Talking about HRT

Many women who had been relying on hormone replacement therapy reconsidered or stopped the treatment after the Women's Health Initiative issued its widely reported warnings in 2002. The WHI, a long-term research study established by the National Institutes of Health, reported the potential of serious side effects: a 58-percent increase in risk for ovarian cancer; a 24-percent increase in risk for breast cancer; and a 31-percent increase in risk for stroke.

But without HRT, women may experience hot flashes, diminished sex drive, forgetfulness, low energy, and sleep disturbance.

"The study has scared women into not using any hormones at all," laments Dr. Lee Raymond Light, an internist and specialist in anti-aging and preventive medicine with the Naples Longevity Clinic, who says there is no increased risk in cancer from bio-identical hormones, which are molecularly identical to those made by the human body.

Dangerous Deficiencies
"Without a normal level of hormones, we don't function normally," says Naples-based Dr. Blane Crandall. He and a growing number of physicians draw a parallel between other hormone deficiencies, such as thyroid and adrenal, and the lowered estrogen levels typical of menopause.

"Diminished amounts of any hormone you can name are consequential," says Dr. Daved Rosensweet, whose Naples practice, Life Medicine and Healing, also specializes in bio-identical hormones. "And in all cases, [it] will diminish health, vitality and happiness."

When doctors find that patients have thyroid deficiencies, it's a matter of course to treat them to restore normal levels and peak functioning. Diminished estrogen levels-which can occur when a woman reaches the age when her ovaries shut down-potentially have similar deleterious effects on the human system.

"Everything in the body atrophies in the absence of estrogen," says Crandall. Then why, more doctors are asking, wouldn't they treat an estrogen deficiency as they would address any other hormone deficiency?

A flawed study?
Many physicians take issue with the WHI study. Dr. Jimmy Orr, who is medical director for Lee Cancer Care and president of the National Society of Gynecologic Oncologists, says, "The study was terribly flawed. The numbers can be very misleading." The reported statistical increase in breast cancer, for example, was actually just one case in 1,200. In addition, the study included only women who were well through the menopause years-over age 60-and no longer symptomatic.

Other physicians object to basing a study on the type of HRT used. In all cases, they say, researchers used an estrogen derived from pregnant mares' urine, and not what are termed "natural," or bio-identical, hormones.

Light says Premarin, the horse-derived estrogen product used in the WHI study, is not true replacement therapy. Instead, he says, "Women taking Premarin have received hormone-substitution therapy."

"Horses have estrogens that human females do not have, some of which have been shown to be genotoxic," says Rosensweet. "[They] lack the human female estrogen estriol that may be cancer-protective."

Others say Premarin has been effective for some patients. "It's not that it's bad. It's bad if you give it to the wrong person in the wrong dose," says Crandall.

Orr agrees. "I'm an advocate for estrogen," he says. "I know it does have a significant amount of benefits for women."

Every woman's physiology is different, and a "one-size-fits-all" mentality in hormone levels will result in overkill for some, and insufficient levels for others, Light says. The WHI study put all women at the same dosage level, which physicians say is guaranteed to cause trouble for some.

"If we did thyroid studies the same way," says Crandall, "it would kill some people, and for other people it wouldn't be enough."

Tailor-made Therapy
Just as women vary in size, shape and health, they produce varying levels of the hormones estrogen and progesterone in their childbearing years. Most doctors who advocate natural hormones try to match HRT with those levels. Generally, they use varying doses of hormone, and monitor levels through blood or saliva tests until optimum levels are achieved. Often they include the normal variations in hormone levels that occur during a woman's natural cycle.

These "tailor-made" hormones are derived from plant sources, like soy, and created by compounding pharmacies. They can be formulated into an oral form-as a pill-or into a topical treatment like a lotion, or even a vaginal ring. The latter two applications bypass the liver when metabolized and allow for lower effective dosages to be prescribed.

"It's not one-size-fits-all," says Light. "The patient is given individual attention."

Because many insurance policies don't provide coverage for either the doctor visits necessary to determine and monitor correct dosage levels or the natural hormones themselves, women who choose bio-identical HRT generally have to pay for the treatment themselves.

Light recommends that menopausal women do their homework. Patients should consider the doctor's experience and expertise in women's medicine, knowledge of different types of hormone therapy, including risks and benefits, and sensitivity to a patient's individual preferences and risks.