Hormone Therapy Informational Session

Hormone Therapy Informational Session Ann Stanger, MD 2940 Chapel Valley Rd. Madison, WI 53711 (608)233-2378

Ann Stanger, MD
Graduate of Indiana University School of Medicine
Came to Wisconsin for OB/GYN residency at the University of Wisconsin Hospitals/Clinics
Opened an independent private practice in 2001.
Has been testing for and prescribing human identical hormones since 2001
Added Digital Infrared Thermal Imaging in 2008

Topics of Discussion
Symptoms of perimenopause and menopause
Women’s Health Initiative and what it means
Symptoms of imbalances of thyroid hormones, adrenal hormones and ovarian hormones
Testing for hormone imbalances
Hormone therapy options
Screening

Perimenopause
The 5-10 year period prior to the complete cessation of menses when periods are changing.
Symptoms usually start around age of 35-40.

Perimenopausal Symptoms
Changes in menstrual cycle timing and flow
Fluid retention
Glucose/insulin imbalances
Increased body fat, especially abdominal
Decreased energy/fatigue
Altered thyroid function
Decreased libido

Perimenopausal Symptoms, Continued
Anxiety/depression/mood swings
Sleep disturbances
Hot flashes/night sweats
Forgetfulness, inability to concentrate
Dry or itching skin
Dry or thinning hair

Menopause
The cessation of the menstrual period.
Considered to be menopausal after one year without a period.

Menopausal Symptoms
Any/All of the perimenopausal symptoms
Amenorrhea/missed periods
Vaginal dryness, pain with intercourse
Joint and muscle pain
Insomnia
Frequent urination
Frequent urinary tract infections

Who needs hormone therapy?
Severe symptoms-unable to function at work/home, increased pain, sleep deprivation
Increased health risks-bone loss, memory issues, cardiovascular disease
Desire for improved quality of life-improved energy, appearance, libido

What can you do now to decrease your need for hormone therapy later?
Maximize adrenal health
The adrenal gland is the source of precursor hormones that can be converted to estrogens and testosterone by the body after menopause
The healthier the adrenal gland, the easier the menopausal transition

Lifestyle changes for improved adrenal health
Regular bedtime prior to 10 pm
Good quality sleep
Regular daily exercise
Stress management
Avoid excessive caffeine, alcohol, sugar, white flour products
Healthy diet with many cruciferous vegetables

Why not take hormones?
Hormone therapy is controversial because of concerns about cancer, heart disease, strokes and blood clots.
Hormones were routinely recommended after menopause until the results of the Women’s Health Initiative study were released. The WHI was stopped early because of an increase in adverse outcomes.

Women’s Health Initiative (WHI)
NIH sponsored, Wyeth funded
Multi center study recruited 1993-1998
Ages 50-79, mean 63.2
Randomized, blinded, placebo controlled
Goal was to show that the hormones helped to prevent cardiovascular disease in the postmenopausal woman
Continuous conjugated estrogen plus progestin therapy arm (CCEPT) 16,608 women (with a uterus)
Estrogen therapy (ET) arm 10,739 women (had hysterectomy)

CCEPT Arm breakdown
33.4% ages 50-59
45.3% ages 60-69
21.3% ages 70-79
Not on hormones prior to the study
Same dose for all, 0.625 mg conjugated equine estrogen and 2.5 mg medroxyprogesterone acetate (MPA) or placebo
No perimenopausal or early menopausal women included

CCEPT Arm of WHI
40% drop out of both the treated and untreated group
Halted early after mean of 5.2 years (planned duration 8.5)
Stopped because of increased adverse outcomes
More heart disease, strokes, DVT, breast cancer in the treatment group

ET Arm of WHI
10,793 women without a uterus
All on 0.625 conjugated equine estrogen or placebo
Ended after 6.8 years average
Increased risk of stroke
Decreased risk of fracture
Neutral risk for heart disease
Neutral risk for breast cancer

The Other Side of the Story
Same dose for all, no other hormone is dosed this way
No screening for pre-existing illness that would have predisposed to heart disease and stroke
Billed as a preventive trial for CAD, yet started at average age 63
Used oral hormones which increase HS-CRP and clotting factors

Thomas, et al Progestins initiate adverse events of menopausal estrogen therapy
Climacteric. 2003 Dec;6(4):293-301
Synthetic progestins caused endothelial disruption, accumulation of monocytes in the vessel wall, platelet activation and clot formation.
The CCEPT arm used MPA, a synthetic progestin
Human identical progesterone does not have these side effects

Progesterone
Human identical progesterone has a different affect on the body and breasts than does medroxyprogesterone acetate (MPA)
Progesterone was not used in WHI
Progesterone cannot be patented, therefore no incentive on the part of drug companies to fund studies using it

Progesterone studies
Some small studies have been done regarding human identical progesterone therapy
1981 Cowan, Am J Epidemiology. 1000 women followed from 1945-78. Progesterone deficiency was associated with 5.4 times greater risk of breast cancer

Foidart, Fertility and Sterility 1998 looked at the topical affects of estradiol and progesterone.
Estradiol increased the number of cycling epithelial cells in the human breast.
Progesterone reduced the estradiol induced proliferation of normal breast epithelial cells

Fromby, Annals of Clinical Lab Science 1998
Progesterone was found to inhibit growth and induce apoptosis in breast cancer cells in vitro.

Cardiovascular effects of Bio-identical hormone therapy
Hypertension 2009, March 30, Langrish et. Al
Compared human identical (transdermal estradiol and vaginal progesterone) to standard hormone (oral ethinylestradiol and norethisterone) therapy in 4 week cycles for 12 months.
Monitored 24-hour ambulatory BP, arterial stiffness and renal factors.
Women on the human identical hormone therapy had lower BP, better renal function and less activation of the renin-angiotensin system.

The Bio-identical Hormone Debate
Holtorf, K; Postgraduate Medicine , 2009, Jan;121(1)
“ The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy?”
Review of published papers and data
Data and clinical outcomes demonstrated that bioidentical hormones are associated with lower risks, including risk of breast cancer and CVD, and are more efficacious than the synthetic and animal derived counterparts.

What hormones are involved in the hormone therapy I recommend?
Thyroid hormones (TSH, T3 and T4)
Adrenal hormones (cortisol, pregnenolone, DHEA-S)
Ovarian hormones for women (estradiol, estriol, testosterone)
Testicular hormones for men (testosterone)

Thyroid hormones
Made by the thyroid gland
Iodine and iodide are required for adequate thyroid hormone production
Related to metabolism
Affect mood and energy
Autoimmune thyroid disorders are becoming more common

Symptoms of Thyroid Hormone Excess
Weight loss
Anxiety
Insomnia
Diarrhea
Fast heart rate
Heat intolerance

Symptoms of Thyroid Hormone Deficiency
Weight gain
Fatigue
Brain fog
Dry skin/eczema
Hair loss/eyebrow thinning
Menstrual irregularities
Heavy periods
Low body temperature

Adrenal Hormones
Cortisol (also known as hydrocortisone)
DHEA which circulates mostly as DHEA-S
Pregnenolone

Cortisol/Hydrocortisone
Primary hormone of chronic stress management
Can become depleted over time from chronic stress
Low cortisol production is an underappreciated cause of fatigue
When cortisol becomes depleted, the “fight or flight” hormones are used by the body to manage stress causing anxiety, irritability, insomnia, hot flashes.

Pregnenolone
Decreases with age
Improves memory/brain fog
Improves mood
Considered the “mother hormone” because it is a precursor to the other hormones

DHEA-S
Dehydroepiandrosterone sulfate
Decreases with age
Decreases with stress
The original “anti-aging” hormone
Improves mood and sense of well being
Improves immune function

Ovarian Hormones
Progesterone
Estradiol
Estriol
Testosterone

Progesterone Deficiency Symptoms
Premenstrual syndrome symptoms
Anxiety
Headache
Mood swings
Sleep disturbances
Irregular periods/spotting

Progesterone Excess Symptoms
Fatigue/tiredness
Sleepiness
Depression
Bloating
Acne

Estrogen Deficiency Symptoms
Sleep disturbances/insomnia
Memory loss/trouble with concentration
Depression
Lack of libido
Vaginal dryness
Dry skin
Hair loss

Estrogen Excess Symptoms
Breast tenderness/fullness
Fluid retention/edema
Irritability
Nausea
Headaches
Dizziness
Weight gain
Sweet craving

Testosterone Deficiency Symptoms
Decreased libido
Difficulty with orgasm
Diminished sense of well being
Lack of drive and focus
Loss of muscle mass
Depression
Fatigue
Decreased bone density
Decreased pubic/body hair

Testosterone Excess Symptoms
Acne
Oily skin
Increased facial hair
Scalp hair loss
Deepening voice
Anger/irritability

Testing for Hormone Levels
Testing can be done via blood, saliva or urine
Testing for estrogen and progesterone must be done at the proper time of the cycle to be helpful
For the woman who it still having menstrual cycles, that is during the luteal phase, about cycle day 18-23, or the week prior to the next period
Testing should be done in the morning for most hormones when the levels are at their peak

How I test hormones in my practice
Estradiol, progesterone and free testosterone are drawn in the morning on cycle day 18-23 in the perimenopausal woman and any morning for the menopausal woman.
TSH, free T3 and free T4 are drawn at the same time.
Four part saliva collections are used for cortisol and DHEA testing

Routes of Administration
Hormone therapy can be administered in many ways
Topical/transdermal gels, creams, patches
Vaginal creams, gels, suppositories
Oral/sublingual tablets, capsules, troches, drops

In my practice
I usually recommend compounded estradiol and estriol (also known as BiEst or E2/E3) cream dosed twice daily. Patches of estradiol are another option.
Progesterone capsule at night
Testosterone cream in the morning either topically or vaginally
DHEA and Pregnenolone orally in the morning
Armour thyroid and iodine/iodide in the morning
The doses and uses of these hormones depend on symptoms and the levels on laboratory testing

Hormone therapy
Human identical hormones may be safer than those studied in WHI
Progesterone must be used along with estrogen in a woman who has her uterus. Unopposed estrogen will cause uterine cancer over time.
Estrogen use is a risk for the breast and some sort of monitoring of the affect on the breast is necessary.
Dosed for the individual to relieve symptoms
Testing of hormone levels is necessary
Duration of therapy is an individual decision

Cancer Screening
Annual physical with breast and pelvic exam
Colonoscopy after age 50 or sooner for family history.
Screening Pap smear every other year until age 65
Mammography
Digital infrared thermal imaging (thermography) of the breasts

Thermography
No radiation
No compression
Highly sensitive to early changes in breast tissue
May detect changes in the breasts years in advance of micro calcifications being detected with mammography
Allows more time for non-invasive interventions to improve outcomes

Questions?

Hormone Therapy Informational Session

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