, obesity, and depression.
Serotonin calms the stress response and thus has the opposite
effect from cortisol and adrenaline. Serotonin is responsible for
the “stop eating signal” and thus when levels of serotonin are
normal we have less cravings for sweets and carbohydrates.
Serotonin levels naturally decrease with age. Exercise increases
levels of serotonin and vitamin B6 is necessary to produce
It is important to eliminate chronic stress. Whenever a
stressful situation arises we need to channel that negative energy
elsewhere. Stress increases heart rate, blood pressure, muscle
tension, and respiratory rate. Living a healthy lifestyle has been
shown to prevent stress. When the body is relaxed it produces more
nitric oxide, which counterbalances cortisol. Eating properly,
routine exercise, yoga, pilates, meditation, and a healthy sex life
are helpful for preventing stress. Meditation and yoga share the
same philosophy concerning relaxation and the control of breathing.
It is very difficult to remain anxious when breathing slowly and
deeply in a regular pattern. Relaxation techniques lower blood
pressure, heart rate, and respiratory rate. Meditation has not only
been shown to reduce stress, but can improve chronic pain, elevate
mood, increase circulation, and improve digestion. Exercise is
important because endorphins are released which counterbalance
Many women say they have never had chronic stress or anxiety
until they reached their forties. The reason for this is that
anxiety is much more common after perimenopause. In perimenopause,
progesterone is deficient for the first time in their lives.
Progesterone has calming properties, so when the progesterone is
supplemented, the anxiety often diminishes.
Unfortunately at times progesterone and lifestyle changes, such as
diet and exercise, are not enough to eliminate anxiety. The herb,
valerian, can be used which acts on the receptor of GABA, an amino
acid that is responsible for calming. GABA itself can be taken as a
supplement, which has had promising results. Anxiolitics, such as
Valium and Xanax, can be prescribed by your physician when all else
fails. These anxiolytics work on the GABA receptor, similar to
valerian. Unlike the SSRIs, Valium and Xanax are very addictive.
Kava is another herb that is used to treat mild anxiety.
The most common headaches are classified as migraine or
tension-type. The cause of headaches is not completely understood,
especially why certain people have a higher predisposition toward
getting them. Women are three times more likely to suffer from
chronic headaches than men. Allergies are the most common
triggering source for headaches. The second most common cause of
headaches is a hormonal imbalance. An excess or deficiency, in
almost every hormone, can be related to headaches. Hormones are
what cause us to perceive pain. The hormones serotonin and
histamine act as neurotransmitters and induce pain responses at
nerve endings. Endorphins block these neurotransmitters and prevent
the sensation of pain. An overproduction of prolactin has been
linked to headaches. Too much or too little thyroid production has
also caused headaches. The most common hormones associated with
headaches in women are the sex hormones. Headaches are very common
when sex hormones are fluctuating. They are common in puberty,
perimenopause, menopause, and postpartum. They also are common in
women on oral contraceptives and with women who suffer from PMS.
Most cyclical headaches occur in women right before their menses or
during their menses. Fluctuating estrogen levels are what is
usually responsible for these headaches. It is the sudden drop in
estrogen that is most symptomatic. Women experience a drop in
estrogen prior to menses, and estrogen levels are at their lowest
point during menstruation. Women on oral contraceptives make very
little of their own estrogen, secondary to the high doses of
synthetic hormones they are taking. I have found estradiol cream,
balanced with progesterone, to be very effective in treating
headaches. Every woman responds differently to her individual
hormones, so the same treatment does not work on everyone.
Migraine headaches are classified as with or without aura.
Migraines with aura have neurological components. Visual auras are
the most common aura. Seeing bright light, usually in one eye,
followed by obscured vision is the most common symptom. Numbness is
the second most common aura, usually on one side of the face.
Migraine headaches are secondary to vascular changes within the
brain. To be classified as a migraine headache, certain other
symptoms have to be associated with the headache. Symptoms of
migraines are severe pulsating pain on one side of the head.
Migraines are often initiated by exercise, and associated with
nausea and photophobia. If none of these symptoms are present, then
it is not a migraine headache. Migraines often have a heredity
link. They can be triggered by changes in hormones, diet, sleep,
and stress. Mild migraines at times will respond to
over-the-counter aspirin, acetominophen (Tylenol), non-steroidal
anti-inflammatory drugs (NSAIDS), caffeine, or a combination of
these drugs. The triptan drugs were a medical breakthrough in the
treatment of migraine headaches. Sumatriptan (Imitrex) arrived in
the U.S. in 1993. At first it was only available as an injection,
and now it is available in a nasal spray and tablet. Now there are
six other triptan drugs available: almotriptan (Axert), eletriptan
(Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan
(Maxalt), and zolmitriptan (Zomig). They are available in tablet
form and have different effectiveness and different half-lives.
Axert, Repax, and Maxalt were shown to be the most successful from
a meta-analysis of clinical studies. The above drugs are good at
alleviating migraines once they set in, but there are other drugs
that have been shown to be preventative. Propranolol, a
beta-blocker commonly used to treat hypertension, has been shown to
be a reliable migraine prophylactic. Depakote, an anti-epileptic
drug, has also been successful. Amitriptyline, a tricyclic
antidepressant, is reliable but it has a sedating effect. These
drugs are usually taken daily by patients who have multiple
Tension-type headaches can either be
classified as episodic or chronic. Having more than 15 days per
month of symptoms is described as chronic and less than this is
episodic. These headaches are much milder than migraines and they
do not prohibit activities. A dull, non-throbbing pain occurs on
both sides of the head and nausea is not associated with them.
Tightness in the scalp and neck is often associated with this type
of headache. Photophobia may occur but much less often than with
migraines. Unlike migraines, they are not exacerbated by exercise.
Episodic tension-type headaches usually respond to the traditional
over-the-counter analgesics described above. Chronic tension-type
headaches also respond to these analgesics, but excessive abuse of
these drugs can result in analgesic-abuse (rebound) headaches.
Chronic headaches are best treated with a preventative medicine
like amitriptyline. This drug does not completely eliminate the
headache, but it will lessen its severity.
It is amazing that thoughts on nutrition are constantly
changing. For years we have known what foods are healthy or
unhealthy. Scientists have known since the 1960's that the
saturated fat in red meat and dairy products can raise cholesterol
and lead to coronary heart disease. Initially these findings were
downplayed to appease the cattle and dairy industries. The
synthetic fats were invented to replace saturated fats, but
scientists determined that the newer fats are more detrimental to
health than saturated fats. These fats are still being used by the
food industry because they are inexpensive and increase the shelf
life of processed foods. Nutritionists have always known about the
perils of simple sugars, yet their prevalence continues to grow.
There is a constant debate whether a low-fat diet or a
low-carbohydrate diet is better for you. Asking your doctor for
their opinion has always been a poor option because nutrition is
very rarely taught in medical school.
The calories we get from food either come from protein,
carbohydrates, or fats. A gram of protein or carbohydrate gives us
four calories, whereas a gram of fat gives us nine calories. When
food was not as plentiful as it is today, it was imperative for us
to consume as many calories as possible, so the craving for fatty
foods was an important inherited trait. Now food is plentiful but
unfortunately we cannot reverse our evolutionary desires. Today
Americans eat too much, and as a result, more than one half of
Americans weigh too much. We need to eat smaller portions.
Carbohydrates enter the bloodstream as glucose and glucose is an
instant energy source for all tissues in the body. Carbohydrates
can be subdivided into “good” carbohydrates and “bad”
carbohydrates. “Good” carbohydrates consist of fruits, vegetables,
and unprocessed starches (whole grain breads and cereals, brown
rice, whole wheat pasta). “Good” carbohydrates provide dietary
fiber and some essential vitamins and minerals. Fiber is the
structural part of fruits and vegetables that cannot be digested.
Fiber is important in preventing constipation and colon cancer.
Societies that have the highest percentage of fiber and grain have
the lowest incidence of colon cancer. Fiber also gives us a sense
of fullness, which helps us from over eating. Fiber removes bile
acids from the small intestine, resulting in lower cholesterol
The main difference between “good” and “bad” carbohydrates is
the glycemic index. Glycemic index measures how fast a food we eat
releases glucose into the bloodstream. The “good” carbohydrates
have a low glycemic index. When glucose enters the bloodstream a
surge of insulin is released from the pancreas. Insulin is the
hormone that enables the glucose to enter the cells within the
muscle and other tissues. At times of activity, glucose is
immediately consumed by muscle cells. This is why carbohydrates are
an excellent source of fuel during exercise, especially high
glycemic carbohydrates. At times of rest insulin still causes cells
to absorb glucose, but the glucose is stored away in fat and muscle
cells. The intake of carbohydrates, especially “bad” carbohydrates,
needs to be limited at times of inactivity. Whole grains and fruits
are broken down much slower in the digestive tract compared with
“bad” carbohydrates so the surge of glucose and insulin is not as
“Bad” carbohydrates consist of simple sugars, refined pasta,
white rice, and white bread. These are the most important items to
be removed from our diets. They have a high glycemic index. These
foods give the surge in glucose, which then cause the surge in
insulin. The surge in insulin can also cause us to over eat because
after the insulin surge our blood glucose falls increasing our
craving for more glucose. Increased insulin levels also decrease
the ability for the body to metabolize fat. Not only does this
cause us to gain weight but cells become resistant to insulin,
which can lead to diabetes. High insulin levels inhibit the
activity of glucagon. Glucagon is a hormone that is responsible for
releasing stored fuels when blood sugar is low. Without glucagon
our body cannot self regulate its blood glucose level, causing the
hunger signal to set in. Eating another high glycemic snack results
in a continuous cycle of high blood sugars followed by low blood
sugars, then the craving for sugar again. The simple sugars consist
of anything sweet; sodas, cookies, candies, cakes, etc.
Proteins are made up from combinations of the twenty amino
acids. There are eight essential amino acids that the body needs
through nutrition. The remaining amino acids can be synthesized
from the eight essential amino acids. Protein is important for
building muscle mass. All protein sources are good for you but some
have a higher percentage of fat in them. The low fat sources of
protein are: turkey and chicken breasts, dry beans, most fish,
shell fish, egg whites, tofu, reduced fat dairy (cheese, yogurt,
milk). Proteins with a higher fat content are: red meats, liver,
sausage, bacon, hot dogs, ribs, poultry leg and thigh, egg yolks,
dairy products. A diet that is excessive in protein can put stress
on the kidneys, resulting in kidney stones or renal failure.
Fats role in heart disease led to the fat phobia. Fats are
nutritionally very important. Fat is essential for the growth and
maintenance of the nervous system. Fat is also integral in proper
functioning of the fat soluble vitamins, vitamins A, D, E, and K.
Fats can be broken down into saturated and unsaturated fats.
Saturated fats are solid at room temperature, whereas unsaturated
fats are in a liquid form at room temperature. Saturated fats are
bad for us because they are dangerous to the heart and they
increase the bad cholesterol, LDL. Saturated fats also promote
insulin resistance. Saturated fats are found in fats from animals
(dairy products, poultry, red meat) and tropical oils (coconut and
palm oils). Unsaturated fats are better for us and they consist of
monounsaturated and polyunsaturated fats. Unsaturated fats can
lower cholesterol and are felt to be protective to the heart. We
should never eat foods deep-fried because even if it is fried in
unsaturated fat, the heat can break the double bonds of unsaturated
fat, changing it into a saturated fat. The oils in olives and
peanuts are monounsaturated. Polyunsaturated fat sources are the
oils that come from corn, soybean, sunflower, and safflower.
Monounsaturated fats are slightly better for our bodies than
polyunsaturated fats. Omega-3 fatty acids are polyunsaturated fats
and are protective to the heart. Foods that are rich in omega-3
fatty acids include tuna, salmon, mackerel, walnuts, flax and
canola oils. It is still smart to eat good fats in moderation
because of their high caloric content. Additionally, the body
easily stores dietary fats as body fat. Trans-fatty acids are
synthetic fats that are common in processed foods, labeled as
“partially hydrogenated” or “vegetable shortening”. Like saturated
fats, trans-fatty acids raise LDL cholesterol and lower HDL
cholesterol, leading to heart disease and strokes. It is best to
avoid these fats as well.
In the 1980's the general population was not only becoming aware
that we got more than twice as many calories from fat, but that
saturated fats were partially responsible for heart disease. As a
result came the fat free diet. Products were coming up overnight
with their “fat free” or “low fat” slogans and they were a huge
economic success. Unfortunately these products were loaded with
simple sugars and as a result had nearly as many calories. These
products had a psychological effect on people as well because we
felt we could eat more than the usual serving because they were
good for us. Instead of losing weight, people gained weight by
eating these products. A lot fat diet is good for us, as long as
high glycemic foods are not replacing the fat calories. Dean
Ornish, M.D. has shown that a low fat diet and exercise can reverse
heart disease. The Atkin's diet is very popular, and it is
essentially a carbohydrate-free diet.
Today we are seeing low-carbohydrate products saturating the
food industry, similar to the fat free gimmick of the 1990's. The
problem with this diet is that one can eat unlimited amounts of
fatty meats, butter, and cheese. Though this diet has been
successful for weight loss, it does not promote healthy eating.
This diet is high in saturated fats and causes the body to go into
ketoacidosis, a disturbed acid balance. This diet can also cause
bone loss and increased uric acid levels, leading to gout. The
Atkin's diet causes rapid early weight loss, but most of this is
water and some lean muscle weight. After one year, people regained
more weight on the low carbohydrate diet compared to those on low
fat diets. The problem with a lot of diets is that they are very
hard to adhere to. I prefer diets for lifelong health, not
short-term weight loss. The key to this is giving up processed
foods in favor of natural foods. Boyd Eaton, M.D. wrote Paleolithic
Prescription in 1988 with the philosophy that farming made us fat.
His solution is to eliminate processed grains from our diet and
replace them with fruits and vegetables favored by our early
ancestors. He also advises against mass produced meats and favors
lean free-range animals like those hunted by our forebears. Not
only are the meats we buy in the supermarket fatter, but they are
usually injected with hormones to make the animals grow bigger. I
also recommend trying to eliminate milk products, such as butter,
cheese, and cream. Milk products are high in saturated fats. We are
the only mammals who continue to use milk products after weaning
from breast milk.
The most important thing is moderation. Over-eating is the biggest
issue whether you are on a particular diet or not. Instead of crash
dieting, reduce certain foods from your permanent diet. Avoid the
“bad” carbohydrates and trans-fatty acids whenever possible. Reduce
the amount of saturated fats and increase the omega-3 fatty
Exercise is important for everyone, even if weight loss is not
an issue. It is important for maintaining cardiovascular health,
and cardiovascular disease is the leading cause of death in both
men and women. Exercise lowers blood pressure, cholesterol, and
triglyceride levels. Exercise has been shown to lower the risk of
hypertension, diabetes, and some cancers. Overweight women who
exercise have less heart disease than thin women who do not
exercise. Exercise also has an anti-aging effect by lowering
cortisol and increasing endorphins, dopamine and serotonin. By
increasing endorphins, dopamine, and serotonin, exercise might be
more effective than traditional antidepressants in treating
depression. Endorphins neutralize the effects of cortisol, giving a
post exercise calming effect. This result can prevent anxiety and
insomnia and possibly help with hot flashes. Exercise improves
metabolism and fat oxidation. Exercise builds muscle and muscle
dictates metabolism. It not only burns fat but most importantly it
burns intra-abdominal fat. It is the intra-abdominal fat that puts
women at increased risk for heart disease and diabetes. Exercise
improves bowel motility and digestion. It improves the endocrine
(hormone producing) and immune systems. Exercise protects from
osteoarthritis by strengthening the muscles within the joints and
increasing the flexibility of the ligaments and tendons within the
joints. Weight bearing exercise improves bone strength, improving
or preventing osteoporosis.
Proper exercise involves stretching, aerobic activity, and weight
training. Yoga is a great form of exercise because in involves
stretching and breathing control (see next chapter). If done
properly it is considered an aerobic workout as well because of the
elevation in heart rate from the stretching. One of the problems
with aging is that we have gone through life without stretching.
Stretching our muscles prevents a lot of chronic problems we face
such as back and joint pain. Flexible muscles prevent injury
because tight muscles are more prone to injury during routine use.
With proper and routine stretching, we can get back to the
flexibility of our youth. Stretching not only improves physical
relaxation, but improves mental relaxation as well. It is best to
stretch after warming up the muscles with exercise, because muscles
respond better when they are warm. If possible, stretching should
be performed daily. Aerobic exercise involves getting your heart
rate above baseline and maintaining it there. Walking, running,
biking and swimming are the most common aerobic exercises. Aerobic
exercise is important for maintaining cardiovascular health and for
burning calories. Forty-five minutes of aerobic exercise at least
five times a week is important for maintaining health. Aerobic
exercise is often avoided because low energy levels lead to
procrastination. It is important to remember that energy levels
will improve significantly after exercise is completed. Painful and
strenuous exercise is not necessary. Moderate exercise, such as
walking is almost as beneficial as strenuous exercise. Pilates is
becoming more popular and it focuses on strengthening the core
muscles. The core muscles consist of abdominal, lower back, and hip
muscles. Improving the core muscles makes all the other muscles
work more efficiently. It also has been shown to prevent lower back
pain and improve balance. Weight training is very underrated in
women. It is much harder to burn fat without incorporating weight
training into your regiment. If muscles are not used they diminish
in size. Muscles burn an enormous amount of calories, even when at
rest. So any loss of muscle mass results in a reduction in
metabolism and less calories are burned in the muscles. The best
workout involves circuit training. Numerous machines are used with
repetitions of 15-20, while not resting between exercises so the
heart rate remains elevated. This adds an aerobic component to the
weight training. Weight training should be performed 2-3 times a
SAMe (S-Adenosylmethionine) is a combined product of ATP and
methionine. It is not a vitamin because the body produces all that
it needs. In order to produce SAMe the body needs adequate levels
of methionine, folate and vitamin B12. As a supplement it is used
primarily for depression. It works by enhancing the impact of the
neurotransmitters serotonin and dopamine. It is also used to
alleviate the symptoms of arthritis and it is being studied to see
if it slows the progression of arthritis. Researchers have found
SAMe as effective as pharmaceutical agents for pain and
inflammation. SAMe is also felt to regenerate the liver, so it can
be helpful for people who drink too much or have other liver
Melatonin is primarily used for insomnia and jet lag. Melatonin
is a hormone produced by the pineal gland but only in the absence
of sunlight. As soon as the sun rises the pineal gland stops the
production of melatonin and instead makes serotonin. Melatonin is
what triggers sleep. Higher melatonin levels produce a deeper
sleep. It decreases stress by decreasing cortisol levels and
stimulating GABA. It is a strong antioxidant, protecting against
free radicals, thus protecting against cancer. It is felt to be
anti-aging because of its effect on stress and cancer protection.
Woman who work at night have less melatonin production and as
result they have an increase in breast and colon cancers. It also
improves thyroid function by enhancing the production of T3.
Coenzyme Q10 is beneficial for people with congestive heart
failure and other forms of heart disease. It has also been used
with limited results to enhance athletic performance. The body
naturally produces CoQ10 but it can become deficient if
cholesterol-lowering drugs are being used.
Glucosamine is derived from glucose and is a key component for
making cartilage. It is used to treat osteoarthritis. Not only does
it alleviate symptoms but also it slows progression of the disease
by regenerating cartilage.
Chondroitin sulfate, like glucosamine, is used to treat and
protect against osteoarthritis. It is naturally produced in the
body like glucosamine but additional supplements are beneficial.
Like glucosamine, chondroitin is a major component of
Creatine is responsible for bringing ATP to muscle cells. It is
used to increase athletic performance. Muscles use ATP for energy,
so creatine can make muscles work harder and longer while training
and then recover faster.
Isoflavones are hormones that plants produce. Phytoestrogens are
isoflavones because they are plant hormones that have an estrogen
like effect. They bind to the same receptors as estrogen, and can
actually prevent estrogen from binding, blocking estrogen's
influence. Our bodies do not have the enzymes to convert
phytoestrogens into estrogens, so our levels of estrogen will not
go up by taking phytoestrogens. Isoflavones have been shown to
lower cholesterol. Soybeans are the most common source of
Ipriflavone is a synthetic isoflavone. Since it is synthetic it
will not be obtained in our foods, and can only be obtained through
a supplement. It was synthesized for preventing and treating
osteoporosis. It gives an estrogenic effect only on the bones and
does not prevent hot flashes or act on other tissue like the heart,
breast or uterus. Ipriflavone most likely works by inhibiting bone
breakdown, similar to estrogen's effect on bone.
5-hydroxytryptophan (5-HTP) is a precursor for serotonin.
Serotonin deficiencies are common in depression, so supplemental
5-HTP may increase serotonin levels. 5-HTP is also used to help
with anxiety, insomnia, fibromyalgia, weight loss, and chronic
Lycopene is an antioxidant found in tomatoes and watermelon.
Lycopene reduces the oxidation of LDL cholesterol, thus preventing
heart disease. Lycophenes have been postulated to reduce the risk
of cancer. Cooked tomatoes, such as tomato sauce, have a higher
concentration of lycopene than raw tomatoes.
Hormones are produced by endocrine glands
throughout the body. Hormones are chemical messengers that
circulate through the bloodstream and regulate activities in all
tissues within our bodies. All hormones are derived from
cholesterol; enzymes convert cholesterol into many different
As hormone levels decline, a woman has three choices. She
can take nothing, take synthetic hormones, or take
bioidentical hormones. Taking nothing is very natural but we also were not
designed to live much after menopause. One hundred years ago, the
average woman died before menopause. With the advancement of
medicine, women are now spending a significant fraction of their
life in menopause.
Bioidentical hormones are structurally and
chemically equivalent to the hormones made by the endocrine organs.
hormones require a prescription from a
physician, they are not drugs or medicines. It is a process of
replacing a hormone that the body has always produced. The natural
production of the hormone is low because of age. Hormone
insufficiency has been implicated to be a major cause of aging.
Hormone levels begin to decrease in the mid-thirties, and
progressively decline after this.
I do not like the term “natural” hormone replacement because making
these hormones is not a natural process. The starting materials for
these hormones are derived from plants and changed in a laboratory
into human hormones. Some people consume soy, yams, or other
plants, thinking that they are getting human estrogen from these
plants. We do not have the enzymes in our bodies to convert plant
hormones into human hormones. Before we had the ability to
synthesize hormones in the laboratory, the easiest way to get
hormones was from animal species, like horses. Foreign or synthetic
hormones are completely different molecules than the original
hormone. When these molecules act on the hormone receptors, they do
not fit properly, thus producing an abnormal effect. The reason why
synthetic hormones are used today is because pharmaceutical
companies are still producing them, and aggressively marketing them
to physicians. These companies do not produce
bioidentical hormones because they did not invent them, thus they cannot patent them.
Today it is amazing that physicians prescribe foreign or synthetic
hormones when they can prescribe the exact molecule that the human
body produces. Unfortunately there are no large randomized
controlled studies on bioidentical hormones.
The three main estrogens produced by the human body are estrone
(E1), estradiol (E2), and estriol (E3).
Estrone accounts for 10% of the circulating estrogen in a
reproductive female. Estradiol and estrone can be converted to one
another in the body by enzymes. In addition to being produced by
the ovary, estrone is also formed from androstenedione in fatty
tissue. Androstenedione is in the androgen family of hormones like
testosterone. After menopause, when the ovary stops producing
estrogen, a woman's only source of endogenous estrogen comes from
the peripheral conversion of androstenedione to estrone; hence
estrone accounts for the majority of estrogen in a menopausal
woman. Estradiol accounts for another 10% of the circulating
estrogen in pre-menopausal women. Most traditional prescriptions of
estrogen have either estrone or estradiol. Premarin has estrone, as
well as thirty other equine estrogens. Estrace and estrogen patches
consist of estradiol.
Estriol accounts for the remaining 80% of circulating estrogen.
It is the weakest and most benign of the estrogen family. It is
also the predominant estrogen in pregnancy. It is felt to be
protective by counterbalancing the aggressive effects of estrone
and estradiol. Some studies show it has a protective effect against
breast cancer. Vegetarians and Asian women have higher levels of
estriol and lower levels of breast cancer. Women with breast cancer
were found to have lower levels of estriol relative to estrone and
estradiol. Sisters and daughters of women with breast cancer were
found to have lower than normal levels of estriol. One of the
reasons why an early pregnancy is protective against breast cancer
is possibly because of high estriol levels. Estriol is extremely
effective in preserving the lower genital tract. As a vaginal cream
it is very effective at alleviating vaginal atrophy, preventing
urinary and vaginal infections, and preventing urinary
incontinence. Estriol has not been shown to be protective to the
heart or bones. Vitamin E can increase estriol levels. Estriol is
often referred to as the forgotten estrogen because it is rarely
prescribed. Although research on estriol is limited, all evidence
points to its protective nature, so I believe it is a mistake not
to prescribe it with the other estrogens.
Women who take supplemental estrogen should take either Biest or
Triest. Triest is an exact ratio of the hormones described above.
It consists of 10% estrone, 10% estradiol, and 80% estriol. Biest
is 20% estradiol and 80% estriol. The theory behind using Biest
instead of Triest is that estrone is the most aggressive of the
estrogens and menopausal women already have enough estrone in their
bodies. In reality, estrone and estradiol are readily converted to
one another so whether you take one or the other, both estrone and
estradiol are going to be in the body.
There are several ways to take estrogens; the most common way is
oral administration. Swallowing a pill is very easy and oral
administration improves the cholesterol profile more than other
routes of administration. Oral estrogen reduces insulin-like growth
factor-I (IGF-I) and increases growth hormone. The downside of oral
estrogens is the “first pass liver effect”. Anything we ingest
immediately goes to the liver. When the liver processes the
hormones, it makes steroid hormone binding globulin (SHBG). SHBG
binds hormones, making them unable to perform their functions. The
liver also is responsible for making clotting enzymes, and oral
estrogen leads to a greater production of these enzymes. Oral
estrogens increase the risk for gallbladder disease and raise
triglyceride levels. Oral estrogen showed a reduction in lean body
mass and an increase in fat mass, when compared with transdermal
estrogen. I prefer transdermal, via creams or gels, or sublingual
(under the tongue) administration of estrogen. This causes the
estrogen to go right into the bloodstream without the “first pass
liver effect”. When the ovary produces estrogen, it immediately
gets into the blood stream via the ovarian vessels. The transdermal
and sublingual routes closely resembles this physiologic process.
Transdermal application of estrogen does not increase the risk of
gallbladder disease or raise triglyceride levels like oral
administration does. Transdermal estrogen also is less of a risk
factor for blood clotting because the estrogen does not initially
go through the liver.
Despite what recent studies have led many physicians and women
to believe, estrogen is protective to the heart. The American
College of Obstetrics and Gynecology (ACOG) now recommends that
women no longer take HRT for cardiovascular protection. This is
based on the findings from the Women's Health Initiative (WHI)
study, but only the effects of synthetic hormones on older women
were studied. See the chapter on research on HRT. More than 40
observational studies have shown that menopausal women receiving
estrogen have less heart disease than menopausal women not on
estrogen. We cannot just ignore the other studies. Heart disease is
the leading cause of death in women and they usually do not develop
heart disease until after menopause, when estrogen is deficient. In
multiple studies, estrogen also has been shown to prevent
artherosclerosis. It does this by lowering total cholesterol,
lowering low density lipoprotein (LDL) cholesterol, raising high
density lipoprotein (HDL) cholesterol, and lowering lipoprotein
(a), homocysteine, and C-reactive protein (CRP). Estrogen also has
direct vascular effects. It increases vascular dilatation by
relaxing the smooth muscle cells within the vessel wall. Estrogen
increases endothelial cell growth, increases insulin sensitivity,
and decreases coagulation factors. It also decreases uptake of LDL
cholesterol in the coronary arteries and inhibits the oxidation of
LDL. This results in a decrease in artherosclerosis and an overall
protection to the coronary arteries.
Nothing is better than estrogen at preventing osteoporosis. The
majority of bone loss occurs in the first five years of menopause
without estrogen supplementation. Without estrogen women lose
approximately 3-5% of their bone mass per year for the first five
years, and then approximately 1% per year thereafter. Not only does
estrogen prevent osteoporosis by reducing bone resorption, studies
have shown that it helps to rebuild bone mass as well. Estrogen has
also been shown to reduce the chance of a fracture in weaker bones.
Menopausal women have a 15% chance of developing a hip or wrist
fracture, and a 20% chance of developing a vertebral fracture. When
long-term estrogen replacement is complemented with adequate
calcium intake, hip and wrist fractures are reduced by 55% and
vertebral fractures are reduced by 80%. Hip fractures are so
serious that approximately 20% of women hospitalized because of a
hip fracture die within a year.
Colon cancer is the third leading cause of cancer deaths in
women, after lung cancer and breast cancer. The risk for developing
colon cancer is reduced by 50% with estrogen use. The longer one
uses estrogen, the more protection they receive. This risk
reduction is maintained for approximately ten years after
discontinuation of estrogen. The WHI did not see as great as a
result, but patients were observed for only five years. Between
1960-1990, mortality rates from colon cancer rose in men by 16%,
whereas in women they fell by 21%. This time period is when women
started using more estrogen replacement, so estrogen could account
for these findings.
Studies on estrogen and the risk of Alzheimer's disease have
shown mixed results. The Manhattan Cohort Study showed that
estrogen reduced the chance of Alzheimer's disease by 60%. It also
showed that of those women who get Alzheimer's disease, women on
estrogen get it later in life than women not on estrogen. The
Leisure World Cohort Study showed that estrogen reduced the risk of
Alzheimer's disease by 35%. It also showed that women on larger
doses of estrogen and longer duration of use had even more of a
reduction in risk. The results of the Women's Health Initiative
Memory Study (WHIMS) were published in July 2003. This study
evaluated the chance of developing Alzheimer's disease among 4500
women older than 65. Over a five-year period twice as many women on
Prempro developed dementia compared with a placebo. Prempro is
Premarin and Provera (See the chapter on Reaserch on HRT) and it
may be the Provera that was responsible for the increase in adverse
outcomes. Provera has been shown to increase the incidence of
strokes; thus the memory of the women could have been affected by
transient strokes (transient ischemic attacks) within the brain.
The WHIMS found no significant increase or decrease in Alzheimer's
disease in women taking only Premarin. Additionally, the women
studied were much older than the women in previous studies. This
might suggest that older women do not get the same protection from
hormones as younger women. It is quite possible that estrogen
receptors in the brain are down regulated after prolonged absence
of estrogen. One of the first things most women notice after
estrogen depletion is short-term memory loss and “brain fog”. In
many women this is reversed with estrogen supplementation.
The biggest fear of women who use estrogen is breast cancer.
Among women surveyed, 40% felt that the leading cause of death in
women is breast cancer, where as in reality it is 4%. Whether or
not estrogen causes breast cancer is still not known. Prior to the
WHI study, there were more than fifty case control and cohort
studies with mixed findings; thus the findings have been
inconclusive. If there is an increased risk, the risk must be
small. (See the chapter on research on hormone replacement
therapy.) The largest cohort study looked at 46,355 women who were
evaluated for 15 years in the Breast Cancer Demonstration Project.
There were 2082 incidents of breast cancer. Women taking estrogen
alone had a 1.2 fold increase in breast cancer, whereas women
taking estrogen and a progestin had a 1.4 fold increase in breast
cancer. Progestins (synthetic progesterone) have recently been
shown to be more responsible than estrogen in the rising incidence
of breast cancer. These risks are shown to decrease after stopping
HRT, and are almost nonexistent five years after stopping.
These studies only looked at unnatural hormones, so the hormones
a woman naturally produces have not been properly evaluated.
Unnatural estrogens have been shown to increase density and mitotic
activity in breast tissue. It is unclear if natural hormones have
the same effect. Studies have shown that women who take HRT have a
greater chance of surviving breast cancer. The breast cancers in
women who use HRT are more likely to be lobular in origin. As a
result, there is a 40-60% reduction in mortality when compared with
women who developed breast cancer without a history of HRT.
Unfortunately studies on
bioidentical hormones are limited regarding breast cancer. Estriol has been postulated to be
protective but doctors are not using it, so studies will continue
to be limited. Every baby a woman has lowers her chance of breast
cancer by 7%. It very well could be the high levels of estriol
during pregnancy that is responsible for this protection.
Macular degeneration is a major cause of vision loss in the
elderly. Because the average age of the population continues to
increase, macular degeneration will be more of a concern in the
future. Multiple studies have shown that estrogen use decreases the
incidence of macular degeneration.
Estrogen has many other benefits. First of all, it is the
hormone that makes women feminine. Estrogen is what makes a woman
feel like a woman. Estrogen increases libido, preserving sexuality.
Estrogen prevents hot flashes and night sweats. Woman lacking
estrogen have difficulty sleeping and estrogen restores sleep. It
increases stamina, giving a woman more energy. Estrogen keeps the
vagina young and healthy by preventing vaginal atrophy. Vaginal
atrophy is thinning of the vaginal tissue and shortening and
narrowing of the vagina. Vaginal atrophy can result in decreased
vaginal secretions and painful intercourse. There are more estrogen
receptors in the vagina and urogenital tract than anywhere else in
the body. As a result, estrogen protects from bladder and vaginal
floor problems such as urinary incontinence and pelvic organ
prolapse. Estrogen is also beneficial to the skin. Skin collagen is
affected by loss of estrogen. Skin collagen is responsible for
keeping the skin youthful by making it more elastic and thicker,
which leads to fewer wrinkles. As women age the skin thins and
estrogen prevents this thinning. Estrogen also keeps hair and nails
youthful. Adequate estrogen levels also can prevent migraine
I recommend using estrogen daily. The older philosophy is to take
estrogen only on days 1-25 of the month. Not only is it less
confusing to take it daily, but many women have hot flashes and
other side effects from estrogen withdrawl on days 26-31. Some
practitioners recommend reproducing the menstrual cycle when
replacing estrogen. They tell their patients that if they are not
menstruating then they are not putting enough estrogen in their
body. Menopausal women do not need to have the estrogen levels of a
nineteen year old. The only purpose of having high fluctuating
levels of estrogen is for reproduction. Though some menopausal
women menstruate with supplemental estrogen, it is not imperative.
The only purpose of menstruation is to ready the uterine lining for
Progesterone is produced by the corpus luteum in the ovary after
ovulation and by the placenta during pregnancy. After ovulation
(approximately day 14), the corpus luteum starts producing
progesterone. The corpus luteum is the remainder of the egg left
behind in the ovary. The second half of the cycle is thus called
the luteal phase; it is the progesterone dominant phase of the
menstrual cycle. Progesterone peaks approximately 6-8 days prior to
the next menses, which occurs around day 21-22 of the cycle.
Progesterone is responsible for stabilizing the thickened
endometrial lining in the uterus.
If conception occurs, the corpus luteum continues to produce
progesterone until 6 weeks after conception. The placenta then
takes over the production of progesterone. If conception does not
occur, the corpus luteum regresses, causing the progesterone level
to fall. When the progesterone level gets back to its initial
baseline, menstruation sets in and a new cycle is started. If
ovulation fails to occur, progesterone is not produced. In
perimenopause, ovulation is sporadic, so progesterone levels begin
to decline. In menopause, progesterone is completely absent.
Rarely do menopausal women take progesterone; instead they are
prescribed a synthetic progestin. There are many different
synthetic progestins invented and patented by pharmaceutical
companies. Hormones act on receptors and that receptor is looking
for a specific molecule. The molecular structure of progesterone is
not exactly the same as that of a synthetic progestin. The
synthetic hormone can bind to the receptor but it does not fit
exactly right, causing a different effect. Progestins also have
been accused of tying up the receptor, not giving a pure
progesterone response, causing estrogen dominance in tissues
throughout the body. Synthetic progestins have a different effect
on breast tissue, the cardiovascular system, and the brain when
compared with progesterone.
Provera is a synthetic progestin, not progesterone or even close
to it. Provera attenuates the benefits of estrogen. Provera raises
LDL and total cholesterol, and lowers HDL cholesterol. As a result,
it is damaging to the vascular system. A study published in the
Journal of Reproductive Medicine showed that progesterone did not
negatively affect estrogen's positive effect on the heart, whereas
Provera did. In another study progesterone, but not Provera,
enhanced the beneficial effect of estrogen on exercise induced
myocardial ischemia (lack of oxygen to the heart). In several other
studies, Provera was shown to constrict coronary arteries, causing
vasospasm and myocardial infarction (heart attack), whereas
progesterone dilated coronary vessels in primates. It is felt that
natural progesterone has a direct impact on reducing platelet
aggregation through its ability to enhance endothelium-derived
nitric oxide. Progesterone also increases HDL cholesterol, making
it even more protective to the heart. The data from these studies
demonstrate that progesterone has a different effect on the body
compared to Provera.
Provera also increases the risk of breast cancer. Studies
looking at estrogen versus estrogen and Provera show an increase
incidence of breast caner in the latter. Studies have shown no
increased risk when natural progesterone is added to estrogen. It
is believed that progesterone is cancer protective by
counterbalancing the aggressive effects of estrogen.
Critics of this philosophy state that both progesterone and
Provera act on the same receptors, thus they should elicit the same
response. These molecules are completely different from one another
and thus elicit different responses. Provera has been shown to
cause bloating, breast tenderness, mood disturbances, somatic
complaints, and lowers core body temperature. One reason why women
stop taking HRT is because of the side effects of Provera. In
contrast, women enjoy the way they feel on natural progesterone.
Instead of causing bloating, it is a natural diuretic. It also
reduces irritability, anxiety, depression, and raises core body
temperature. With such different effects on the same receptor, it
is readily apparent that these two hormones are not
interchangeable. Additionally it is felt that Provera may provide
insufficient balance for estrogen, making a woman estrogen dominate
causing the diseases above.
After the WHI study, progesterone is now thought of as a
dangerous hormone because of the increase in disease seen with
Prempro. If progesterone is so dangerous, we should see disastrous
events during pregnancy because this is when progesterone is at its
highest. We should also see complications in younger women when
they are naturally producing progesterone. We do not see either of
Initially when women were started on HRT, they were only given
estrogen. Physicians started to see an increase in endometrial
cancer (cancer of the uterus) secondary to the unopposed estrogen
in the uterus. Instead of prescribing progesterone, they started
prescribing synthetic progestins. If a woman has had a
hysterectomy, only an estrogen is prescribed. The philosophy behind
this is that if a woman no longer has a uterus she cannot develop
endometrial cancer and thus does not need progesterone or a
progestin. Progesterone has many positive effects in the body
besides protecting the uterus. Progesterone is responsible for
counterbalancing estrogen in all organ systems.
Progesterone is cancer protective. Progesterone reduces the
mitotic change in endometrial and breast tissue. It reduces cell
proliferation; it enhances natural killer cells, interleukin-2, and
the p53 molecule. Natural killer cells and interleukin-3 are
important components of the immune system. Molecule p53 coordinates
the actions of more than 60 genes that prevent damaged cells from
turning cancerous. Progesterone increases apoptosis, cell
destruction before damaged cells are converted to malignant cells.
Several studies have shown that the higher a woman's progesterone
level, the less likely she is of developing cancer cells.
Additionally, progesterone is a calming hormone. It reduces
anxiety, irritability, and depression. This is why progesterone
should be the first line treatment for PMS. Progesterone is helpful
for insomnia as well. It prevents osteoporosis by aiding in bone
formation. Adequate progesterone helps prevent uterine fibroids,
ovarian cysts, and fibrocystic breast disease.
It is usually recommended to take progesterone for two weeks a
month, replicating the natural menstrual cycle. I often prescribe
progesterone daily because it is less confusing this way and women
generally feel better when on progesterone. If women are still
menstruating, I recommend using it for two weeks starting on day 14
of the menstrual cycle so their menses stays regular.
Half of the testosterone produced in women is made by the
ovaries; the other half comes from the adrenal glands. Testosterone
is important for maintaining muscle mass, strength, and endurance.
It is important for proper vitality and energy levels. Adequate
testosterone levels have been shown to improve memory and mood.
Testosterone is important in burning fat, especially in the
abdomen. It is also important for preserving libido and enhancing
orgasms. It protects from osteoporosis and cardiovascular disease.
It lowers the risk of heart disease by lowering cholesterol and
triglyceride levels and normalizing blood clotting.
Artherosclerosis increases as testosterone levels decrease.
Testosterone reduces blood glucose levels by increasing insulin
sensitivity, resulting in less abdominal fat. Testosterone has also
been thought to increase creativity and confidence. Testosterone
helps preserve the integrity of the skin by increasing skin tone.
Synthetic testosterone, such as methyltestosterone, does not have
all of the same benefits and may even cause damage to the heart by
increasing LDL cholesterol and decreasing HDL cholesterol.
Unlike estrogen and progesterone, a woman's ovaries continue to
produce testosterone after menopause. Most of this testosterone is
converted into estrogen and this is where the majority of a
menopausal woman's endogenous estrogen comes from. Testosterone
peaks around age 25 and its production, like most hormones,
diminishes with age. Supplemental testosterone is important for
most women, and if a woman has had her ovaries removed, it is
especially important. Testosterone levels are highest around
ovulation, which is responsible for increasing libido at the proper
time for fertilization. The first signs of too much testosterone
are acne and facial hair.
DHEA (dehydroepiandrosterone) is produced by the adrenal glands.
DHEA is the most abundant hormone in the bloodstream. It peaks at
approximately age 25, and after that we lose approximately 2% per
year. The majority of testosterone in a woman comes from the
peripheral conversion of DHEA. DHEA is an anti-stress hormone; it
reverses the effect of stress on the immune system. It improves
mood and acts as an antidepressant. It also improves memory,
energy, and stamina. Brain cells have been found to degenerate more
rapidly when DHEA is low. DHEA is felt to be beneficial to the
cardiovascular system. It has been shown to improve
artherosclerosis and reduce platelet aggregation. It also has been
shown to prevent osteoporosis.
Pregnenolone is produced by the adrenal glands and it is the
first hormone sythesized from cholesterol. If there is not an
adequate supply of pregnenolone, the production of other hormones
becomes deficient because pregnenolone is the precursor for other
hormones. Pregnenolone functions in cellular repair, especially in
the brain and nervous system, thus preserving brain function. It
can help to improve memory, alleviate stress, improve intelligence,
improve energy, and improve mood.
The thyroid gland is a bi-lobed gland that is found on both
sides of the trachea (windpipe). It is responsible for producing
the hormones thyroxine (T4) and triiodothyronine (T3). These
thyroid hormones control metabolism. They also regulate body
temperature and energy levels. Women are more likely than men to
develop a thyroid disorder. A deficiency in thyroid hormones is
termed hypothyroidism. The most common cause of hypothyroidism is
Hashimoto's disease, which is an autoimmune disease where
antibodies destroy the thyroid gland. The most common symptoms of
hypothyroidism are weight gain, fatigue, constipation, hair
thinning, and intolerance to cold.
Many other conditions can cause these same symptoms, so
laboratory analysis of thyroid hormones is also appropriate in the
diagnosis. The most common test is to measure thyroid stimulating
hormone (TSH), but there are often inaccuracies with this test
alone. Many women who have hypothyroidism have normal TSH levels.
Measuring T4, T3, and TSH, as well as a good clinical history will
more accurately diagnose thyroid disorders.
Hyperthyroidism is when the thyroid is over producing thyroid
hormones and typically has the opposite symptoms as hypothyroidism.
The most common symptoms of hyperthyroidism are weight loss,
diarrhea, heart palpitations, intolerance to heat, poor memory, and
muscle weakness. The most common cause of hyperthyroidism is
Grave's disease, which is a condition where antibodies stimulate
the thyroid gland to produce more thyroid hormones. Women are nine
times more likely to develop hypothyroidism than hyperthyroidism.
Approximately 10% of women have an undiagnosed thyroid condition.
The basal metabolic rate drops 5% every decade of life, which is
why hypothyroidism is very common in women over the age of
The endocrine hormones respond to each other and abnormal levels
of hormones affect other hormones. Too much or too little thyroid
hormone affects the menstrual cycle, which can result in ovulatory
problems, causing infertility. Ovulatory problems also change
bleeding patterns, resulting in irregular bleeding or amenorrhea.
Thyroid disease can also be responsible for miscarriages. Estrogen
dominance can also cause hypothyroidism, by inhibiting the uptake
of thyroid hormones. Estrogen dominance is common in anovulatory
states such as perimenopause. Estrogen dominance can be treated
with natural progesterone. There is good evidence that
hypothyroidism is responsible for causing artherosclerosis, leading
to heart disease.
The thyroid gland can become enlarged, forming a goiter. Most
thyroid goiters do not affect the amount of thyroid hormone
released from the thyroid. All thyroid goiters need to be evaluated
by a physician because a significant percentage of them are
The underlying disorder of hypothyroidism is usually not
curable. In order to treat hypothyroidism, thyroid hormone must be
replaced. The most common treatment is with levothyroxine
(Synthroid). Synthroid is synthetic thyroxine (T4). The problem
with synthroid alone is that some people are not able to convert T4
to T3; T3 is the most active thyroid hormone. Another problem is
that some people only convert T4 to reverse T4. Because of this it
is also important to treat women with T3. Cytomel is a prescription
form of T3. Some practitioners prefer Armour thyroid. Armour
thyroid is derived from pig thyroid and contains T3 as well as T4.
I prefer prescribing bioidentical T3 and T4 from a compounding
Taking too much thyroid hormone is dangerous because it can
cause heart problems and osteoporosis. Hyperthyroidism is usually
treated with radioactive iodine, which destroys the thyroid gland.
After treatment, most of these women are now hypothyroid and need
thyroid supplementation for the rest of their lives.
The Women's Health Initiative (WHI) is the largest study to date
on the risks versus the benefits of hormone replacement therapy
(HRT). It was stopped three years early on July 9, 2002. This made
headlines across the world because the study was stopped early due
to the belief that the risks of HRT outweighed the benefits. Many
studies have been done looking at the risk/benefit ratio of hormone
replacement therapy, but most of these studies were smaller
observational studies. The WHI involved 27,000 women in multiple
cities, which was sponsored by the National Institute of Health
(NIH). This study was a randomized, doubly blind study. The
patients were randomized to hormones or a placebo (sugar pill) and
neither the patient nor the doctor knew which arm of the study they
were on. This is the gold standard when looking at research. The
purpose of the study was to assess the long-term risk/benefit ratio
of HRT in disease prevention. The study evaluated the incidence of
heart disease, strokes, breast cancer, osteoporosis, and colon
caner. The study was supposed to last eight years until 2005.
Two different studies were undertaken. 16,608 women without a
hysterectomy were in the study involving
Premarin/medroxyprogesterone acetate (Prempro), which was the study
that was stopped in July, 2002. Per 10,000 women per year taking
Prepro instead of a placebo they saw 8 more cases of breast cancer,
8 more strokes, 8 more incidents of pulmonary embolism, 7 more
heart attacks, 6 fewer cases of colon cancer, and 5 fewer hip
fractures. Only 2.5% of the women on Prempro had these adverse
health problems. Even the authors of the WHI stressed that this
increased risk should not be a cause for major alarm.
This study has many faults. First of all quality of life was
never evaluated. Ever since the results of this study were
published, millions of women have gone off of their HRT. After
stopping their hormones, many women are suffering, and are fearful
to go back to taking hormones. If a study concludes that the
relative risk of a drug is only slightly elevated, the difference
in quality of life must be evaluated.
There have been multiple observational studies prior to the WHI
with no conclusive evidence that estrogen replacement therapy
increases the risk of breast cancer. The relative risk for
developing breast cancer on Prempro in the WHI study was 1.26. A
relative risk of 1.0 is considered of no risk and many doctors do
not consider a drug to be a risk until the number reaches 2.0. In
contrast, the relative risk of developing lung cancer from smoking
is 29.0. There are also numerous other risks for breast cancer that
are greater than taking Prempro; night shift work (RR 1.36), not
having children (RR 1.40), left handedness (RR 1.42), having your
first pregnancy after 29 years old (RR 1.48), obesity (RR 1.60), an
average of two alcoholic drinks a night (RR 1.7), greater than 13
years of education (RR 1.79).
Most women are convinced that taking HRT is going to cause them
to develop breast cancer. It takes approximately seven years to
diagnose breast cancer once it develops, so we cannot say that
Prempro causes breast cancer because these women were only
evaluated for five years. It raises the question that perhaps
Prempro promoted the growth of pre-existing breast cancers. Many
breast cancers have estrogen and progesterone receptors, so taking
HRT will make a lot of these cancers grow more rapidly and thus
they are diagnosed earlier.
Though this study was short lived, the Provera in Prempro has
been shown to increase the risk of breast cancer in earlier
studies. Studies looking at estrogen versus estrogen and Provera
show an increase incidence of breast caner in the latter. Studies
have shown no increased risk when natural progesterone is added to
estrogen. Additionally, it is felt that Provera may provide
insufficient balance for estrogen, making a woman estrogen
dominant, causing an increase in breast cancer. The WHI found a
decreased incidence of breast cancer in the group taking Premarin
without Provera, though it was not statistically significant.
Seeing an increased incidence of heart disease was very
distressing, because physicians have been giving HRT to women for
years, telling them that it was good for their hearts. This was not
surprising for the practitioners who have looked at the previous
studies involving Provera. Provera is a synthetic progestin, not
progesterone or even close to it. Provera attenuates the benefits
of estrogen. Provera raises LDL and total cholesterol, and lowers
HDL cholesterol. As a result, it is damaging to the vascular
system. A study published in the Journal of Reproductive Medicine
showed that progesterone did not negatively affect estrogen's
positive effect on the heart, whereas Provera did. In another study
progesterone, but not Provera, enhanced the beneficial effect of
estrogen on exercise induced myocardial ischemia (lack of oxygen to
the heart). In several other studies, Provera was shown to
constrict coronary arteries, causing vasospasm and myocardial
infarction (heart attack), whereas progesterone dilated coronary
vessels in primates. It is felt that natural progesterone has a
direct impact on reducing platelet aggregation through its ability
to enhance endothelium-derived nitric oxide. Progesterone also
increases HDL cholesterol, making it even more protective to the
The Heart and Estrogen/Progestin Replacement Study (HERS) study
was published in 1998. Previous studies like the PEPI study and the
Nurses' Health Study suggested that HRT may provide
cardio-protective benefits in women without coronary artery
disease. The HERS study evaluated whether or not Prempro could
prevent myocardial infarction in postmenopausal women with
established heart disease. They saw an increased incidence of
myocardial infarction in the first year of Prempro, but then a
protective effect in years 2-4. They found similar findings in the
WHI; the major risk was in the first year of treatment.
from these studies demonstrate that progesterone has a different
effect on the body compared to Provera. Critics of this philosophy
state that because both progesterone and Provera act on the same
receptors, they should elicit the same response. These molecules
are different from one another structurally and thus elicit
It was stated that the women in the WHI study were healthy.
However, their average body mass index was 28.5, which is
equivalent to 5'6”, 180 pounds . Fifty percent of the participants
had a history of smoking, thirty-five percent had hypertension,
4.5% had diabetes, and 2% had a history of a heart attack. The
biggest problem with the study was the average age of the women was
63, and only one third of the participants were in their
Only 25% of the women had a history of HRT use. We have known
for a long time that the vasculature loses its estrogen receptors
once artherosclerosis sets in. As a result, women no longer benefit
as much from a cardio-protective standpoint when given estrogen at
this time. It is also presumed that women start developing
cardiovascular disease rapidly after menopause without the
protectiveness of estrogen. Estrogens and especially
medroxyprogesterone acetate (Provera) can cause embolisms in
artherosclerotic arteries. An embolism is when a plaque in an
artery dislodges and travels elsewhere. If an embolism occurs in
the coronary arteries, it causes a heart attack. If an embolism
occurs in the carotid arteries, it causes a stroke. This is why an
increase in heart attacks was seen in the WHI and the HERS studies,
especially in the first year of use. The HERS study was similar to
the WHI in that these women started taking Prempro many years after
menopause, after artherosclerosis had set in.
HRT should be started at menopause, not at age 63. To support
this theory we should look at the studies involving birth control
pills. Birth control pills (OCPs) have very large dosages of
synthetic hormones, much larger than HRT. When perimenopausal women
are given oral contraceptive pills (OCPs) there is no increase in
heart disease or breast cancer. OCPs have actually been shown to
decrease the risk of cardiovascular disease. The reason for this is
that these women have not gone for a significant period without
estrogen in their bodies.
Women in the WHI study with a previous hysterectomy were either
given Premarin or a placebo. This study was halted in March 2004
because it was felt that Premarin did not have benefits over a
placebo. It was determined that there was no increase or decrease
in heart disease or breast cancer. Though there was a 9% reduction
in heart attacks and a 23% reduction in breast cancers in women on
Premarin; these numbers were not statistically significant. There
were significantly fewer colon cancers and cases of osteoporosis in
women on Premarin. There was a statistically significant increase
in strokes in women on Premarin. This again can be attributed to
unhealthy women being given estrogen after many years of not having
its protectiveness. There was not an increase in strokes in women
in their fifties on Premarin.
Of the forty observational studies evaluating estrogen and
cardiovascular disease, almost every one has shown that estrogen
has a protective effect. We cannot dismiss what we know about
hormones based on one study. Estrogen decreases total cholesterol,
increases HDL, and decreases LDL. It does raise triglyceride
levels. It also lowers lipoprotein (a), homocysteine, and
C-reactive protein (CRP) levels, giving additional cardiovascular
benefits. Estrogen also has direct vascular effects. It increases
vascular dilatation by relaxing the smooth muscle cells within the
vessel wall. Estrogen increases endothelial cell growth, increases
insulin sensitivity, and decreases coagulation factors. It also
decreases uptake of LDL in the coronary arteries. This results in a
decrease in artherosclerosis and overall protection to the coronary
arteries. It's no wonder that heart disease is much less common in
women prior to menopause before estrogen levels decline
Prempro and Premarin were used in the WHI study because they are
the most widely used of all HRT. Although Premarin is not as
harmful as Provera, it is still consists of foreign substances. Its
name originates from PREgnant MARes urINe. It consists of 30
different equine estrogens and all except one are foreign to the
human body. The only hormone that resembles a human hormone is
estrone. Premarin is three times more potent than your own hormones
and can exist in the body for more than six weeks after taking it.
A study showed that one ingredient, 4-hydroxy equinlenin, causes
single-strand breaks in DNA and oxidation of DNA bases. It is well
known that damage to DNA can lead to cancers, such as breast
It is hard to believe that a woman would take potentially
harmful synthetic or foreign hormones when she can take the exact
replica of the hormones she produced her entire life.
Pharmaceutical companies will not produce
bioidentical hormones because they cannot patent them. But they can develop a synthetic
hormone, patent it, market it, convince physicians to use it, and
then make a lot of money. They then donate their drugs to be used
in studies. The major limitation to the WHI was that it only
evaluated two forms of HRT, Prempro and Premarin. Obviously larger
studies need to be performed using
bioidentical hormones. We would
see much different results; it does not make sense for these
hormones to be protective to a woman in her 40's but not in her
Another problem with the study is that it did not evaluate
different routes of administration, such as transdermal
application. It is shameful that all forms of hormones are grouped
together as HRT as if they are all the same medication. I wish
headlines would state “Prempro is bad for you” instead of stating
“HRT is bad for you”. People need to understand that women are
healthiest when their hormone levels are at their prime. It is not
until hormones start declining and synthetic hormones are added
that we start to see health problems. Instead of discontinuing
Prempro, Wyeth pharmaceuticals recently introduced a lower dose of
Hormones are found in blood, saliva, and urine. The most accurate way to determine hormone levels is by blood.
Blood tests can determine both the level of the free hormone and the amount of hormone that is bound to its carrier protein.
Blood tests can accurately determine deficiencies of a hormone, and can show if adequate replacement has been prescribed.
The downside of a blood test is that hormone levels change from moment to moment and day to day. Thus the hormone level is evaluated
only at the time of the blood draw.
Proponents of saliva testing argue that only the free hormone is measured which determines the level of active
hormone available to tissues. A limitation of salivary testing is that when hormone levels are low, there may not be sufficient
hormones in the saliva to measure. In addition, saliva can become contaminated if any blood is in the specimen. Many practitioners
feel that saliva tests are extremely inaccurate and that hormone levels in the saliva are not consistent with levels in the rest of
Unfortunately, none of the hormone tests can measure what is happening at the receptor site or measure the hormone
levels in tissues. If proper hormone levels are not achieved, then the person is not getting the full benefit of the replacement
hormone. Each person responds differently to a dose of hormones because absorption and metabolism of hormones varies among
individuals. Additionally, hormone levels can be affected by the route of administration of the hormone.
When prescribing hormones for a woman, I recommend checking hormone levels in the blood before beginning, and then
again eight to ten weeks later. It is important to take the hormone as prescribed in order to evaluate hormone levels.
When hormone levels are checked, it is optimal to check the level approximately 2-6 hours after taking the hormone. This is when
the hormone level is peaking. If patients are not feeling the desired effect of the hormone or are having abnormal symptoms,
it is recommended to recheck the blood level of the hormone, so micro-adjustments can be made.
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Contact Kenton Bruice,
M.D. with your questions about bioidentical hormone