I like to think of treatment of menopause treatment as a series of "steps"... always consider the lowest level treatment and only advance to the next step if it is necessary for control of symptoms. With medications, "less is more" -- in other words, a person is always better off taking the lowest amount and lowest level of treatment that will work for them. Especially with women who need hormones, the lowest amount should be taken that will give the relief that is needed.
The steps I consider when helping a woman control symptoms related to the menopausal change include:
1. exercise, diet, lifestyle changes
2. herbal medications, nutritional supplements
3. low dose hormones that are the same as the body produces
4. pharmaceutical hormones, stronger than our natural hormones
Step 1 - Exercise, Diet, Lifestyle Changes
The first step: exercise. improving diet, and making changes in your lifestyle are improvements all women who have mild symptoms should make to feel more comfortable and improve their health in the future. Exercise can help to even out hormone production and, since it also helps to reduce circulating stress hormones, can be useful in women who note their symptoms are worse during and after stressful situations. Stress hormones, your "fight or flight" reaction, set you up for exercise, speeding up your heart rate, increasing your blood pressure and blood sugar, and more... and exercise works to reverse these effects. And, of course, exercise improves health in many ways at the same time. Even as little as 30 minutes of moderate exercise 3 times a week can make a difference. Building exercise into your daily routine works too - it doesn't have to be a session at the gym - take the stairs whenever you can, park in the far corner of the lot if it isn't raining... see how you can add more activity to your day, wherever possible.
Since many vegetables contain plant-based hormones, also called "phytohormones", eating more vegetables can help to even out our own hormone levels to a certain extent... When hormone levels are very low, these weak phytohormones can exert a small hormone-like effect. When natural hormone levels surge, phytohormones can have a dulling effect, moderating natural hormone action. A simple piece of advice I stumbled across, is to serve your plate with ¾ vegetables and ¼ meat, and to have 5 different colours of food in each meal!
Dressing in layers that can be quickly and easily shed, and installing a ceiling fan over your bed are two changes you can make that can improve your comfort and your sleep if you are suffering from hot flashes. I have found that the more quickly you can cool yourself off when your internal temperature setting rises, the less time the hot flash tends to last and the less discomfort you will feel.
These general "step 1" improvements, and others along these lines, are good for all women experiencing hormonal change to consider. Small changes can add together to make a significant difference and can add to any higher level therapy you may need to consider. As well, these are all healthy changes. Your reproductive years are becoming part of your past and you want to look forward to a healthy and happy retirement doing things you've always wanted to do. It's a good time to consider what you can do to stay healthy and active as you age gracefully and make these changes part of your life.
Step 2 - Herbal Medications, Nutritional Supplements
The second step to consider is herbal medications and nutritional supplements. I'm not a fan of taking a lot of supplements, but you might benefit from targeted ones. The two herbal medicines I have found most useful in my clients are black cohosh and vitex (also called chaste berry). Some women find good relief from hot flashes with black cohosh alone but others do better with a combination product that contains both ingredients. These combinations are available from several reputable companies and are much simpler and less expensive to take than taking each separately. Black cohosh is rich in phytohormones, so helps to regulate swings in estrogen levels, while vitex helps to increase progesterone effect, creating improved hormone balance. I have had perimenopausal women with heavy menstrual flow (a sign of low progesterone in relation to the amount of estrogen being produced) report normalizing of their periods after starting vitex.
A useful nutritional supplement that I have successfully used with clients, is magnesium, taken at bedtime. Magnesium tends to relax muscles, especially if it is lacking in the diet - and one study I read suggested that as many as 30% of diets are lacking in magnesium. A supplement taken at bedtime will sometimes help improve sleep and, since we also need magnesium for healthy bones, you might benefit from this supplement in more than one way! Also, magnesium is absorbed better if taken away from meals so taking it at bedtime makes sense regardless of the reason you are taking it.
Another supplement I have found useful for addressing sleep problems associated with stress, is pantothenic acid or vitamin B5. Waking in the middle of the night with your mind racing and unable to return to sleep in spite of being exhausted can be associated with a spike in production of stress hormones - hormones that should remain low during the night. Pantothenic acid can help prevent these nighttime spikes in production, improving your sleep. I usually suggest 100mg be taken at bedtime for middle of the night awakening, or at suppertime for those who have trouble falling asleep. Combination B-Complex vitamins all contain some vitamin B5. You will note that some combinations are labelled as "stress formulas" and these are safe and well worth trying for minor anxiety symptoms.
Of course, there are many herbal and nutritional supplements that can be helpful, and you may want to consult with a naturopath or specialized pharmacist for expert one-on-one advice. However, avoid getting caught up in taking a lot of different supplements and herbal medicines. As with prescription medicines, the more you take, the greater the chances of interactions and side effects. I generally suggest a trial of one month with a supplement and, if you don't notice an improvement, don't continue taking it.
Step 3 - Bioidentical Hormones
If you have severe symptoms of hormone imbalance, there's a good chance you would benefit from directly supplementing the missing hormone(s) - step 3. Aiming for the lowest level for the minimum time you need it is especially important when it comes to hormones.
And, with hormones, it is also best to use a hormone that is exactly the same as the one you are replacing, if you want it to do everything that your own hormone would do. Hormones are very complex molecules. They work by attaching to a specific hormone receptor, much like the way a key fits into a lock. Different sections of the molecule attach to different receptors in various tissues in the body, so changing even just one part of the molecule means that it will then have a different action on receptors for that piece of the molecule that was changed. In other words, any change in the molecule will change some of its functions in the body.
Hormones that are exactly the same as those we produce, are sometimes referred to as "bioidentical" hormones, meaning that they are biologically identical to those we produce. These identical molecules would, of course, keep all the effects of our own hormones when supplemented in a similar amount and timing. Bioidentical hormones are available commercially or can be compounded by a pharmacist.
Estradiol, our strongest estrogen, is commercially marketed as tablets, patches and vaginal cream or suppositories. Progesterone, the hormone that balances estrogen, comes as capsules and vaginal gel. Testosterone, the "male" hormone that women also need in small amounts, is available in capsules and cream.
Some doctors will prescribe the commercial testosterone cream for women, but it is packaged in packets or pumps with measured doses suitable for men. Women risk being overdosed when using these, although some will try to guess at the correct dose - which would result in a different dose every day and the chance of overdosing very easily. Too much testosterone in women, by the way, tends to cause side effects of acne, increased facial hair growth and, if overdosed for long enough, lowering of the voice.
So, one of the pharmacist's roles is to compound (or prepare from "scratch") dosage forms that are suitable for a particular patient. Testosterone cream for women is one such preparation that many pharmacists have made for years. An appropriate testosterone dose for a woman would be 1mg or less daily when applied to the skin, although doubling the dose initially for a week or two is often advised to see results sooner. Commercial testosterone creams are available in Canada in packets or pumps of 25 and 50mg, so it is difficult to imagine how any woman could measure an accurate and appropriate dose from one of these products.
As well, the "route of administration" or method of getting the hormones into the body can make a significant difference in how much you need to take. Swallowing hormones, although convenient, is really not an efficient method of taking hormones. Everything you swallow is filtered by the liver, and the liver works hard to keep hormones out of the body. Generally, you need to take about 10 times more hormone if you swallow it than if you use a suppository, patch or cream that is absorbed through the skin. This filtering is probably a function that developed during our evolution to prevent hormonal effects from accidental ingestion of a part of an animal that contained hormones. Our digestive systems are really designed to keep hormones from reaching the rest of our bodies.
At the same time, swallowed hormones make the liver work overtime, and this is seen as increased risks of gall bladder disease and liver toxicity. Testosterone, in doses intended for men, taken by mouth is even associated with cancers of the liver when used for extended periods of time. So, from all of this information (and more!) I have concluded that introducing hormones into the body through the skin, or the mucosa (by using drops under the tongue, or inserting a suppository or cream into the vagina or rectum) offer the best method of replacement.
And the dose should result in a blood level that is no higher than a normal level for a younger women in her reproductive years. Considering that we would be adding to a woman's existing production and that normal levels can vary from person to person, it is unlikely that the same dose would be ideal for everyone. Unfortunately, with many commercial forms of hormones, notably gels in pump containers, patches and some very tiny tablets, the dose form makes it difficult to individualize the dose to what is right for you.
As a compounding pharmacist, I was always looking for a system that would allow for accurate measuring while allowing a flexible dose. Creams can offer the advantage of an adjustable dosage, if they are packaged in a manner that allows this. Some patches can be cut without changing absorption (you would have to check each product to be sure) but, again, we would be dealing with "guessing" where to cut the patch.
The best system I could come up with, at a reasonable cost, was to pre-package creams in a syringe (with no needle) so a measured amount could be squeezed out and applied to the skin. Other measurement systems I've seen included a special jar or tube that allowed the user to fill a syringe themselves with the appropriate amount, but there could sometimes be problems with air bubbles that would result in a reduced dose plus women want a system that is convenient and easy to use. I'm waiting for an engineer to take an interest in our dilemma!
There is so much to discuss about low dose bioidentical hormone replacement - I've barely scratched the surface. Hopefully, this summary has given you some insight into issues you can discuss with your doctor, if you are unable to find relief with lower level menopause therapies...
Step 4 - Pharmaceutical Hormones
If considering pharmaceutical hormones or birth control pills for treatment of menopause symptoms, step 4 of our treatment choices, you need to weigh the pros and cons… These hormones, that are different from those produced by our bodies, are the strongest therapy option and one I rarely recommend for menopause symptoms, as there are better choices available, as explained in step 3 above. At one time experts seemed to believe that if hormones "kept you young" then the more, the better! However, now we know that too much hormone activity can be as problematic as too little, and dosages have been steadily reduced over the years.
A little history: Original doses of Premarin, conjugated equine estrogen (CEE), were as high as 2.5mg daily and it was taken alone. With use, it was noted that the endometrial lining of the uterus became thickened, and risk of cancer in this area was increased. Doses were reduced to 0.625mg and a second hormone, medroxyprogesterone, was added to prevent endometrial growth – this regimen worked very well to reverse the endometrial cancer risk. Several studies were done with the 0.625mg tablets that suggested it lowered risk factors for other diseases of aging so, although a lower 0.3mg tablet was available, it was less often prescribed. I suspect that the 0.3mg dosage would have been enough for many women.
While researching another issue years ago, I stumbled across early studies on medroxyprogesterone dating back to the early 1990s suggesting a possible increased risk of breast cancer. However, about the same time, a study by the World Health Organization failed to identify an increased risk of this cancer. So, its use continued until the landmark Women’s Health Initiative (WHI) study was stopped earlier than scheduled in 2002, due to its clear findings of more overall risk than benefit from the combination therapy of CEE and medroxyprogesterone. Stopping a study early gets the attention of the science community and the media, and most doctors stopped prescribing both of these hormone preparations right away.
Since then, risks of hormone therapies have been reassessed and researchers indicate that the warnings in the early 2000s were exaggerated. This resulted in a generation of women suffering more than necessary during the menopausal change. However, few doctors still prescribe the Premarin/Provera (medroxyprogesterone) pharmaceutical regimen that was once so popular.
When it comes to pharmaceutical hormones there are many different varieties, most of which are used for birth control. With all of these different “cousins” of our own hormones, we see subtle differences in their actions and side effects because of the differences in their structure (as described in Part 2 of this blog). There has also been a gradual reduction in the dose of birth control pills being introduced to the market over the years. All of this has made it difficult to analyze the side effects of long-term birth control use in women, with most being combination products with a variety of different hormones. In general, however, birth control pills have been found to be associated with reduced risk of endometrial and ovarian cancers, and with increased risk of breast, cervical and liver cancers. They are generally not recommended in women over 35 who smoke or who have heart disease, high blood pressure, diabetes or blood clots, due to added risk from the hormones in these pills.
Doctors will sometimes prescribe birth control pills to women in perimenopause (the years before periods stop when women are experiencing various hormone changes and symptoms) to control menopause symptoms as well as to prevent pregnancy. This may be a good option if you need birth control and don’t have any of the cautions listed above, but it’s a “one size fits all” approach that, in my experience, only addresses some symptoms a woman may be experiencing.
Perimenopause is characterized by lowered production of progesterone and normal or increased production of estrogen, with classic symptoms of heavier flow and skipped periods. While the synthetic progestin in the birth control pill generally will control the heavy periods, the extra estrogen is certainly not needed at a time when natural estrogen production is often higher than normal, creating a different set of excess estrogen effects for the woman. In contrast, the approach I used (and that of other pharmacists who do similar hormone analysis) offers assessment of symptoms to determine which hormones are missing and makes an effort to replace only those hormones. Some practitioners use saliva or blood hormone tests to assess what hormones are being over or under produced, and choose a therapy based on this information.
Humans have lived since the beginning of our existence with our own bioidentical hormones. While we still need to pay close attention to dosing and timing of supplements, and using the lowest effective dose for the shortest time needed, there is a definite trend toward using bioidentical hormones whenever possible with most physicians for treatment of menopause symptoms. Supplying hormones through the skin (as a patch, cream or gel) or as a suppository, rather than swallowing, also results in less hormone needed and fewer side effects, and avoids potential problems with the liver and digestive system.
Given the many years required for researchers to realize a long-used hormone therapy created more risk than benefit, and the possibility that other subtle but harmful effects could surface in the future, using low-dose bioidentical hormones whenever possible just seems like a logical route to take when non-hormonal therapies do not give sufficient symptom relief.
There is so much to say about understanding and correcting hormone imbalances - I've really just scratched the surface in this article. If you are interested in learning more, I have written a book on the topic -- Can I Speak to the Hormone Lady? Managing Menopause and Hormone Imbalances, published in February 2019. It's available in digital (e-book) and print forms through all major online retailers. Here's a link...
