In Search of Natural Hormones
In Search of Natural Hormones
By Wendy Wetzel, RN, MSN, FNP, HNC
Today menopausal women are more educated and more verbal about the challenges and experiences of the climacteric. In increasing numbers, women seek comprehensive health care advice and treatment for the symptoms that accompany menopause. Even when women are not troubled by uncomfortable vasomotor symptoms (night sweats and hot flashes), they often seek care to prevent or minimize the risks of heart disease, bone loss, urogenital atrophy, memory loss, and dementia.
Products used for menopause support have been limited. Conjugated equine estrogens (CEE) (Premarin®) and medroxyprogesterone acetate (MPA) (Provera®, Cycrin®) are the most commonly prescribed drugs for the treatment of menopausal symptoms. Yet women often experience unwanted side effects or are left with unresolved symptoms. Compliance levels are minimal. Many women either do not fill their original prescription or discontinue therapy within a few months. As word spread that CEE was derived from the urine of pregnant horses and stories of alleged animal abuse circulated, women began searching for more "natural" alternatives to this standard treatment.1,2
What is Natural?
By definition "natural" refers to that which has a form or appearance as found in nature. In common use, it also refers to that which is unadulterated and/or indigenous to the species. For those who seek alternative health care, natural often denotes treatments that do not involve chemically synthesized drugs, surgery, or other allopathic treatments. Within the context of menopause treatment, this poses a dilemma. If health care consumers request "natural" hormones, what choices are available and are they effective?
In spite of the fact that few herbal treatments for menopause have been verified by standard medical research, many women elect to use herbs such as black cohosh, motherwort, vitex, and crampbark. Although these herbs have been successful anecdotally in relieving hot flashes and night sweats, patients should be counseled to seek reputable care from a certified herbalist for proper dosing and formulations. Herbal treatments alone may not prevent osteoporosis and other menopause-related health problems.3,4
Various vitamin and supplement regimens have been suggested to treat the symptoms of menopause. Soy isoflavones can have an estrogen-like effect in the body; increasing the intake of high-quality soy products may assist some women.5 Bioflavonoids, found in citrus pulp, also have a weak estrogen-like effect.5 Other commonly recommended substances include essential fatty acids, flaxseed (ground or as oil), bran, fiber, and B vitamins. Calcium is widely accepted as essential for bone health.3,5-7
Human Identical Hormones
If the strict definition is applied, "natural" hormones are those found in the female body. In spite of major advances in medical technology, the harvesting of human hormones is not possible. Instead, various products, derived from soy and yam sources, have entered the market and are often acceptable to women who seek a natural profile in hormone treatment.
To avoid the ambiguous term of "natural" hormones, hormones derived from botanicals are now called "human identical hormones" (HIH). Formulations incorporating such compounds as 17ß-estradiol, micronized progesterone, and micronized testosterone are identical in molecular composition and form to that of human hormones. Because of this corresponding structure, some believe these products also mimic the activity of hormones in the body.2 For women needing hormone replacement therapy and also wanting a more physiologic profile, these products may offer a solution.2,8
Within the standard pharmaceutical market, a variety of HIH products have been developed. Estradiol products are available in several forms: pill (Estrace®), transdermal patch (Climara®, Alora®, Vivelle®, Esclim®), and vaginal preparations (Estrace®, Estring®); transdermal gels are expected to be released within a year. Progesterone is also available in capsule form (Prometrium®). These products have high patient acceptance and a low side effect rate2,9,10 and have been studied extensively for their efficacy and safety.11,12
Compounding Pharmacies
There is growing enthusiasm and acceptance of hormone products formulated by special compounding pharmacies. (See Focus on Organizations for referral information.) These pharmacies create a variety of capsules and transdermal creams to the clinician’s specifications. The various components of hormone replacement therapy can be combined into one product for ease of use. Most commonly used estrogens include estradiol, estrone, and estriol, while progesterone and testosterone are provided in micronized forms. These components are also derived from soy and yam sources. Although these have not been studied as extensively as standard pharmaceutical agents, patients and clinicians alike report symptom relief as well as improvement of other health conditions, including osteoporosis.7,9
Compounding pharmacies can also prepare estrogen and testosterone implants. These 3 mm pellets which are surgically inserted under the skin of the lower abdomen in a simple office procedure afford women up to six months of estrogen therapy. Because they do require a minor surgical procedure, they are often reserved for women who have proven refractory to all other forms of estrogen replacement.13,14
Over-the-Counter Products
In addition to available prescription hormone products, consumers are using an increasing assortment of over-the-counter products. Progesterone cream, as well as a variety of soy-based capsules and elixirs, are available in most health food stores. While these products are popular, they have not been studied in great detail and may provide only minimal symptomatic relief. Several popular brands of progesterone cream have been widely publicized, but often vary greatly in their actual potency.2,15
Conclusion
Following a complete evaluation (including a physical examination, pap smear, breast exam and mammogram, bone densiometry, lipid profile, and/or thyroid levels when appropriate), the choice of HIH therapy should be made as a joint decision between patient and clinician. Compliance is enhanced when the patient actively participates in the therapeutic plan and is honored in terms of her desires and beliefs.
With careful interviewing and problem-solving techniques, the patient and clinician can become partners in menopause treatment. (See HIH in Practice for helpful interview questions.) Short- and long-term follow-up should be planned as many women will require dosage adjustments until maximum comfort and benefits are achieved. There is no single hormone regimen that will be appropriate for all women. Treatment must be customized for each patient for maximum benefit.
Ms. Wetzel is a nurse practitioner at A Woman’s Place in Flagstaff, AZ.
References
1. Northrup C. Should you get off premarin? Health Wisdom for Women 1997;4:2-5.
2. Weil A. Is hormone replacement for you? Self Healing 1999;1:6-7.
3. Beal MW. Women’s use of complementary and alternative therapies in reproductive health care. J Nurse Midwifery 1998;43:224-234.
4. Weed S. Menopausal Years, the Wise Woman Way. Woodstock, NY: Ash Tree Publishing; 1993.
5. Lark S. Undoing estrogen dominance. The Lark Letter 2000;March:1-8.
6. Soffa V. Alternatives to hormone replacement for menopause. Altern Ther Health Med 1996;2:34-39.
7. Taylor M. Alternatives to conventional hormone replacement therapy. Comprehensive Ther 1997;23:514-32.
8. Wetzel W. Human identical hormones: Real people, real problems, real solutions. Nurse Practitioner Forum 1998;9:227-234.
9. Northrup C. Women’s Bodies, Women’s Wisdom. New York: Bantam; 1998.
10. Wetzel W. Micronized progesterone: A new perspective for women’s health care, a case study review. Nurse Practitioner 1999;24:62-76.
11. Sarrell PM. Micronized Progesterone: An Update on Progestogen Therapy. Littleton, CO: Medical Education Resources; 1998.
12. Sauer M. Progesterone use in reproductive and gynecologic endocrinology: Current and future perspectives. Contemporary OB/GYN 1997;42(suppl):S4-S11.
13. Notelovitz M, et al. Metabolic and hormonal effects of 25-mg and 50-mg 17 ß-estradiol implants in surgically menopausal women. Obstet Gynecol 1987;70:749-754.
14. Warner J. Analysis of estradiol (subdermal) implants in 200 postmenopausal women followed for 10 years. Is this a viable method of HRT? Poster presented at: The North American Menopause Society Conference; September 1997; Boston, MA.
15. Ahlgrimm M. Taking a closer look at progesterone creams. Am J Nat Med 1997;4:10-11.
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