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| Doctor, What should I expect from HRT? | ||
| Q: I am an Ob/Gyn and patients are asking me for "Natural
Estrogens" and natural progesterones for HRT. They
understand the studies are not as complete as other HRT medications
but desire to stay away from Premarin. Could you please discuss
these medications and their use in HRT.
A: The request for "natural hormones" is nearly universal. But there is a lot of misunderstanding regarding this idea. What is natural? Compounds derived from nature? Or compounds from pharmaceutical companies that are structurally similar to hormones produced by the ovaries? Premarin is a mixture of many compounds, estrogens progestagens and even androgens. It is derived from the urine of pregnant mares and contains mainly oestronsulphate but also equilines that are natural for horses but not for women. The estrogen activity of equilines is about the same as estradiol. So no difference in activity but difference in source. Natural estrogens (in women) are estradiol and estron. Micronized estradiol is a very popular prescription in Europe. With oral ingestion of estradiol, the estradiol is converted in the intestine to estron and absorbed as such and during the passage through intestine and liver most of it is converted to estronsulphate. Estronsulphate is the pool for the active compound estradiol. So, no difference in the end result with estronsulphate tablets and micronized estradiol. Is estronsulphate now a natural estrogen or not? In premenopausal women the estron:estradiol ratio is about 1. With oral estrogen medication there are much higher levels of estron than estradiol. Is this natural? With transdermal estrogens, estradiol is absorbed through the skin and partly converted to estron. The ratio estron:estradiol is about 1 just as before menopause. This looks much more natural than all other ways of administration. The same is true with progesterone. The only natural compound is progesterone. But this is absorbed very poorly both in the intestine as through the skin. Nowadays we have special products with micronized progesterone with a reasonable absorption pattern (Prometrium). This product is expensive and high doses are needed. With sedative and hypnotic side effects. because of the rather bad properties of progesterone in the early days progestagens are developed with the same activity as progesterone, and mostly several other activities. This are the no natural progestins. Progesterone is developed also in a vaginal cream with good absorption pattern (Crinone). The natural progesterone creams (very popular among women) give no measurable progesterone levels in serum and are not protective for the endometrium. Herbal remedies for perimenopausal symptoms is something for believers. The use of herbal remedies can be compared with religion. No proof, but many know for certain that it works. As an obgyn specialist in gynecology, I limit my comment to proven remedies. Only with red clover (and only with one brand, Promensil) a proof of benefit for hot flushes exists. When you wish an overview of non-western medicine you have to consult an alternative practitioner. Please check-out this great article on your question called, Alternatives to Menopause Management. Reprinted with the kind permission from Andrew Dott, MD, MPH and the Institute of Endocrinology and Reproductive Medicine. |
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| Q:
I am a 35 year old female that had a partial hysterectomy 11 years
ago. In December 2000, my remaining ovary had to be removed due
to recurrent painful ovarian cysts. I started HRT after surgery,
then began to have severe migraines within a few weeks (I have a
history of migraines). My MD suggested I discontinue HRT and see
"what happens". The migraines went away. I then
decided to try herbal HRT, and went with a cream that had wild yam in
it. On the 3rd day of use, I had to be rushed to the ER with a
severe migraine (B/P was 158/96). I discontinued this and waited
a few months, then tried Soy Isoflavones ... same result. Currently,
I take 81 mg ASA, 800 iu Vit. E, Red Clover, Black Cohosh,
Calcium/Magnesium, and Nortryptaline every day. The hot flashes
are almost unbearable! How long can I expect these hot flashes
to continue, and is there anything (other than HRT) to minimize them?
A: Migraine can be worsened by oral HRT. With transdermal HRT no worsening of migraine is seen. So, try patches with estradiol. Start with a low dose and increase the dose until reasonable success is reached. |
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| Q:
I'm menopausal, tried Prempo for 8
months, after 4 months
started having panic attacks, feeling
depressed, some spotting for 3 months, finally stopped. Off Prempo
Dr. wants me to start on patch 0.05 Estradern for
a month then Provera 2.5 added the next month. US probe 8. Will
bleeding start up heavier when probe is 8 or has no barrier?
Would staying off Estrogen, would the
lining of uterus go back to normal? Wouldn't I have had panic attacks
and depression on Prempo sooner than 4 months? I'm 54 and
FSH 56, estradiol 15.
A: First of all: what is the reason to take estrogens? Is there a proper indication (complaints? high risk of cardiovascular disease or osteoporosis) or is it because it is good for you? Without proper indication: stop and wait and see what happens. When you really need estrogens, try the estraderm or other patch, but do combine this with an adequate amount of progestagens as in the Combipatch. Adding Provera to continuous estrogens is possible but in higher dose on a sequential base. Or with the low dose of 2,5 but than from the beginning. Otherwise bleeding will be a problem. |
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| Q: What can be done about the weight gain associated with
taking Premarin? I started taking it 4 months ago and have
gained 5 pounds and rising steadily. I follow a healthy diet and
walk 2-3 miles almost daily. It's a struggle
just to slow the weight gain much less stop it.
A: Weight gain is a problem of nearly all women, especially in this age group. But estrogens can not be blamed for it. There is a lot of scientific evidence that with the use of estrogens weight gain is less than without estrogens. Your healthy diet contains perhaps more kJ than necessary. And your exercise is maybe not strenuous enough. |
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| Q: I am a 44 years old. In the past year, my periods
have been heavier with cramping, but the cramping is not every month.
I spot anywhere from 2-weeks to a few days before my period. My
flow is very heavy at times to the point on 1 or 2 occasions I had to
change a super tampax AND a pad within 1-1/2 hours. Then it
either slows or stops then becomes heavy again for about a day.
My periods also contain clots. My doctor wants to put me
on prometrium 200mg. I will start taking it 14-days after
the onset my period. I'll take it for 2 weeks then stop.
She said I should start my period. If things are the same after
I
take this, spotting, clots, she might do a D&C. What is the
purpose of this treatment for just 2-weeks? It doesn't
appear I should have to worry about any side-effects given I'm only
taking it for 2 weeks? Can you please tell me what prometrium is
and the purpose of this treatment? A: Your doctor has diagnosed an ovulatory disturbance. After ovulation the ovary secretes progesterone. A shortage of progesterone can cause bleeding problems. With 2 weeks of Prometrium the ovulatory cycle is mimicked and everything will be alright if the diagnosis is correct. Otherwise further investigation is necessary. |
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| Q:
I'm 38 years old, and I have been experiencing a lack of menstruation
for about 11 months now. I have been on Premphase for about a year and
a half and have not truly had a period since June 6, 2000. I was
told I had no estrogen so that is why I was put on the Premphase. The
dosage that I have been on is 0.625 mg/5 mg. In Nov. I was taking and
extra dosage of Provera 10mg, so a total of 15mg, that was to see if I
would start to menstruate. I also have not had a sex drive for quite a
long time and of course that is not good for my marriage either. I'm
going to have a testosterone level done on May 29, 2001 to see if that
could be the cause for the no sex in my life. I'm kind of
confused! Why would I experience all the symptoms of
menstruation but I don't menstruate? My breasts get very tender and I
experience my migraines and I have a bloated feeling all the time.
I know that the Premphase can cause some of these but, is there
anything that you can tell me I should try or do? I also would
like to know am I really in the final stages of menopause? If you can
please tell me anything that I could do? A: Premphase will induce withdrawal bleeds in about 90% of women. The other 10% are amenorrhoeic. That is not a problem at all. Breast tenderness indicates a high enough dose of estrogens. Migraines is a troublesome problem. This can be aggravated by oral estrogens, but not by transdermal estrogens. Maybe you can try an estrogen patch. Progestagens are also necessary with patches for 10-14 days each month! |
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| Q:
I am 46 years old and have an fsh count of 53, I have not had a period
since February 2001 and I am feeling extremely depressed and on edge
all of the time. I tried PemPro and was not able to tolerate it
due to severe abdominal cramping and very sore breasts. What do
you recommend? A: First of all, try a course of progestagens (10 days 10 mg Provera). With a withdrawal your ovary is still producing estrogens. Without withdrawal no ovarian function is to be expected. With withdrawal, you can switch to low dose birth control pills or to monthly courses of 10 days of progestagen. Without withdrawal: continue HRT but with lower dose. Your sore breast suggest a high dose of estrogens, either endogenous or exogenous. |
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| Q:
I had a tvh/bso in 1996 due to
endometriosis, and have been on 2 mg estradiol HRT since. I
have tolerated the HRT very well. Recently I began taking
2,000 mg./day Glucophage (Metformin) for PCOS. Since the Metformin
works in the stomach and intestine, I may not be absorbing
the HRT efficiently now. I started having hot flashes and
dryness. The nurse suggested taking the oral HRT pill and
inserting it vaginally to increase the absorption. I thought
the oral pills needed to be processed in the liver to be effective?
I do not use the patch because I swim daily. Is vaginal
insertion a good way to apply the hrt pill? Will it
absorb into the body and deliver more estrogen to the bodies cells
with vaginal application? Thank you for your answer. A: Vaginal application of estrogens can result in very substantial estrogen levels but the dose is not easy to find. With the modern matrix patch, swimming is no problem. Other parenteral application like estradiol gel or intranasal estradiol are possibilities but not available in some countries. Another possibility is to increase the oral dose. |
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