Find out the truth behind common myths about bioidentical hormones.
1: All estrogens are the same.
False. This is the most important question in relation to estrogen. The type of estrogen given to the body determines how the body will react and respond. The body makes three principle estrogens: estradiol, estrone and estriol. All three are present in the body of women before (and after) menopause. Estradiol is the workhorse of the estrogens. Estriol is now being looked at as a potential anti-inflammatory estrogen with benefits to illnesses like multiple sclerosis [Source: Sicotte]. Higher ratios of estriol have been linked to lower levels of breast cancer [Source: Lemon]. Each of these forms of estrogen are made in the body. They do have slight variations with some of the forms of estrogen used in Western medicine. Premarin is a form of estrogen collected from the urine of horses. This collection of estrogens is similar but not necessarily identical to the ratio the body makes. Experts argue that this exception to what the body makes is what creates the problems seen with traditional hormone replacement. Greater attention is now being paid to study and utilize hormones made identical to those of the body, referred to as bioidentical hormone replacement.
2: Estrogen increases the risk for breast cancer.
False (mostly). There is no single factor responsible for breast cancer. But again, the type of estrogen used can make a difference. Hormone replacement users might actually see a greater breast cancer risk if they are using progestins along with the estrogen. Progestins are the synthetic form of the body’s hormone, progesterone. Progestins have been found to be cancer producing, whereas the body’s workhorse estrogen, estradiol, has not [Source: Olsson]. So again, the form of hormone replacement is very important in terms of risk. The study that brought to light many of the problems with conventional hormone replacement was called the Women’s Health Initiative. The second part of this trial used Premarin (only in women who no longer had their uterus) and found no increase in instances of breast cancer [Source: Anderson].
3: Estrogen is only good for hot flashes.
False. Estrogen prescriptions are commonly given as a treatment for hot flashes. Various forms of estrogen have been used to treat vaginal dryness and bladder problems associated with lack of hormones in the vagina. Multiple studies have documented the efficacy of various estrogen forms in helping bone mass, including estriol and estradiol [Source: Ansbacher, Itoi]. Research has also shown that estradiol may benefit and protect the brain from loss of function [Source: Asthana]. As mentioned previously, the bioidentical form of estrogen, estriol, is now being used to help treat multiple sclerosis. Conventional thinking used to be that estrogen medications or estrogen plus progestins prevented heart disease, but that is no longer standard care following the Women’s Health Initiative [Source: Anderson, Rossouw]. Unfortunately, these studies did not use the bioidentical forms of estrogen or progesterone, which may have provided substantially different results. Interestingly, estradiol has been shown to help the heart’s workload and protect cholesterol from oxidation (damage that can make the cholesterol more harmful) [Source: Alfie, Shwaery].
4: Everyone should avoid estrogen.
False. There are very few 100 percent truths in medicine. Many women will not require estrogen at all or will actually do worse with additional or supplemental estrogen. Conversely, other women will find estrogen benefits their memory or mood. Symptoms like hot flashes may interfere significantly with quality of life or perhaps with sleep to the point where health can become compromised. In these situations, women and their doctors should discuss various options available to help treat these symptoms. What works for one will not be exactly true for another. Unfortunately, certain forms of estrogen may be very unhealthy for the body, while other forms provide many potential benefits. No form, however, will be needed by everyone.
5: Estrogen increases the risk of blood clots.
True (mostly). An increased risk of blood clots depends on the form of estrogen in question. Estrogen supplementation may be associated with increased risk of blood clots. Birth control pills may increase this risk in some women who have a family history of blood clots. Risk can also go up for smokers. It is important to note that the body’s own estrogen, estriol, is not associated with an increased incidence of blood clots [Source: Utian]. When a patient is considering birth control or hormone replacement therapy of any type, family history of blood clots and tobacco use should both be disclosed to the physician.
6: Prempro is the same as estrogen.
False. Prempro is a combination of the estrogens obtained from horse urine and progestins. Progestins are synthetic versions of the body’s own progesterone. Premarin is the same type of estrogen without the progestin. Prempro was a drug removed early from the Women’s Health Initiative due to its risks for heart disease, stroke and breast cancer. Progestins are used in women who have not previously had a hysterectomy, as estrogen can overstimulate the uterus. Those with a history of Prempro usage could potentially be at a higher risk for certain chronic problems like heart disease, stroke or breast cancer versus those who used Premarin only. Unfortunately, it was only with these fairly recent studies that conventional medicine learned that slight changes in the structure of progesterone (to progestins) may cause significant impact in lowering the safety of the medication.
7: Estrogen will actually lower blood pressure.
True. Estradiol (the body's natural estrogen) has been shown in multiple studies to lower blood pressure [Source: Mercuro, Alfie]. This could be very important for those with a family history of high blood pressure.
8: Estrogens should only be taken orally.
False. Estrogens come in oral form but can also be active as creams or patches placed on the skin. Oral forms of estrogen are absorbed through the gastrointestinal tract, then taken up by the liver. Because of this absorption, oral forms of estrogen can induce changes in the liver. Estrogen placed on the skin restricts these types of influences on the liver [Source: Ansbacher]. Oral forms of estrogen can have negative effects on the growth hormones as well [Source: O'Sullivan]. Growth hormone declines with age, but it's still important to help maintain adequate lean muscle mass so we don't want it to decline any faster than normal.
9: Hormone replacements over a long period of time cause breast cancer.
False (usually). Any patient concerned that previous hormone use will increase their risk for breast cancer should focus on the risk factors that they do control. One such risk factor is a person’s weight. Our fat cells can actually produce hormones and inflammatory chemicals that can increase the risk of breast cancer. In fact, obesity may increase the body’s chances of metabolizing estrogen down an unhealthy pathway in the liver [Source: Schneider]. Work on other factors that might either influence your body’s immune system or overall metabolism by having an optimal vitamin D level and balanced thyroid function. Keep the liver working appropriately with regular intake of cruciferous vegetables (broccoli, cauliflower, brussels sprout). And just as important, make time to exercise and relax. Avoid processed, manufactured foods, especially ones with hydrogenated or partially hydrogenated oils. Diet and exercise are extremely important for a healthy immune system (which seeks out cancer cells and destroys them) and optimal health in general. Do not wait for cancer to either happen or not happen; take charge by managing factors that will substantially limit your risk.
10: Doctors are nearly as confused as patients are on the issue of hormones.
True. Unfortunately, medical training did not prepare doctors to think about hormone replacement beyond a one-size-fits-all process. They were not taught to study the various forms of estrogen in the body and the interactions estrogen has with other hormones, including thyroid and cortisol. It took nearly 40 years to understand that changing hormones in the body from their naturally occurring structure would cause a problem for the body. Even now, research on bioidentical hormones is not widely disseminated to medical students, even though patients are scanning the Internet for more information on the topic. With hormone replacement, the right decision is one that accounts for that patient’s desires, goals and risk factors. One patient’s treatment plan can be completely different from another. Hormones made by the body, or supplemented, are not simple or uniform. They will have a place in the treatment of some conditions and will need to be avoided in others. Work with a doctor who is willing to listen to your symptoms and concerns to produce a treatment plan that is right for you.
Lots More Information
- Sicotte, NL., Liva, SM., Klutch, R., et al. (2002). Treatment of multiple sclerosis with the pregnancy hormone estriol. Ann Neurol, 52:421-428.
- Lemon, HM., et al. (1966). Reduced estriol excretion in patients with breast cancer prior to endocrine therapy. JAMA, 196;1128-1136.
- Mercuro, G. (1998). Estradiol-17beta reduces blood pressure and restores the normal amplitude of the circadian blood pressure rhythm in postmenopausal hypertension. Am J Hypertens, 11(8 Pt 1):909-13.
- Alfie, J. (1997). Hemodynamic effects of transdermal estradiol alone and combined with norethisterone acetate. Maturitas, 27(2):163-9.
- Olsson, HL. (2003). Hormone replacement therapy containing progestins and given continuously increases breast carcinoma risk in Sweden. Cancer, 97(6):1387-92.
- Ansbacher, R. (2001). Pharmacokinetics and efficacy of different estrogens are not equivalent. Am J Obstet Gynecol, 184(3):255-63.
- O'Sullivan, AJ., Crampton, LJ., Freund, J., Ho, KKY. (1998). The route of estrogen replacement therapy confers divergent effects on substrate oxidation and body composition in postmenopausal women. J Clin Invest, 102:1035-40.
- Anderson, G.L., Limacher, M., Assaf, A.R., Bassford, T., Beresford, S.A., Black, H., et al. (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the women's health initiative randomized controlled trial. JAMA, 291.1701-1712.
- Utian, WH. (1980). The place of estriol therapy after menopause. Acta Endocrinol, (suppl 233):51-56.
- Rossouw, J.E., Anderson, G.L., Prentice, R.L., LaCroix, A.Z., Kooperberg, C., Stefanick, M.L., et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the women's health initiative randomized controlled trial. JAMA, 288:321-333.
- Ansbacher, R. (2001). The pharmacokinetics and efficacy of different estrogens are not equivalent. Am J Obstet Gynecol, 184(3):255-63.
- Itoi, H. (1997). Comparison of the long-term effects of oral estriol with the effects of conjugated estrogen, 1-alpha-hydroxyvitamin D3 and calcium lactate on vertebral bone loss in early menopausal women. Maturitas, 28(1):11-7.
- Asthana, S. (2001). High-dose estradiol improves cognition for women with AD: results of a randomized study. Neurology, 57(4):605-12.
- Shwaery, GT. (1998). Antioxidant protection of LDL by physiologic concentrations of estrogens is specific for 17-beta-estradiol. Atherosclerosis, 138(2):255-62.
- Schneider, J. (1983). Effects of obesity on estradiol metabolism: decreased formation of nonuterotropic metabolites. J Clin Endocrinol Metab, 56(5):973-8.