Through the 1970s and 1980s, so many health problems were associated with hormone replacement therapy (not the least of which was cancer) that my blanket recommendation to patients was "Avoid it until we know more." I maneuvered around the problem by treating menopausal symptoms with acupuncture therapy as well as Chinese traditional herbs, Western herbs, homeopathic remedies, and other nutritional medicines. I continue to prescribe these on occasion, but I've found natural hormone replacement therapy to be far more effective for most women.

Over the past 10 years, with a growing body of evidence in support of an anti-aging role for estrogen, progesterone, and testosterone, these hormones have become increasingly difficult for me to ignore. As with the other anti-aging hormones (dehydroepiandrosterone, or DHEA; pregnenolone; melatonin; and thyroid), levels of the sex steroid hormones decline with age. Restoration to youthful levels promotes optimum health and may well extend life span.

Because public consciousness of these hormones has been relatively high, most people have preformed opinions about them. This is especially true of unnatural estrogen, which most doctors and the general public don't realize is a far cry from natural human estrogen.

When unaccompanied by its sister hormones, estradiol causes cancer.  The second approach involves Premarin, a combination of estrogenic compounds extracted from the urine of pregnant mares (Pre-marin--get it?). Premarin contains 5 to 19 percent estradiol, 75 to 80 percent estrone, 6 to 15 percent equilin (strictly a horse hormone and possibly a human carcinogen), plus trace amounts of other horse hormones. These equine hormone molecules make a lousy match for those produced by the human female body. They may be great for horses, but in humans, they transform the tightly choreographed and highly complex "dance of the sex steroids" into a chaotic free-for-all.

Estrogen replacement with Premarin (not to mention estradiol and similar products) is fraught with risks. Experts have long debated its safety. Next time you're in the mood for some scary reading, check out the fine print on the package insert for Premarin (or read the hormone's entry in the Physicians' Desk Reference). You'll find a very long litany of what can go wrong when mismatched molecules are tossed into your finely tuned endocrine system.

One of my patients, Margaret, didn't believe me when I told her that the estrogen she had been taking for nearly 15 years was actually horse urine in pill form. When she found out that I was right, she went ballistic. And she got even madder when I told her the rest of the story.

You see, drug companies couldn't make any money by selling natural estrogen, because it isn't patentable. So they had no interest in funding research for it or in developing products containing it. This is despite that fact that their synthetic estrogen is unsafe, less effective, and almost certainly responsible for many serious health problems.

When you stop to think about it, the situation is appalling. On the one hand, we have an undeniably toxic drug that causes a vast array of side effects and adverse reactions and for which there is a safe, natural alternative. On the other hand, we have drug companies that control the research (through funding) and the marketplace (through advertising and education for physicians) to protect their bottom lines. Those bottom lines are very large: Female replacement hormones are one of the biggest money-makers in the history of the pharmaceutical industry.

Surely the drug-makers know that natural hormone replacement would prevent the carnage. But because they can't profit from it, they have zero interest in exploring its use. If ever there was a Catch-22, this is it.  And don't even get me started on the 80,000 pregnant mares that "manufacture" Premarin for the pharmaceutical industry. They're confined to tiny stalls (to prevent them from lying down) and deprived of exercise, with urine collection devices strapped to their underbellies to collect their "product." If this barbaric practice were justifiable in terms of alleviating human disease, perhaps the ethics issues could be rationalized away. But we have natural, medically preferable alternatives available.

Incredibly, natural estrogen replacement has never been studied. We have absolutely no scientific data on the actual hormone molecules that all women make throughout their lives. All of those media reports about estrogen--indeed, the whole debate about the benefits and risks of female hormone replacement--concern only the unnatural types. Apparently, nobody ever questioned whether using horse estrogen instead of human estrogen mattered. It's a case of apples being passed off as bananas.  One of the first to notice this problem was leading nutritional physician Jonathan V. Wright, M.D., of Kent, Washington, who describes the problem this way: "We need to take the last 40 years' worth of study on so-called estrogen, jam it in the wastebasket, and start over. All of those studies involved giving human beings horse estrogen. The next time I see a menopausal horse, I will be happy to prescribe Premarin, a horse estrogen! But for menopausal people, we need people hormones.

"There has been not one, not a single . . . well-controlled long-term study of the use of estrogens that are actually identical to human estrogen as replacement therapy for women. Without that kind of study, the best thing we can say is that we don't know anything. We've wasted 40 years in studying horse hormones in humans, and it's about time to start studying human hormones in humans. Then maybe we'll know something. But right now we know nothing scientifically, and we have to fly by common sense and the seat of our pants until we get the real human studies done."

Premarin and other unnatural estrogen replacement products enjoyed a sunny outlook until reports that they contribute to cancer began to cloud the horizon. To make a long (two-decade) story short, unnatural estrogen stimulates hormonally sensitive tissues, raising the risk of breast, uterine (endometrial), and ovarian cancers. Women taking unnatural estrogen are at least four times more likely to develop endometrial cancer. Similarly, taking unnatural estrogen for at least six years produces a 40 percent increase in women's risks of developing the almost uniformly fatal ovarian cancer.

Of greatest concern is the link between unnatural estrogen replacement and breast cancer, which has already reached epidemic proportions in the United States. In an article published in the New England Journal of Medicine, researchers at Harvard Medical School reported that women who used unnatural estrogen replacement for five or more years after menopause were 30 to 40 percent more likely to develop breast cancer than those who did not.  As I said before, all of these studies and statistics are based on unnatural estrogen-like compounds. Amazingly, nobody ever bothered to examine real estrogen to see whether it would have similar effects. This information presented women and their doctors with a dilemma. Do you try unnatural estrogen replacement and risk getting cancer? Or do you forgo replacement therapy and risk heart disease and osteoporosis, not to mention menopausal symptoms?

Most doctors buy into the former option, and they feel justified in recommending it to their patients. Their argument: Unnatural estrogen is better than no estrogen, because eight times as many women die of heart attacks as of breast cancer. Plus, unnatural estrogen reduces osteoporosis risk. "Basically, you are presenting women with the possibility of increasing the risk of getting breast cancer at 60 in order to prevent a heart attack at 70 and a hip fracture at 80," says Isaac Schiff, M.D., chief of obstetrics and gynecology at Massachusetts General Hospital in Boston. His statement is clever, but it doesn't tell the whole story. First, unnatural estrogen increases risk of uterine and ovarian cancers as well as breast cancer. Second, women can profoundly decrease the probability of heart disease and osteoporosis simply by making dietary and lifestyle changes. Third, cancer is more devastating at an earlier age.

Earlier in the chapter, I mentioned that estrogen contains both pro- and anti-cancer compounds. Specifically, estradiol and estrone promote cancer, while estriol prevents it. For women in menopause, doctors usually prescribe either estradiol or Premarin. Both increase lifetime exposure to the pro-cancer types of estrogen. The unnatural, horse urine - derived compounds in Premarin are converted by the body primarily to estrone, the estrogen implicated in cancers of the breasts and uterus.

The fact that estriol prevents cancer was revealed by research conducted by H. M. Lemon, M.D., in the late 1960s. Women with breast cancer make less estriol and so are presumably more vulnerable to the disease. Women who are cancer-free have high estriol levels. Estriol presents none of the health hazards associated with estradiol and Premarin. It protects against cancer by blocking the action of estrone.

In Europe, estriol has been in use for more than 20 years. European clinical studies have shown that estriol safely and effectively relieves menopausal symptoms. In one major German study conducted by 22 gynecologists from 11 large hospitals, more than 900 women were given estriol and monitored over a five-year period. The estriol proved very effective at relieving menopausal symptoms, was well-tolerated, and produced no significant side effects.

Why hasn't this safe and preferable alternative to unnatural estrogen become standard therapy in the United States? Blame the power of the pharmaceutical and advertising industries and the medical profession's resistance to change. In 1978, the Journal of the American Medical Association published an article by Alvin H. Follingstad, M.D., in which he called for doctors to switch to estriol as a safer form of estrogen replacement. He argued that while estriol prevents cancer, the other two naturally occurring estrogens--estradiol and estrone--increase risk. He cited the problem-free use of estriol in Europe and reported that the hormone stopped the spread of metastatic breast cancer in 37 percent of a group of women who were past menopause. Sadly, Dr. Follingstad's admonitions fell on deaf ears.

With the advantage of hindsight, we in the medical community now know how right Dr. Follingstad was. Sometime in the 1960s, we got on the wrong track, prescribing unnatural estrogen that caused millions of potentially preventable cancers. Now that we're aware of the mistake we made, don't we have a scientific--if not a moral--obligation to go back, start over, and do it right?

We can now state with certainty that unnatural estrogen causes cancer. We have no proof that natural estrogen does not cause cancer. But is there any reason why it would? After all, women have been manufacturing estriol, estradiol, estrone, and progesterone all their lives. So if we're going to replace these hormones, let's use the exact same molecules that the female body produces on its own.

Going back to the drawing board, Dr. Wright sought to create the most-natural possible estrogen replacement by emulating the estrogen balance within the female body. His research led to the formulation of triple estrogen, a natural, physiologically balanced form of hormone replacement therapy. Triple estrogen consists of a combination of the three human estrogens in the proportions in which they occur naturally: 10 percent estrone, 10 percent estradiol, and 80 percent estriol. Triple estrogen is the closest approximation to the natural spectrum and balance of hormones that the female body makes (or would make, if it has already stopped).

Triple estrogen has become standard therapy among alternative and nutritional medical doctors. It is available by prescription from any compounding pharmacy (that is, a pharmacy that can mix medications to a doctor's specifications). The usual starting dose is 2.5 milligrams per day, which equals 0.625 milligram of Premarin. Every woman is different, however. You may need more or less. Work with your doctor to find the best dose for you. Because balancing the sex steroid hormones is so important, and because unopposed estrogen is undesirable, I usually start my patients on triple estrogen along with micronized progesterone capsules (100 to 200 milligrams per day) or progesterone cream (one-half to one teaspoon daily). Both hormones should be stopped altogether for the first 7 to 10 days of the menstrual cycle or for one week each month if menstruation has stopped.

Some women experience a return of their menopausal symptoms when they abruptly change over from estradiol or Premarin to triple estrogen. This does not mean the natural version isn't working. With unnatural estrogen replacement, the body is subjected to--and adjusts to--long-term exposure to unfriendly molecules. These molecules bind with the hormone receptor sites on cells differently than natural molecules. The return of menopausal symptoms simply means that the body needs time to adjust to the natural molecules.

If you're already taking estradiol or Premarin, you can avoid menopausal symptoms by making the switch to natural estrogen gradually. Each month, decrease your dosage of estradiol or Premarin by one-third and increase your dosage of natural estrogen by an equivalent one-third.  To make this process easy, I recommend the following: Take Premarin (or another drug hormone) on days one and two and triple estrogen on day three. Continue this dosage pattern for one month (or cycle). Then during the second month, take Premarin only on day one and triple estrogen on days two and three. By the third month, the transition to triple estrogen is complete. If the changeover still causes menopausal symptoms, you can slow the pace even more.

Don't give up if your initial attempt to make the switch doesn't seem to work. Hormone pathways are complex and quirky. If you've been jamming them with molecules that look funny and communicate in scrambled tongues, don't expect your body to adjust immediately. Give it the time it needs to relearn the proper hormone language.

My ideas about hormones and hormone replacement therapy began changing in 1994, on a family vacation to Maui. Since it didn't take up much space, I packed a copy of Natural Progesterone: The Multiple Roles of a Remarkable Hormone by John Lee, M.D.--just a tidbit to glance at if my compulsion to read medical journals reared its ugly head. A few days into our vacation, I picked up the book at bedtime, fully expecting to be bored to sleep. But when I started reading that little gem, I was so fascinated that I couldn't put it down. I was introduced to "unopposed estrogen" and the "dance of the steroids"; I discovered why unnatural hormones are dangerous and how osteoporosis can be reversed. What Dr. Lee said spoke directly to my heart as well as my mind: Clearly we shared a commitment to finding nontoxic and natural approaches to medicine.

Every free moment over the next few days, I lay on the beach, lost in Dr. Lee's book, my kids bouncing beach balls off my head and spraying wet sand on the pages. My wife was appalled: "We're supposed to be on vacation, Tim. You need to get away from your work. Why don't you read Grisham or at least some kind of fiction?" But her words came too late. I was hooked. In a small but significant way, that book would change my life. For the first time in my career, I felt a glimmer of hope that I could understand hormones.

One of Dr. Lee's principal messages was that balancing female hormones does not stop at replacing estrogen. Citing the failure of unnatural estrogen to safely address menopausal symptoms, he helped focus attention on natural progesterone, the other side of the female hormone replacement equation. In a premenopausal female body, estrogen is always in balance with progesterone. These hormones work together to keep a woman healthy. Unopposed estrogen, even when it's natural, can lead to problems.

For instance, unnatural estrogen replacement is known to increase a woman's risk of endometrial cancer. Adding progesterone to the mix eliminates this risk. The good news is that the idea of hormonal balance has finally taken hold--sort of. The bad news is that doctors have traditionally prescribed unnatural forms of both hormones: estrogen from horse urine (Premarin) and synthetic progesterone (Provera).

If any one individual is responsible for raising consciousness about progesterone, it is Dr. Lee. His name has become synonymous with natural progesterone replacement for treating menopausal symptoms, reversing osteoporosis, and preventing cancer, among other ailments. In the 1970s, Dr. Lee attended a lecture at a meeting of the San Francisco Orthomolecular Society in which biochemist Ray Peat, Ph.D., chided doctors for replacing estrogen after menopause without prescribing progesterone as well. This concept intrigued Dr. Lee. And so over the next several months, he read everything he could get his hands on about progesterone. He concluded that Dr. Peat was absolutely right. Progesterone's importance had been underestimated, and unopposed estrogen--that is, estrogen without progesterone--was responsible for numerous diseases, not the least of which was cancer.

Dr. Lee began using natural progesterone as a last resort in treating patients who had osteoporosis but could not take estrogen (because they had a history of cancer or another condition that contraindicates its use). For more than six years, he monitored the bone status of 63 patients with osteoporosis using regular dual photon bone absorptiometry (a highly sensitive measure of bone mineral density). To his amazement, instead of the expected 4.5 percent bone loss, the patients registered remarkable increases--an average of 15.4 percent. Their bones were remineralizing. His discovery was all the more amazing because stimulating new bone growth is unheard of. Estrogen only slows bone loss--it cannot reverse it.

What's more, these patients reported reversals of many other symptoms that had been bothering them. Their energy levels and sleep patterns improved, their skin appeared healthier, their libidos increased, and they lost weight more easily.

To educate women and their doctors about natural progesterone replacement, Dr. Lee and Virginia L. Hopkins co-authored the pioneering book What Your Doctor May Not Tell You about Menopause--a must-read for menopausal women. In the introduction, Dr. Lee describes how his discoveries slammed into conventional medicine's wall of resistance: "I talked to my colleagues and gave talks at our hospital staff meetings. The reception was warm, but their looks of perplexity led me to understand that I had hit what others have called cognitive dissonance. While unable to dispute my work, my colleagues could not understand how the knowledge I presented was missing from their own education and the textbooks (and the pharmaceutical advertising) on which they relied. In their minds, the file marked 'progesterone' was filled with advertising about synthetic progestins, which are not the same thing."

And by all means, stay on a regular exercise program. Nothing stops bone loss and maintains bone health as effectively as exercise. Walk for at least 30 minutes every day. And for your upper body, try strength training. If you have special fitness needs, you may wish to consult a personal trainer, who can set up a workout routine for you.

In the movie Liar, Liar, an attorney falls under a spell that not only prevents him from lying but transforms him into an embarrassingly honest individual. When a judge asks him, more or less rhetorically, "And how are we today?" the lawyer, unable to hide the truth, replies, "Fine, except I had a disappointing sexual encounter last night." The judge quips, "As you get older, you'll find that happens more and more." This may be a funny line for a film. But from the perspective of anti-aging medicine, it's definitely the wrong message. Men don't want to have this kind of experience as they get older. Nor do women. Testosterone can prevent and correct a loss of libido--and it works for both sexes.

Postpubescent females continue to make testosterone, too, but in much smaller amounts than males. Then at menopause, female testosterone production declines in tandem with the other sex steroid hormones. More than 50 percent of women past menopause report declines in sexual desire. Some women with reduced testosterone output have weaker sexual urges, and their fantasies--once libido-enhancing--now fall flat. Their orgasms are nonevents: shorter, less intense, more localized. Estrogen/progesterone replacement alone cannot correct the lack of sexual desire caused by a testosterone deficiency. The physical changes, lethargy, and lack of libido that accompany menopause and andropause are usually attributed to aging itself rather than to declining hormone production. Doctors tell patients who experience these symptoms to just "live with it." My advice: Don't.

If  testosterone production is declining, hormone replacement can be powerful anti-aging medicine. Its rejuvenating effects go well beyond generating stronger and more frequent libidinal impulses. For men and women,  testosterone energizes the entire body, instilling a heightened sense of well-being. It increases lean muscle mass, reversing the fat accumulation and muscular atrophy that accompany aging. Like estrogen and progesterone, it fights osteoporosis. And  testosterone improves cardiovascular functioning and protects against heart disease.

Hormone replacement therapy makes just as much sense for men at andropause as for women at menopause. It has anti-aging effects, restoring testosterone to the level of a 30- to 40-year-old male. Unfortunately, doctors rarely consider such treatment for men.

Because it regulates sexual attraction and sex drive, testosterone has been dubbed the love hormone. A declining libido signals a declining testosterone level. When this happens, hormone replacement can make all the difference for both men and women.

Take the case of Jenny and Mark Alexander, patients of mine whom I've known for more than two decades. Happily married with two kids in college, they came to me with a problem. Jenny was the first to bring it up. "I've lost that old romantic spark," she told me. "We used to have a great sex life, but I'm just not interested anymore. I don't even think about it. Mark has slowed down a little in the past few years, but even so, I still can't seem to keep up with him. And when we do make love, I don't get aroused the way I used to. Those Roman candle orgasms are a thing of the past. What's wrong with me? I've been taking the natural estrogen and progesterone you prescribed, but they don't seem to help." I suggested that Jenny add a small dose of supplemental testosterone to her hormone replacement program. It worked like a charm. "All of a sudden, I'm interested in sex again," Jenny reported. "My orgasms are back, too. In fact, now Mark can't keep up with me." That was easily solved: Mark began using hormone replacement as well.

Beyond restoring libido, testosterone may protect men from heart disease in the same way that estrogen and progesterone protect women. A team of physicians at Columbia University found that men with low testosterone levels were much more likely to have arteries narrowed by atherosclerosis than men with higher testosterone levels. Several other studies have found a correlation between low testosterone and unhealthy blood lipid profiles: elevated total cholesterol, LDL cholesterol, and triglycerides, and low HDL cholesterol. There's some evidence, too, that a testosterone deficiency may contribute to high blood pressure and an increased risk of diabetes.

 

Blood levels of testosterone normally range from 15 to 100 milligrams per deciliter in women and from 300 to 1,200 milligrams per deciliter in men. Testosterone replacement may prove beneficial for women whose blood levels are below 60 and for men whose blood levels are below 900. Although the hormone can be administered by injection, oral forms (tablets, capsules, and lozenges) and skin patches are much more convenient.

If a testosterone deficiency is the sole cause of a diminished sex drive, as is typically the case for women at menopause and men at andropause, then testosterone replacement is worth a try. If psychological factors such as depression are playing a role, however, testosterone replacement probably won't help much. In these cases, despite diminished sexual desire, orgasms will remain normal. I've found that trial supplementation of the natural antidepressant St.-John's-wort (hypericum) often works wonders. I usually prescribe 330 milligrams three times daily. If you try it, use a standardized extract only. Give it at least a month to work.

Although there is no indication that testosterone supplementation causes prostate cancer, men with a history of the disease should not use testosterone replacement. All men over age 50 should have an annual prostate-specific antigen (PSA) screening, whether or not they are on testosterone. Testosterone replacement can cause slight, transient elevations in PSA level. This is not an indication of cancer but normal stimulation of the prostate gland's activity.

Older males often experience increased frequency and urgency of urination, especially at night. Supplementation with extract of the herb saw palmetto (Serenoa repens) relieves these symptoms--collectively called prostatic hypertrophy--by preventing the conversion of testosterone into dihydrotestosterone. Dihydrotestosterone causes prostatic hypertrophy.

Hormone replacement is a complex issue with many questions and few definitive answers. Any decision to take or not take hormones, natural or otherwise, must be based on individual circumstances and should be made with the counsel of a physician. All options should at least be considered before a choice is made. More and more physicians are recognizing the importance of natural hormone replacement therapy. If your doctor is not among them, you may want to consult with one who is. The American College for the Advancement of Medicine can refer you to a physician in your area who has experience in natural hormone replacement.

Hypothyroidism is among the most insidious age-accelerators around. Many people who have it don't even know it. In the next chapter, you'll find out how this condition speeds the aging process--and how natural thyroid hormone brings it under control.

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