Hormone Therapy: Does Your Doctor Understand It?

You may have waited a few months to see your primary care doctor or gynecologist. Now you are in the waiting room. You may be fanning yourself to relieve the hot flashes that occur throughout the day and night. Lately you have been waking up at 2:00 a.m. to 3:00 a.m. It sometimes takes hours to get back to sleep, and sometimes you don’t. You drag yourself through the day and life is just not fun anymore.

You are depressed. Is this what it feels like to get old? You are only 50! Some days you feel so depressed, if you had the energy, you would dig a hole and jump in.

And what’s with your memory lately? Have you developed “snapping finger syndrome”; the more you snap, the more likely you will remember the name of that restaurant, movie, or your husband? Are you developing Alzheimer’s? Maybe if you ignore it, it will go away…

Will your doctor be able to help? Here are some clues.

1. He/she may ask you when you had your last period. If it has been less than a year ago he/she may pronounce that you are not in menopause, and therefor do not need treatment. If your doctor tells you this, you are in the wrong place! The textbook definition of menopause is no menses for 12 months. This is an arbitrary time frame and has nothing to do with treating and understanding the real patient who sits before you. The symptoms reviewed are typical of estrogen deficiency. To ignore them in a patient who is suffering in favor of following a text book definition is simply wrong. These symptoms can all be resolved with estrogen; why withhold it?

By the way, when symptoms of estrogen deficiency, such as hot flashes first appear, that is when significant bone loss could and often does occur. Don’t let your bones melt away, while the doctor waits for a textbook time frame to be reached. What is more important; the textbook or patient?

2. These symptoms mentioned at the beginning of this article are due to estrogen deficiency, not progesterone. Many doctors seem to think that progesterone is safer than estrogen. They substitute progesterone when the body is screaming for estrogen. If you have these symptoms, and are offered progesterone, run, do not walk out of that office!

Progesterone will not only fail to relieve your hot flashes, memory problems, lack of sexual interest and depression, but could make them all worse! Progesterone is only present to a significant amount on day 14-26 of a healthy young woman’s menstrual cycle. This hormone peaks in the “premenstrum”. Its job is to prepare the woman for pregnancy. It is a sedative, increases appetite and sometimes weight, stimulates the breast tissue (and can enlarge breasts). It is also the hormone which that causes PMS. The women who experience bloating, irritability, headaches and lack of motivation, adding excess or unnecessary progesterone can bring it back. As if you weren’t suffering enough, a physician who treats a perimenopausal woman with progesterone only is adding a whole bunch of potential hardship to her.

Why does it seem to help sometimes? Because progesterone “primes” the receptors for estrogen. By doing this, the decreased estrogen in a perimenopausal woman is heard better, and thus the symptoms may decrease. This leads patients and some doctors to conclude that the hormone needed is progesterone. It is not. The hot flashes, insomnia, lack of energy and sexual interest will return, usually in 3-6 months, as the levels of estrogen continue to decline.

I recently saw a patient who was menopausal. She had been treated with a walloping 200 mg of progesterone. This is 2 x the usual dose for protection of the uterus. She was given zero estrogen! She gained a considerable amount of weight. Her breasts were enlarged, she was depressed, and her sleep was horrible with soaking night sweats!

Should progesterone be given at all if it is so bad? If you have a uterus, and want to take estrogen, the answer is “yes”. Progesterone protects your uterus against overstimulation by estrogen. This essentially removes any risk of uterine cancer in taking hormone replacement. Hormones in their natural state, balance each other out and unlike congress, work together for the benefit of the human body. There are a variety of ways to administer progesterone, but the usual way is a daily dose of 100 mg taken before bed.

Is there a difference between natural progesterone and synthetic progesterone? Absolutely! Natural progesterone has been shown to cause less breast stimulation than synthetic, and less cardiac risk. It does not increase LDL (bad cholesterol) or decrease the HDL (good cholesterol). Synthetic progesterones called progestin, MPA, or anything but “progesterone” may cause all of that as well as headaches and migraines.

Why use these synthetic progesterones at all? Because in some cases women may develop bleeding on estrogen replacement that does not respond to natural progesterone. The synthetic progesterones are stronger and thus, may be able to better “do the job”.

3. “Let’s have you come in every month to check your progesterone level”. If your doctor says this or something similar, it is another cue to exit his or her office. Progesterone is used to keep the uterine lining thin; plain and simple. It does not matter at what level it is in your blood, the real and only important question to ask is, is it doing the job? An ultrasound of the uterus will tell the answer. It is a safe, non-invasive, no-radiation way of determining the effectiveness of progesterone.

There is substantial research to guide physicians in dosing progesterone therapy. I would suggest following the recommendations from this information. If a question or problem arises, such as bleeding, an ultrasound should be ordered. End of story.

Here is the truth: estrogen is a good thing, only contraindicated in women who have had breast cancer with estrogen positive receptors. Estrogen is needed by most tissues in a woman’s body, and, thus, they work better with estrogen on board. That includes the brain, bones, heart and sexual organs. Estrogen has been shown to prevent Alzheimer’s disease. This fact alone should have doctors running to their desks to pull out their prescription pads! Estrogen replacement can take away the achiness and stiffness people associate with “just getting older”. It can also decease osteoarthritis (also called wear-and-tear arthritis, the most common form). It helps supply collagen under the skin and in joint spaces. And helps to keep sexual organs and interest at a healthy level. We have excellent tools to provide estrogen at a little to no risk for most women. Let’s make aging a fun process! Imagine all you have learned and remembering it with vitality and energy of a healthy body. Patients deserve this. And they deserve a physician who knows enough about hormones to be able to provide it.