Bone Health & HRT Options

Bone Health and Hormone Replacement Therapy Options
by Steven Masley, M.D.

The following outline is copied from my PowerPoint presentation. You are welcome to read and use, but any commercial use is strictly copyrighted to Steven Masley, M.D.

This information is not intended for medical decision making. Always consult your own physician who knows your personal medical history before making medical decisions.

BONE HEALTH AND OSTEOPOROSIS

What is OSTEOPOROSIS?

• Osteoporosis is the insidious loss of bone mass that results in fractures of weakened bone.
• 23 million Americans have osteoporosis--mostly women, but men enjoying longevity are at risk too
• There are 15 million fractures yearly in the US, which increase our health bill by over $10 billion.

Definitions

• Osteopenia is diagnosed when your bone density is 1 standard deviation below that of a 30-year person of your sex
• Osteoporosis is diagnosed when your bone density is 2.5 standard deviations below that of a 30-year person of your sex (the 5th lowest percentile)

Problems with osteoporosis

• Impaired mobility, resulting in additional bone mass loss
• Compressed abdomen, and reduced appetite
• Reduced pulmonary function
• Sleep disorders
• Shortened survival and “quality of life”
• Results in needless pain and suffering

Who is at increased risk for osteoporosis?

• Family history
• Unhealthy lifestyle
• Hyperthyroidism
• Even if related to medication use
• Steroid use
  – Includes:
  • asthma therapy, high dose intranasal inhalors, and potent steroid creams
  • Alcoholism

Calcium Balance

• Calcium balance is the difference between calcium absorption and calcium excretion
• Calcium is well absorbed from food with a few exceptions
  – Wheat bran and spinach are not absorbed due to high phytate levels
  – Cottage cheese is absorbed, but sodium and animal protein induced losses negate gains from calcium

Negative Calcium Balance (Six ways to lose calcium)

• Caffeine decreases renal reabsorption of calcium
  – Young women may compensate with adequate intake
• Tobacco increases calcium excretion
• Sodium (salt) and phosphate (colas) intake increases calcium excretion
  – Sodium itself can change teenage girls from positive to negative calcium balance
• Animal protein intake increases calcium excretion, leading to negative calcium balance
• Inactivity stimulates bone to release calcium
  – <4 hours per day on your feet is a risk factor

Protein impacts bone density

• You do need protein intake for healthy bones
  – Plant protein sources are the best
  – Inadequate protein results in poor bone strength
• For every 1 gram animal protein intake
  – You loose 1 mg calcium (acid protein pulls calcium out of your bones)
  – Eating 60 grams (~4 ounce serving of poultry, egg whites, or fish) /day of animal protein causes you to lose 22 grams of calcium / year
  – Lose 220 grams per decade and you lose ~16% of your bone mass retirement fund each decade

Sodium (Salt) impacts bone density

• For every 1 gram sodium (salt) intake
  – You lose 15 mg calcium
  – Eating an extra 3 grams of sodium per day and you lose 16 grams of calcium per year
  – Lose 160 grams of calcium per decade and you lose 11% of your calcium fund per decade
  
  Most people are NOT in calcium balance; thus, their calcium fund drops excessively every year

THE SOLUTION

• Ensure you are in a state of positive calcium balance (MEANING, your calcium intake is greater than output)
  – This lecture will teach you to predict your state of calcium balance
• Minimize things that cause you to lose calcium form your bones

Epidemiological Studies (Learning from populations worldwide)

• Higher animal protein intake is associated with higher fracture rates
• Countries with the highest calcium intakes, also have the highest vertebral and hip fracture rates.
• Eskimos, with high calcium intakes, over 2000 mg per day, have high protein intakes and high osteoporosis rates.
• Vegetarian populations are reported to have greater bone density than omnivores. The data is not conclusive, yet the calcium / protein ratio plays a part here as well.

Reaching Peak Bone Mass

• We reach our peak bone mass in our early twenties, remodel until early thirties, and gradual loose bone density thereafter
  – To achieve a maximal bone mass, we must concentrate on teenagers and early adults
• Exercise triggers bone to increase its density
• Calcium intake correlates strongly with increased bone mass
• Animal protein, sodium, phosphate intake (the typical school lunch program in America) has a negative impact on reaching peak bone mass

Recommended calcium intake for women (2000)

Calcium needs vary with activity and lifestyle

• Calcium needs vary by lifestyle!!!
  – A vegan woman who exercises for 90 minutes 6 days per week, doesn’t drink coffee or colas, doesn’t smoke, doesn’t eat salt can maximize her bone strength with less than 700 mg daily
• The WHO calls for ONLY 500 mg calcium intake daily (but that is with hours of exercise daily)
  – A sedentary woman who smokes, drinks coffee and colas, and has a high meat and salt intake may not get adequate calcium with over 1500 mg daily
  
  If you already have osteopenia or osteoporosis, we recommend 1500 mg of calcium daily

Quantitate Your Calcium Intake

• Calcium Sources
  • Food Item . Calcium content (mg)
  • Yogurt (8 ounces) 415
  • Cow’s milk (8 ounces) 300
  • Soy milk (Calcium fortified-8 ounces) 300
  • Rice milk (Calcium fortified-8 ounces) 300 Orange juice, calcium fortified 300
  • Figs, dried (10) 269
  • Cheddar cheese (1 ounce) 204
  • Oatmeal, instant (1 pkt) 163
  • Tofu (1/2 cup) 130
  • Navy beans (1 cup, cooked) 128
  • Kale, and other greens (1 cup) 94
  • Garbanzo beans (1 cup) 80
  • Almonds (1 ounce) 75
  • Cottage cheese (1/2 cup) 69 (0 net)

If your needs exceed your intake,
Add calcium supplements to correct the difference

CALCIUM SUPPLEMENTS
• Calculate your calcium needs
• Calculate your calcium intake
• Add the extra calcium you need

• Don’t exceed your calcium needs
– Excess calcium can block other mineral absorption
– High calcium intakes (excessive) linked but not proven to cause prostate cancer

FOR STRONG BONES, ADD MAGNESIUM & BORON TOO
• Calcium without magnesium leads to constipation
• Add calcium to magnesium in a 2 to 1 ratio
– 500 mg calcium with 250 mg magnesium
– More than 500 mg of magnesium daily can cause loose stools
• Add boron 0.5 mg to 1mg daily (Included in the Pritikin Multi-vit)

WHAT ARE THE COMMON CALCIUM SUPPLEMENTS?
• Calcium carbonate
• Calcium citrate (best absorbed)
• Calcium maleate

CAUTION WITH CALCIUM CARBONATE SUPPLEMENTS
• Calcium carbonate can contain lead
– Both natural and synthetic forms can contain lead
– Calcium carbonate is cheaper and makes smaller pills, but is it worth it?

FOCUS UPON REACHING PEAK BONE MASS BY AGE 21
• Teach and encourage TEENS aged 12-21 to:
– Add calcium to their diets
– Exercise
– Prevent excess calcium excretion

Menopause Is a Normal Stage of Life
MENOPAUSE
• Average age is 52 years of age
• It occurs when the ovaries stop producing estrogen and estrogen levels decrease 50%
• Women lose ~15-20% of their bone density when they go through menopause
• A women with low bone density, might choose to postpone going through menopause (by ~5-10 years) to postpone loosing her a rapid withdrawal from her bone density fund

Menopause impacts calcium balance (Ave age 50-52)
• With a drop in estrogen, the bone density set point drops and calcium is rapidly excreted over three years
– Most studies find that calcium supplements alone during this short initial phase are ineffective
• Hormone replacement therapy prevents this loss in bone density

The First 3 Years of Menopause
• Calcium supplements are of limited benefit initially without HRT
• Adding HRT resets the bone density set point and prevents rapid bone loss; but, HRT has other substantial heatlh risks. These risks need to be discussed with your health care provider carefully before deciding upon therapy options.

> 3 Years After Menopause
• Calcium intake does not stop bone density loss, but it does slow the loss in bone density
• Physical activity does reduce the risk of hip fractures in this age group
• Vitamin D supplements (400 IU daily) are very effective in decreasing the rates of bone density loss
• Hormone Replacement Therapy (HRT) slows bone density loss, but once the bone mass is lost, there is no evidence that adding HRT alone can increase bone density substantially

AFTER AGE 70
• Maintain positive calcium balance
• Vitamin D needs increase to 600 IU / day
• If you have osteoporosis and increased fracture risk
– Make your environment fall proof
• Avoid throw rugs, cords, etc.
– Build muscle strength and improve balance
– Ensure good vision
– If needed, wear hip pads

Studies on Men
• Studies on men are limited
• Men at high risk of osteoporosis
– History steroid use
– Hyperthyroidism
– Alcoholism
– Other health problems

WHICH MEN NEED EVALUATION & TREATMENT
• If you have taken steroids for asthma, psoriasis, emphysema, other conditions (orally or topically)
• Men who did not reach their peak bone density in their teens
• Men who have not lived an optimal lifestyle lifelong and aim to live well past 80 years of age

THE AVERAGE MAN DYING AT AGE 69 WHO HAS NOT USED STEROIDS FOR HEATLH PROBLEMS DOES NOT NEED TO WORRY ABOUT OSTEOPOROSIS.
I plan to help you live “well” up to 100, so men following the Pritikin Program need to ensure bone health!
BONE STRENGTH AND FRACTURE RISK
Bone strength reduces fracture risk. Strength depends upon:
• Architectural strength
– You can assess by bone biopsies
• Bone density
– You can assess by bone density testing
– Bone density is the most important predictor of fracture risk

WOMEN: DO YOU NEED A DEXA SCAN? (Do you know your cholesterol level?)
• At menopause, a DEXA Scan can help you decide whether you want hormone replacement therapy (HRT), medication therapy, or not.
• If you choose a non-traditional type of HRT, repeating a DEXA Scan in 2 years can give you an idea of the effectiveness of your HRT choice
– One year follow-up has not been reliable, especially for the hip
• DEXA scan reports can be confusing for you and your doctor

MEN: DO YOU NEED A DEXA SCAN?
• With a lifetime healthy lifestyle
– Starting at age 70, check every 10 years
• Without a lifetime healthy lifestyle
– Starting at age 50-60, check every 10 years
• Once you reach osteopenia
– Check every two years

COST OF A DEXA SCAN
• Medicare pays $273. ( early 2001) for a DEXA Scan-which is similar to what many facilities charge
• The Pritikin fee for performing and interpreting a DEXA scan for bone density is $195.
• Your insurance may or may not cover this test
– Medicare covers this expense for women after menopause every two years
– Always check with your health insurance if you want to be sure

WHAT IS THE VARIATION IN DEXA REPORTING?
• BMD (bone mineral density) varies by about 0.5 % between tests
• BMD varies by about 1% between different types of machines
• T-scores vary greatly by data bases
• To follow testing over time, follow BMD
• To see an improvement in BMD with therapy take one year in the spine and 2 years in the hip
DEXA SCAN REPORT
• Your doctor gets a score (%) on your bone density compared to young women, and a score compared to women your age
– At age 70, you don’t need as much calcium as a 30 year old woman does (T score)
– You need to know, do you have enough calcium stored for your age to last your lifetime (Z score)
– Will your calcium stores last you until you are 100 years old ?
WHAT TO ASK YOUR DOCTOR?
• Your doctor should tell you, your bone density score for your age:
– Whether your bone density is above average, average, below average (osteopenia), or much below average (osteoporosis)
– Your goal should be a bone density above average, and to take steps to keep it there
– I reserve medications for people with osteoporosis, (or young osteopenia) who fail to make improvements with lifestyle changes and natural hormonal agents

DO MEDICINES PREVENT DEBILITATING FRACTURES?
• Medicines statistically improve bone density
• Medicines decrease spinal fractures better than limb fractures
• Common bone density enhancing medications include:
– HRT, EVISTA (Raloxifene)
– FOSAMAX (Alendronate), Actonel
– Calcitonin nasal spray (Miacalcin)

Hormone therapy (estrogen + progesterone)
• HRT might increase BMD by 1.7% initially, or show no improvement, but slows BMD loss
• There was no fracture reduction noted in treated women without osteoporosis over 5 years in the HERS trial
• HRT, like all osteoporosis meds to date, better at treating the spine than the hip

EVISTA (Raloxifene)
• Medication used for preventing breast cancer and strengthening bones
• Limited effective in preventing fractures: (In women with osteoporosis by dexa scan)
– NNT = prevent one hip fracture = 1,000
– NNT = prevent one vertebral fracture = 28
– NNH = cause one leg clot (DVT) = 143
– NNH = cause hot flashes = 30
• Expensive ($50-70 per month)
• OK to use it, but also choose to add the lifestyle choices that enhance bone health !

FOSAMAX (Alendronate)
• Medication used to increase bone density
• Limited effectiveness in preventing fractures: (Over three years in women with a prior vertebral fracture)
– NNT = prevent one hip fracture = 100
– NNT = prevent one vertebral fracture = 14
– NNH = side effect of esophageal ulcer = 67
• Expensive ($50-60 per month)
• OK to use it, but also choose to add the lifestyle choices that enhance bone health !

HOW LONG DO YOU USE FOSAMAX?
• Studied for up to 7 years
• Most of 7-year therapy benefit occurred within 2-3 years
• Increased bone mass by 10% within 3 years, then plateau
• 25% of gain lost within 2 years once medication stopped

CALCITONIN (Nasal Spray)
• Miacalcin® is used to treat osteoporosis
• Therapy with 200 units has been shown to
– Increase spinal bone mass in postmenopausal women with known osteoporosis
– It has NOT shown consistent improvements in hip bone density
– It has been shown to reduce fracture rates, although limited reduction
• Caution regarding rare nasal ulcerations
• Cost: $50-70 per month
• Effective for treating acute fracture pain

WHAT ABOUT ACTONEL (Raloxifene) ?
• Actonel might be more effective than Fosamax
• Less esophageal problems (not none)
• Brand new, hence, less well known long term side effects
• Studied for up to 3 years

PREVENT OSTEOPOROSIS
• Treat your bone mass like your retirement fund:
– Build it early
– Deposit often
– Keep it stocked
– Avoid loses
CHOOSE A BONE HEALTHY LIFESTYLE
• Daily weight bearing exercise encouraged
• Choose foods rich in calcium sources and Low in sodium, phosphates, animal protein, caffeine, and nicotine

BONE HEALTH SUMMARY
• Maximize calcium intake
– Calcium supplements slow bone density loss
– Dairy products or other sources of calcium can help young women attain their peak bone mass
– Green leafy vegetables, calcium fortified soy products, and grains are “the healthiest” sources of calcium
• Avoid factors that cause you to loose calcium
– Smoking, excess salt, caffeine, & animal protein intake
• EXERCISE (Mix aerobics with weight training!)
• HRT is effective after menopause in maintaining bone density; but can cause many other health problems
• Vitamin D is effective in seniors in preventing fractures
This information is not intended for medical decision making. Always consult your own physician who knows your personal medical history before making medical decisions.

HORMONE REPLACEMENT THERAPIES

Pharmaceutical and Natural Therapy Options--Deciding What is Best for You

By Steven Masley, M.D.

HORMONE CHANGES AT MENOPAUSE REFLECT CHANGES IN FUNCTION
Pre-Menopause
• Very tolerant of noise, climbing, and fuss
• Vision more peripheral
• Family and nest oriented
• Bone density greater for carrying pregnancy and children
Menopause
• Less tolerant of noise and fuss
• More forward thinking
• Village oriented
• Greater breast cancer risk with continued estrogen exposure
• Bone density needs drop

MENOPAUSE
• Average age is 52 years of age
– Menopause defined when menses stop for 12 months, or an elevated FSH level is noted
– 25% of women enter menopause surgically
– 25% of women have no menopause symptoms
– 30% of women take synthetic HRT
• 50% of women who start synthetic HRT stop in 1 year
• It occurs when the ovaries stop producing estrogen, with estrogen level decreasing by 50%
– Estrogen still produced by the adrenal glands
• Many women have menopausal symptoms before menopause starts if they don’t ovulate and their progesterone production drops

GOALS OF THIS PRESENTATION
• Discover that each woman is different and each woman has different options in how to approach menopause and HRT
• Do you need any HRT after menopause?
– Maybe not
– If so, should you choose natural or pharmaceutical options
– Which ever HRT options you choose, choose HRT options that are identical to human hormones

OUTLINE RECOMMENDATIONS
• If you bone density is good, and you don’t have hot flash complaints, no therapy might be the safest option
• If you have normal bone density, but hot flash symptoms, natural progesterone is the safest first therapy step
• If you need estrogen, consider human forms: estradiol and natural progesterone

HORMONES
Formed by cholesterol modification
• DHEA
• ESTROGEN
– Estradiol, Estrone, Estriol
• PROGESTERONE
• TESTOSTERONE
• Men and women have all these hormones
• As we age, our percentage of each hormone in men and women becomes more similar

Who Should Consider Hormone Replacement Therapy?
• Premature menopause
– Occurring at less than 40 years of age
– Often this is surgically induced
• Symptomatic women (+/-)
• High Osteoporosis Risk (DEXA Scan)

MENOPAUSE SYMPTOMS
• Menstrual cycles change
• Hot flashes/night sweats
• Poor concentration
• Disturbed sleep
• Vaginal dryness and thinning
• Reduced libido
• Change in urinary frequency
• Emotional lability

HORMONE THERAPIES
• DHEA
• Black Cohosh
• Phytoestrogens
• Dong Quai
• Hormone Replacement Therapy (HRT) Choosing Between Pharmaceutical and Natural Therapy Options
– Estrogens, Progesterones, Testosterone
– Topical versus oral

DHEA (Adrenal Mother Hormone)
• DHEA levels decrease with age
• DHEA is partially converted into testosterone, estradiol, and estrone
– Studies have noted improved sense of wellness with minimal side effects
– Therapy being “STUDIED” for: aging, Alzheimer's, lupus, aids, cancer, obesity, heart attacks, immune function, and depression
– Contraindicated in people with estrogen related cancers, prostate enlargement, pregnancy, lactation
– DHEA Might increase cancer rates in healthy people

DHEA Dosing
• Most studies have used 25-50 mg / day
• Side effects include:
– acne and hair growth in women
– feminization in males
– insomnia, aggression, irritability
• Some medical providers will prescribe DHEA, but also follow blood levels
– Hormone levels before and after treatment
• Estradiol, estrone, progesterone, testosterone
– Should men taking DHEA check PSA levels?
• There is NO evidence that following PSA levels improves prostate cancer outcomes with DHEA

BLACK COHOSH
• Plant based hormone therapy
– Steroidal compounds and isoflavones
• Improves menopausal symptoms with 8 mg to 2.4 mg daily
– Recommendations limit therapy to 6 months of treatment
• Long-term safety on uterus, bone, breast, and heart unknown
• Side effects: nausea, headache, and low blood pressure

PHYTOESTROGENS
(Plant Hormones)
Good sources include soy products and flax
u Improve cholesterol profiles,
u Probably decrease blood clots, and improve artery function
u Do NOT improve bone density
u Decrease hot flashes
u May decrease risk of breast cancer and prostate cancer when taken long-term
– Have not been studied well as breast cancer therapy
– I don’t recommend isoflavone supplements

DONG QUAI
(Angelica sinensis, or Female ginseng)
• Poorly studied to date
• Commonly used world wide
– menopause, dysmenorrhea, metorrhagia, even “easy pregnancy”
• Decreases intestinal and uterine contractions
• Decreases blood pressure
– Similar to calcium channel blocker meds
DON QUAI, Rx plan
• Better choices available until studied
– Either Black Cohosh or micronized progesterone
– If used, could be part of a short-term symptom plan, but NOT during pregnancy
• You could use 1-2 grams powdered root tid for Black Cohosh, but I prefer the brand Remifemin as it appears to be the best studied form to date.
– for menopause, dysmenorrhea, metorrhagia
• Side effects
– Photosensitivity
– Digestive problems, rare
– Bleeding, rare
– Increases INR levels (for coumadin users)

HORMONES
• Complicated topic
• 3 main groups of hormones (estrogen, testosterone, and progesterone)
• 3 main types of human estrogens (estradiol, estrone, and estriol)
• Hormones are metabolized into other active hormonal compounds

FOOD INDUSTRY HORMONES ???
• Omnivore girls (those eating meat and poultry) menstruate 2 years earlier than vegetarian girls
• Poultry and Animals are fed LARGE doses of hormones to enhance growth
– How else do you produce a full-grown chicken in five months?
• Dietary hormones “might” be associated with increases cancer risks
• CHOOSE ORGANIC SOURCES OF DAIRY, EGGS, MEAT AND POULTRY, OR, EAT VEGETARIAN

ESTROGEN
• PHYTOESTROGENS
• PHARMACEUTICAL ESTROGENS
– Mostly composed of estradiol and estrone
– Premarin (Collected from pregnant horse urine)
– Estratabs (Synthesized from a yam product)
• NATURAL ESTROGENS
– Bi-Est: 30% estradiol, 70% Estriol
– TRI-EST
• 80% Estriol, 10% Estradiol, 10% Estrone

PRE-MENOPAUSE HUMAN ESTROGEN COMPONENTS
• Estrone
– Appears the most carcinogenic
– Stimulates bone
– Helps hot flashes
• Estradiol
– Appears carcinogenic
– Best at strengthening bone
– Best at helping hot flashes
• Estriol
– Might be anti-carcinogenic
– Minimal bone & hot flash impact
– Good for skin

HISTORICAL
ESTROGEN USE
• Historically HRT has been “associated” with lower cardiovascular disease
– In studies, women who chose to take HRT ate better, smoked less, exercised more, etc, (They did what their doctors told them.)
• Also associated with lower dementia rates
• Thought to slow the loss in bone strength after menopause

ESTROGEN USE STUDIED
• Has NOT been shown to decrease the risk of cardiovascular disease over 4.5 years of treatment (HERS Trial-4.5 years of HRT in women with CAD)
– It did increase the risk of strokes, blood clots, and gallbladder disease (JAMA 1998;280:605-613)
• For every 40 women started on HRT, one extra woman had a blood clot or stroke, and 1 extra in 62 extra had gallbladder disease)
• No reduction in fracture risk in this study (was not aimed to treat women with osteoporosis)

BREAST CANCER AND HRT RISK

· Pharmaceutical estrogen does “slightly” increase the risk of breast cancer

· For synthetic estrogen alone, for every 100 women started on estrogen, one extra gets breast cancer

· For HRT with synthetic estrogen and progesterone, for every 50 women started on combined HRT, one extra gets breast cancer

HRT BREAST CANCER RISK
PHARMACEUTICAL ESTROGEN REPLACEMENT
• POSITIVES:
– Improves lipid profiles, but NO cardiac event benefit proven
– Enhances bone strength and decreases fracture risk
– Enhance symptoms
May help lower risk of colon cancer slightly
• NEGATIVES:
– Increases clotting leading to strokes & leg clots (DVTs)
– Increase breast and ovarian cancer risk
Increases the risk of cardiovascular events
– Increases risk of gallbladder disease

PHARMACEUTICAL ESTROGENS
• Made mostly of estradiol and estrone, plus equine estrogens
• Oral estradiol is converted in the intestinal tract into estrone
• Topical forms provide less reliable dosing and inconvenience, but less conversion into estrone
• You can get topical estradiol !

Synthetic HRT Therapies May Cause More Side Effects than natural HRT

TYPES OF PROGESTERONE
• Synthetic (e.g., medroxyprogesterone acetate (Provera)
– Pharmaceutical progesterone
• Micronized progesterone
– Natural form
– Available in pill and topical form

PROGESTERONE IMPACTS ARTERY FUNCTION & HDL
• Micronized progesterone (natural) enhances artery endothelial function
• Medroxyprogesterone acetate (Provera)
– Appears to inhibit endothelial vasodilation (Nature Medicine 1997;3:324-327)
• Micronized progesterone has the most favorable influence on HDL levels compared to other HRT forms (JAMA 1995;273:199-208)

MICRONIZED PROGESTERONE
• Protects the uterus from cancer (JAMA 1995;273:199-208)
• Decreases hot flash symptoms (for 1/2 of women)
• “Associated” with increased bone density
– At 10 mg topically daily-hasn’t been studied well yet
– Has not been proven to treat osteoporosis
• Improves sexual drive (for 1/2 of women)
• Has NOT been associated with increased breast cancer risk--it “might be protective”
• Improves cholesterol profiles
• Improves the function of arteries
– Helps promote vasodilation

WHO SHOULD USE NATURAL PROGESTERONE?
• Best candidate is a woman with normal bone density, concerns re estrogen risk, and who wants hot flash control (50% of women benefit)
• Benefits should be seen within 1-2 months
• Costs about $30 per month from a compounding pharmacy, also comes over-the-counter for $10/ month
– Yam creams don’t work--avoid polypharmacia
– Micronized progesterone is made from yams, (so are many hormones), and has a limited shelf life

ORAL OR TOPICAL DOSING?
• Topical delivery allows hormones to reach the cells with much less intestinal and liver conversion into unintended hormone compounds
• Micronized progesterone creams are not known by most physicians (They are not “marketed” by pharmaceutical companies)
• You can’t get natural hormones from a typical pharmacy

MICRONIZED PROGESTERONE DOSING?
– 10-20 mg per ml in topical OTC form
– 100-200 mg tablet in prescription form
– If you are taking estrogen and want to add Micronized Progesterone, aim for 20 mg topically or 200 mg orally
– Most MD’s recognize oral Micronized Progesterone 200 mg daily

Natural Estrogens Compared

TRI-EST TOPICAL CREAM
• 80% Estriol, 10% Estrone, 10% Estradiol
• Delivered topically to prevent intestinal and liver conversion of estrogen into other hormonal products, such as estrone
• Available by prescription in compounding pharmacies
• Not well studied in North America for long-term clinical outcomes
• Typical dosage is 1.25-2.5 mg daily topically

BI-EST
• 70% Estriol, 30% Estradiol
– Estriol adds additional skin benefit with a theoretical reduction in breast cancer risk--unproven to date
• Delivered topically to prevent intestinal and liver conversion of estrogen into other hormonal products, such as estrone
• Available by prescription in compounding pharmacies
• Not well studied in North America for long-term clinical outcomes
• Typical dosage is 1.25-2.5 mg daily topically

ESTRADIOL
• Topically by prescription
– Comes in a weekly patch, cream, and gel
• 0.3 mg daily maintained bone density
• Titrate dosing from 0.3 to 1.25 mg to find the minimal dose that controls hot flashes
• Very well studied and accepted by physicians

DO YOU NEED PROGESTERONE WITH ESTROGEN?
• If you have a uterus, estrogen alone promotes uterine cancer
• Even if you have had a hysterectomy, you might feel better with progesterone
• When choosing progesterone, aim for micronized progesterone either topically 10-20 mg daily or in a tablet (which your doctor knows about) at 200 mg daily

ESTROGEN METABOLITES
• Estrogen metabolites are very active
• Balance of different types of metabolites can influence your risk of breast cancer or osteoporosis
• Lab tests (early in development but approved by the FDA, but not insurance companies) are available
• Consider testing if you have an unusual personal or family history ($150-$250 through Rocky Mountain Laboratory)

CAN YOU MODIFY ESTROGEN METABOLISM?
• You can modify your metabolite formation away from breast cancer forming metabolites with diet
– Indoles (broccoli, cabbage)
– Turmeric
– Soy

TESTOSTERONE
• Can be added to topical therapy
• Especially helpful for women who have had ovaries removed, as the post-menopausal ovary still makes testosterone
• Helps bone density and sex drive
• Dosage 0.5-5 mg daily topically (1 mg daily is my typical topical dosage)
If you are using testosterone, it is better to check blood or salivary levels; don't just rely on how you feel
Compounding Pharmacy

MAKING A HRT CHOICE
• Whether you choose no HRT, synthetic HRT, or natural HRT--you need to make an informed choice that best meets your needs
• Understand the risks and benefits of each possible choice
• Educate yourself on this topic, then involve your physician in your informed decision
• Ultimately, you take responsibility for the choice you make

CASE STUDIES:
45 year old woman with perimenopausal concerns
• What could she do?
• First is Lifestyle
– Exercise
– Increase dietary phytoestrogens
– Avoid industrial estrogens
• Consider micronized progesterone cream, 2 weeks per month, 10 mg per day

52 year old woman with menopause symptoms
• What are her options?
• Lifestyle options
– Exercise, Add phytoestrogens, Limit Industrial hormones
• HRT? (yes or no can both be good choices)
• What type of HRT?
– Micronized progesterone
– Bi-est or Tri-est
– Synthetic hormone therapy (estradiol)

75 year old woman
• What are her options? Depends upon her bone density and health history.
• What do her options depend upon?
• Lifestyle
• Natural HRT
• Synthetic HRT

You Are The Consumer; You Should Be In Charge of Your Health