Lack of sleep can affect your health, just like lack of exercise and unhealthy eating. The body rejuvenates, repairs cells, and produces natural killer cells in deep stages of sleep. The body produces antibodies during sleep, which enable us to fight off infections. Lack of sleep makes one prone to obesity, hypertension, heart attacks, and diabetes. Sleep derivation affects metabolism and hormone balance. As a result, the body ages more rapidly when it does not get the proper amount of sleep. Studies have shown that people over 60, who do not sleep well, have twice the risk of dying early when compared with those over 60 who sleep well. Unfortunately as we age, we tend to sleep less. It is not that less sleep is needed later in life, but sleep patterns are interrupted by anxiety, pain, heartburn, and needing to empty the bladder. Proper sleep not only improves alertness and concentration, but memory improves as well. Memory recall is significantly better after a good nights sleep.

Insomnia is much more common in women than in men. Approximately 20% of the population suffers from chronic insomnia. It is also much more common when hormone levels are changing in perimenopause and menopause. Insomnia is not only a frustrating condition, but results in irritability, fatigue, mental confusion, and headaches. Insomnia can either be transient or chronic. Transient insomnia lasts less than two weeks in duration, and can result from jet lag, acute life stresses, or grief. Insomnia can lead to depression. 90% of people who suffer from insomnia for at least six weeks are depressed. Chronic insomnia can usually be broken down into a psychological or biological diagnosis leading to sleeping problems. There are greater than sixty diagnoses that result in sleeping disorders. Common psychological causes of insomnia are depression, anxiety, and drug or medication abuse. The most common biological cause of sleeping disorders is sleep apnea. Sleep apnea accounts for 30% of all insomnia and effects 2-5% of fifty year old women. Sleep apnea usually affects people with larger neck sizes; during sleep they self obstruct their airway, resulting in hypoxia, causing them to awaken. People with apnea can wake up multiple times throughout the night, interrupting sleep. Other biological or medical causes for sleeping disorders consist of cardiovascular, pulmonary, neurologic, endocrine, or gastrointestinal conditions. Primary insomnia is often genetically linked; these people have a history of never sleeping well. Menopausal insomnia is one of the leading causes of sleeping problems in women. It can usually be cured by estrogen and progesterone supplementation.

There are multiple ways to eliminate insomnia. Appropriate diet and exercise is the first line of treatment. Eliminating caffeine from the diet is extremely important. Caffeine has a half-life of six hours, so the stimulant is in the body for hours after intake. It is also important to limit nicotine and alcohol in the evening. Many people end up abusing alcohol, using it as a sleep aid. Alcohol will help initiate sleep, but it causes poor sleep by suppressing rapid eye movement (REM) sleep. Research has shown that lack of REM sleep is equivalent to no sleep at all. For obvious reasons it is important to avoid sugar in the evening. The most important cure is to eradicate the underlying diagnosis causing insomnia. Most sleeping disorders are secondary to stress and anxiety. Cognitive behavior therapy (CBT) aims at eliminating anxiety and is usually more effective than traditional medicines. Maintaining a regular sleep schedule is an important component of CBT.

Approximately 60% of Americans are overweight. If body weight is 10% over ideal weight, one is overweight; if body weight is 20% over ideal weight, one is obese. Diseases that are associated with obesity are cancer, heart disease, hypercholesteremia, high blood pressure, diabetes, and kidney failure. Public health costs from treating obesity related illness is more than 100 billion dollars a year. There are more than 400,000 deaths a year secondary to obesity. There are many over the counter and prescription remedies available, but few actually work and many are dangerous. The best medicine is proper nutrition and exercise. Weight gain is the result of caloric intake being greater than caloric burning. Instead of temporary diets, it is better to make permanent changes to eating habits. See the chapter on nutrition. Unfortunately, metabolism is greatly controlled by our genes and aging, two things we cannot change. If medication is needed to help with weight loss, I prefer natural remedies.

There are many natural remedies that have been shown to be helpful with weight loss. Adequate intake of water is the most important thing other than a proper diet and exercise for losing weight. Green tea has been shown to increase fat oxidation and energy expenditure. It decreases lipolysis of triglycerides, resulting in reduced fat absorption. The active ingredients in green tea that help with weight loss are epigallocatechin-3-gallate and caffeine. Green tea also has antioxidants, protecting the body from cancer. Chromium is important in helping regulate blood glucose levels. Chromium is part of glucose tolerance factor (GTF) and is necessary to produce insulin. Studies have shown that taking chromium increases weight loss, especially fat weight. Most Americans are deficient in chromium. Chromium lowers triglycerides and probably lowers cholesterol levels. 5-hydroxytryptophan (5-HTP) is another natural remedy that aids in weight loss. 5-HTP increases serotonin levels. Adequate serotonin levels have been shown to decrease appetite, whereas low serotonin levels can cause carbohydrate cravings and binge eating. Tryptophan is either converted to serotonin or 5-HTP, so consuming 5-HTP causes tryptophan to be converted to serotonin. Calcium has also shown to be helpful in weight loss. Calcium decreases fat production and increases the metabolism of fat.

Proper will power is also very important. It is natural for us to crave foods high in fat and sugar. These are comforting foods, which is why we often eat them during times of stress. They cause us to relax by calming the brain. These foods cause the release of dopamine which temporarily counteracts the stress hormone, cortisol. It is imperative to fight these cravings because over time the desire for these foods diminishes. Unfortunately these foods often taste better when they have been avoided, so if one falls off the wagon, it becomes that much harder to get back on.

Prescription and over-the-counter medicines for weight loss are either classified as central-acting appetite suppressants, bulk forming drugs, or fat absorption blocking drugs. The over-the-counter central-acting appetite suppressants either have ephedra, ma huang, and/or caffeine. These drugs are stimulants and can have adverse effects on the cardiovascular system. Ephedra contains ephedrine and pseudoephedrine. Their stimulant effect on the central nervous system can result in decreased appetite. Recently the Food and Drug Administration (FDA) banned ephedra secondary to complications from the drug leading to more than 150 deaths. Ephedra caused sudden death secondary to heart attacks and strokes.

The most popular prescription stimulants are dexafenfluramine (Redux), fenfluramine (Pondimin), phentermine, and sibutramine (Meridia). Redux and Pondimin were banned by the FDA in 1997. Fen-phen, a combination of fenfluramine and phentermine, was found to cause damage to heart valves. Phentermine was not implicated in the damage to the heart so it is still available. Phentermine acts like amphetamine so it is no different than speed. The danger with phentermine and Meridia is they both can raise blood pressure. Meridia inhibits the reuptake of the neurotransmitters, serotonin and norepinepherine. Redux and Pondimin also worked by increasing the same neurotransmitters. Meridia works in a similar fashion as the SSRIs; see the chapter on depression. The risk of these drugs outweighs the possible benefit.

The most commonly used bulk forming drug is methylcellulose. The purpose of the drug is to give a feeling of satiety, so less food is consumed. Side effects can be abdominal distension and flatulence. Xenical is a prescription medicine that blocks an enzyme involved in fat absorption. As a result fat is not digested and fat is excreted in the stool resulting in symptoms of gas and steatorrhea (fat diarrhea). Olestra, a fat substitute, is a fat that cannot be digested and is now found in fat free chips, can give the same symptoms. Diuretics are often abused and they can result in electrolyte imbalances. Laxatives are also commonly used and if abused severe swelling and constipation can result when the medication is stopped.

Recently scientists have discovered a protein, YY3-36, which is produced in the stomach. This particular protein is what gives us a sense of fullness after we eat. It has been shown that obese people make less of this protein than thin people. When people are injected with YY3-36, they have been found to eat 67% fewer calories. As of this publication, YY3-36 suppressants are currently in the research phase and are unavailable to the general public. Leptin is a hormone that partially controls hunger and metabolism. Leptin levels increase as people gain weight causing a decrease in appetite. Leptin levels fall when people start to burn fat, which is why it difficult to keep the weight off after dieting. Researchers are currently evaluating the efficacy of injecting people with leptin after losing weight. Researchers are also studying drugs that destroy blood vessels that supply fat cells, causing the cells to die. These drugs are still in the experimental phase.

Heart disease is the number one cause of death in women. More women die secondary to heart disease than all forms of cancer combined. One out of every three women will develop heart disease and half of a million women will die from it annually. In comparison, forty thousand women die of breast cancer yearly. Fifty percent of women die during their first heart attack, whereas only thirty percent of men die. Women are also more likely to have another heart attack within a year. Heart disease is much more common in men in their fifties, but women catch up to men by their sixties. One theory is that a woman’s natural hormones protect her from heart disease, which she no longer produces after fifty. Numerous observational studies have shown that both estrogens and progesterone are protective to the cardiovascular system. After a women reaches menopause she no longer produces these hormones. She is often given synthetic hormones, which are possibly harmful to the heart. See the chapter on hormones and research on hormone replacement therapy. Women can continue to have protection from heart disease if they take bio-identical hormones. Bio-identical hormones are identical to the protective hormones a woman produced until menopause.

Women’s bodies are much different from men’s bodies and heart disease behaves differently between the sexes. Women have smaller hearts and smaller blood vessels. Men usually develop heart attacks when an atherosclerotic plaque in the coronary aterery dislodges and blocks the blood vessel downstream. Heart attacks also result from enlargement of the plaque to the point where it occludes the entire vessel. Oxygen can no longer reach this part of the heart causing pain (angina), irregular heartbeats (arrhythmia), or heart failure. Artherosclerosis is when fatty deposits, cholesterol, and calcium collect on the lining of artery walls, forming a plaque. The most common form of heart attacks in women is secondary to artherosclerosis as well. But women are more prone to developing artherosclerosis in a more diffuse manner. Instead of the plaque gathering in one part of the vessel, artherosclerosis is spread more evenly throughout the vessel. Additionally women who suffer from heart attacks often do not have artherosclerosis. It is felt that women may instead suffer from vasospasm of the major heart vessels. When an artery has spasms, especially in a smaller female blood vessel, it cuts off the ability of blood to pass through the artery. Studies have shown that women with smaller coronary arteries suffer more from heart disease than women with larger blood vessels. The size of arteries in men did not show the same findings. Secondary to different etiologies of heart attacks between men and women, there symptoms are often much different. Men will often have the classic symptoms of a heart attack; pain in the chest radiating to the left arm or jaw associated with shortness of breath. Women, on the other hand, often have atypical symptoms such as nausea, indigestion, fatigue, dizziness, or pain in the upper back. Heart attacks are often misdiagnosed in women because of this. Misdiagnosis could also be attributed to the thought of heart disease as a disease that primarily affects men. 45% of physicians surveyed did not realize that heart disease is the leading cause of mortality in women over 50. Mortality secondary to heart disease is falling in men but continues to rise in women. Now more women die secondary to heart disease each year than men.

The most basic test to evaluate heart disease is the electrocardiogram (EKG). It measures electrical activity within the heart. Breast tissue can distort the findings, making the test less accurate in women. An EKG is also used during a stress test, where the heart is evaluated during exercise. A more accurate test is the echocardiogram. An echocardiogram assesses blood flow through the chambers of the heart under ultrasound guidance. Angiogram is the best test to diagnose heart disease. It is an invasive test that involves threading a catheter from the femoral vein in the leg to the heart. Dye is then injected into the coronary vessels looking for blockages. Complications, such as strokes, can be caused by this procedure. Women with heart disease often have normal angiograms because their disease presents differently from men, as described above. This is also why women have not benefited as much as men from angioplasty. Angioplasty is a procedure treating artherosclerosis by dilating the affected artery with a balloon catheter and then a synthetic stent is placed in this area. The stent enables blood to pass unobstructed through the affected artery. A newer noninvasive test for heart disease is electron beam computed tomography (EBCT). Artherosclerotic plaques contain calcium, and an EBCT evaluates how much calcium has accumulated in the coronary vessels. Unfortunatey if the calcium count is high, an angiogram is often needed to see which blood vessels are affected and how severely they are affected.

Like all diseases, prevention is the best modality. Risks for heart disease are smoking, obesity, high cholesterol, high blood pressure (hypertension), inactivity, stress, and a family history. Laboratory values can also determine who is at more risk for heart disease. Elevated total cholesterol, LDL cholesterol, triglycerides, homocysteine, fibrinogen, C-reactive protein (CRP), and lipoprotein (a) levels are associated with heart disease. Smoking increases heart disease by three-fold over the general population. Smoking not only increases artherosclerosis but causes the plaques within the arteries to become unstable. Smoking also increases fibrinogen, a blood clotting protein produced by the liver. An excess of fibrinogen can cause hardening of the arterial walls, leading to loss of elasticity. Being overweight, especially at the waist, increases the risk for heart disease substantially. Women usually do not start to gain weight in their abdomen until after menopause. Prior to menopause, women are more prone to storing excess weight below the waist. Obesity also increases the chance of developing diabetes, which is another risk factor for heart disease. Fifty percent of women over the age of 45 have hypertension. Hypertension makes it harder for the heart to pump blood into the increased pressure within the arteries. Keeping total cholesterol, LDL cholesterol, and triglycerides low and HDL cholesterol high is very important. Low HDL cholesterol is more of an indicator for developing heart disease in women than in men. Homocysteine is an amino acid that rapidly rises after a woman reaches menopause. Elevation of homocysteine is correlated with arterial wall damage. Folate, vitamin B6, and vitamin B12 can reduce homocysteine levels. Inflammation has recently been shown to increase heart disease. CRP is an indicator of inflammation and people with higher CRP levels have been found to have more artherosclerosis. Research has shown that women with the highest levels of CRP were four times as likely to develop cardiovascular disease. Lipoprotein (a) is composed of apolipoprotein A and an LDL-C-like particle. Elevation of lipoprotein (a) is an indicator for possible artherosclerosis and coronary heart disease. Estrogen has been found to lower lipoprotein (a). See the chapter on estrogen to find out how estrogen is protective to the heart. Stress plays a role in heart disease and women have more stress related angina than men. Additionally depression increases the risk for heart disease and women have a higher incidence of depression. Unfortunately we cannot control our genes, but we can be aware of our risks and seek treatment for abnormal lab values and hypertension and maintain a healthy lifestyle.

Aspirin prevents platelets from clumping together to form blood clots. If symptoms of a heart attack occur, taking an aspirin immediately can save your life. Aspirin thins the blood enabling it to pass easier through the clogged blood vessel. Aspirin also reduces inflammation. C-reactive protein and interleukin-6 are substances associated with inflammation and are markers for cardiovascular disease. In January 2002 the U.S. Preventative Task Force concluded that aspirin could reduce the risk of heart attacks and strokes. Researchers showed that aspirin could prevent heart attacks by 28% when compared with a placebo. The side effects from aspirin are bleeding problems that usually occur in the gastrointestinal system. If there is no history of bleeding problems, all menopausal women should take a baby aspirin daily.

CHOLESTEROL

Cholesterol is essential to the body. The sex hormones are originally derived from cholesterol. The body naturally produces all the cholesterol it needs, so it is not required in the diet. Though cholesterol levels can rise secondary to our diets, cholesterol levels are mainly determined by heredity. Plants do not produce cholesterol, so no fruits or vegetables can increase our cholesterol intake. Animals, fish, and birds produce cholesterol so it is found in meats, egg yolks, and milk products. Saturated fats increase cholesterol levels. Low-density lipoprotein (LDL) cholesterol is commonly referred to as the “bad” cholesterol. LDL cholesterol is responsible for transporting cholesterol within the bloodstream. It then deposits the cholesterol on the lining of vessels forming cholesterol plaques. High-density lipoprotein (HDL) cholesterol is commonly referred to as the “good” cholesterol because it rids the body of cholesterol by transporting it to the liver. A high LDL/HDL ratio is more of an indicator for heart disease than high total cholesterol. The American Heart Association recommends keeping LDL cholesterol below 130, but newer evidence is showing that LDL should be kept even lower than this. The higher the HDL, the more protection you have. Cholesterol levels have been found to fluctuate and levels are often higher in the winter compared to the summer.

The first line of treatment for high cholesterol is lifestyle changes. It has been proven that cholesterol can be lowered with proper diet and exercise. Unfortunately some people only can lower their cholesterol slightly with lifestyle modifications and some people refuse to change. In 1987 the “statin” drugs were introduced, and they are now the leading class of prescription drug used in the U.S. They work by slowing the production of cholesterol in the liver and thus can substantially lower total cholesterol levels. They also work by removing LDL cholesterol from the blood, resulting in lower LDL cholesterol. They have also been shown to reduce C-reactive protein (CRP), which causes inflammation in blood vessels and other organs. In addition they increase HDL cholesterol and lower triglyceride levels. This class of drugs significantly reduces artherosclerosis, resulting in less coronary artery disease and less peripheral vascular disease. As a result they have decreased the risk of heart attacks and strokes by approximately 25%. Limited research has also shown that the “statins” may reduce the risk of Alzheimer’s disease, osteoporosis, rheumatoid arthritis, glaucoma, macular degeneration, and multiple sclerosis. The decrease in these diseases is probably secondary to the anti-inflammatory aspect of the “statins”. Some “statins” are more effective than others because have the ability to reduce inflammation more. The “statin” drugs have been shown to be very safe as well as effective, but they are expensive. Liver enzymes should be checked periodically since the drug works within the liver and1% of people will get liver problems. Other side effects are muscle pain and body aches. ApoA-1 Milano is a rare type of HDL cholesterol originally discovered in people living in Milan, Italy. ApoA-1 Milano has been found to significantly reduce the size of arthersclerotic plaques in a very short time period. A synthetic version of this HDL has been developed and has shown promising results when injected into patients. A new drug, Torcetrapid, has been found to increase HDL levels by nearly 50%.

Numerous natural remedies are used to treat hypercholesteremia. A recent study has shown that a diet rich in plant sterols, oats, barley, almonds, and soy proteins was just as effective as “statin” drugs at lowering cholesterol. Niacin (vitamin B3) has been used with success to lower cholesterol. It has been shown to lower LDL cholesterol by 20%, raise HDL cholesterol by 20%, and lower triglycerides. The main side effect from niacin is flushing. In multiple studies, garlic has been shown to reduce total cholesterol by 10%.

Breast cancer is the most common cancer among women, representing 32% of the cancers in women. One in eight women in their lifetime will develop breast cancer. In the U.S. there are 180,000 new cases of breast cancer annually. Fortunately the five-year survival rate is 86%. But unfortunately breast cancer is becoming more common. One in fourteen women developed breast cancer in 1960. Between 1950 and 1987 the incidence of breast cancer rose approximately 1% per year. It might be secondary to a longer lifespan or it may be secondary to using synthetic hormones. See chapter on estrogen. Increasing age is the greatest risk factor for breast cancer. Other risks include smoking, obesity, alcohol, a strong family history, not giving birth or giving birth late in life, and lack of breastfeeding. 80% of women with breast cancer have none of these risks. Most benign growths, such fibroadenomas, do not increase the risk of breast cancer.

Breast tissue cells are very responsive to estrogen and progesterone. Estrogen causes breast cells to proliferate, whereas progesterone counterbalances the aggressive effects of estrogen. Many breast cancers have estrogen receptors. It is believed that these cancerous cells will grow more rapidly if estrogen is in the body. A recent study showed that women on bioidentical hormones after breast cancer diagnosis had a 50% lower recurrence rate. Indole-3-carbinol (I3C), derived from broccoli, inhibits the growth and proliferation of breast cancer cells. Aspirin has been shown to decrease the risk of breast cancer by 30% because of its anti-inflammatory action.

The biggest fear that women have when taking estrogen is the possibility of developing breast cancer. Among women surveyed, 40% felt that the leading cause of death in women is breast cancer, when in reality it is 4%. Whether or not estrogen causes breast cancer is still not known. Prior to the WHI study there were more than fifty case control and cohort studies with mixed findings, thus the findings have been inconclusive. If there is an increased risk, the risk must be small. See the chapter on research on hormone replacement therapy. The largest cohort study retrospectively looked at 46,355 women who were evaluated for 15 years in the Breast Cancer Demonstration Project. There were 2082 incidents of breast cancer. Women taking estrogen alone had a 1.2 fold increase in breast cancer, whereas women taking estrogen and a progestin had a 1.4fold increase in breast cancer. These risks are shown to decrease after stopping HRT, and are almost nonexistent five years after stopping. These studies only looked at synthetic hormones, so the hormones a woman naturally produces have not been properly evaluated. Synthetic estrogens have been shown to increase density and mitotic activity in breast tissue. Synthetic estrogens are not only foreign to the body, but many are more aggressive than bioidentical estrogens. The use of synthetic estrogens, including birth control pills, could account for the recent increase in breast cancer.

Progesterone is cancer protective. Progesterone reduces the mitotic change in endometrial and breast tissue. It reduces cell proliferation and it enhances natural killer cells, interleukin-2, and the p53 molecule. Natural killer cells and interleukin-2 are important components of the immune system. Molecule p53 coordinates the actions of more than 60 genes that prevent damaged cells from turning cancerous. Progesterone increases apoptosis (cell destruction) before damaged cells convert to malignancies. Several studies have shown that the higher a woman's progesterone, the less likely she is of developing cancer. Synthetic progestins have been shown to increase the incidence of breast cancer. The recent increase in breast cancer could very well be secondary to the lack of progesterone. Progesterone becomes deficient in a woman's forties and it is completely absent by menopause. Women continue to produce some estrogen and they often take synthetic estrogens and progestins. There is strong evidence that this causes the breast to become estrogen dominant. Unless natural progesterone is in her body, she is most likely increasing her risk of breast cancer.

Studies have shown that women who take HRT have a greater chance of surviving breast cancer. The breast cancer in women who use HRT are more localized, lower grade, smaller tumors, and more likely to be lobular in origin. Ductal carcinomas of the breast are more ominous than lobular carcinomas. As a result there is a 40-60% reduction in mortality when compared with women who developed breast cancer without a history of HRT.

Studies on bioidentical hormones are limited regarding breast cancer. Estriol has been postulated to be protective but doctors are not using it so studies will continue to be limited. Every baby a woman has lowers her chance of breast cancer by 7%. This is ironic because when a woman is pregnant she is exposed to more than ten times the amount of estrogen and progesterone than any other time in her life. It very well could be the high levels of estriol during pregnancy that is responsible for this protection. Early pregnancies are protective against breast cancer not only because of the early exposure to estriol, but also because the p53 gene is upregulated in early pregnancies.

Breast cancer can occur secondary to an inherited gene mutation. BRCAI and BRCAII gene abnormalities have been shown to increase the risk of both ovarian and breast cancer. BRCAI and BRCAII are tumor suppressor genes that have a particular importance in breast and ovarian cells. The general risk for carrying a mutation in either BRCA genes is between 1 in 400 and 1 in 800. Jewish women of Eastern European decent have a 1 in 40 risk of a BRCA gene mutation. If an inherited mutation in the gene is discovered, women have an 87% lifetime risk of developing breast cancer. If there is a strong family history of breast and/or ovarian cancer BRCA testing should be performed. It is a blood test and the test is very expensive. If the test is positive, women should be counseled concerning their options.

There are many different treatment protocols for breast cancer. Options change with the type of cancer, nodal involvement, and the estrogen receptor status of the tumor. The decision should be made by the patient with input from the surgeon and the oncologist. Treatment usually consists of a combination of two or more of the following: mastectomy, lumpectomy, axillary node dissection, radiation, and/or chemotherapy. After this, five years of Tamoxifen is usually recommended; see the chapter on SERMs. Tamoxifen works by binding to estrogen receptors within the breast, preventing estrogen from binding to those receptors. After five years, the estrogen receptors become resistant to Tamoxifen, and it is no longer effective. A new drug called Femara is now being used after Tamoxifen. Femara is an aromatase inhibitor that works by decreasing the amount of estrogen production in the body. Studies have shown that Femara decreases the recurrence of breast cancer by 43%. Other aromatase inhibitors are Aromasin and Arimidex.

Osteoporosis literally means “porous bones”. Osteoporosis is when the holes within the honeycomb matrix of the inner bone become larger, making the bone fragile. The world Health Organization defines osteoporosis as bone density that is 2.5 standard deviations below an average 35 year old. 10 million Americans have osteoporosis and 1.5 million succumb to bone fractures each year. When bone density is between 1.0 and 2.5 standard deviations below an average 35 year old, one has osteopenia. Approximately 20-30 million Americans have osteopenia. Do not be alarmed if your bone density is slightly low because you are being compared to bone at its maximum density. Women reach maximum bone density at age 35. Older bone is constantly being replaced by newer bone tissue. After age 35, bone is broken down faster than it can be rebuilt. Bone loss is a consequence of advancing age, but it is much more rapid in women after menopause. The loss of estrogen and progesterone at menopause is responsible for the majority of the disease. Women lose the majority of their bone in the first five years after menopause if they are not taking supplemental estrogen and progesterone. This is why 80% of all people with osteoporosis are women. The most common area for an osteoporotic fracture is within the vertebral bodies in the spine. This can result in curvature of the spine, loss of height, chronic back pain, and leads to further fractures in the vertebra. The second most frequent place of a fracture is in the hip. Hip fractures are so serious that approximately 25% of women hospitalized secondary to a hip fracture will die within a year.

There are no symptoms of osteoporosis. Besides being a woman, there are many other risk factors for osteoporosis. Uncontrollable risks include an early menopause, having a family history of osteoporosis, having a small frame, and fair skin (Caucasian, Asian). Medical and nutritional risks include hyperthyroidism, calcium deficiency, alcohol, smoking, and corticosteroid use. The national Osteoporosis Foundation recommends that women over the age of 65 get a bone density test. I think it is important to get one at the age of 50 so a baseline is established prior to menopause. Any woman with a documented vertebral, hip, wrist, or rib fracture, should get a bone density test right away. The best test is called a dual x-ray absorptiometry (DEXA) scan. This test accurately measures the density of the bone at the three most common areas of fractures; the spine, hip and wrist.

Women are diagnosed with depression twice as often as men are. Women have been taught from an early age to express their feelings, whereas men are taught to deal with their feelings internally. Possibly depression is just as prevalent in both sexes, but women are the ones seeking help. Underweight women have twice the incidence of depression compared to overweight women; the reason for this is unknown. Depression could also be hormonally related. Depression is commonly seen in early teenagers and perimenopausal women, when their hormones are fluctuating drastically. Depression is also common in menopause, during the second half of the menstrual cycle (luteal phase), and postpartum, when there are drastic hormone changes. There also could be some anatomical differences between men and women. Research has shown that women store both emotion and memory in the same parts of their brain, whereas men store them in separate areas.

It is unclear what exactly causes depression, but research shows that it is most likely related to our inherited genes plus a triggering environmental effect. It is felt that heredity may account for as much as 80% of the risk for depression. Researchers have isolated a gene that is responsible for regulating serotonin function. People with the short arm of the gene are twice as likely to develop depression after a triggering environmental effect. Symptoms of depression are prolonged sadness, inability to feel pleasure, sleeping too much or too little, difficulty eating and suicidal thoughts. Approximately twenty million Americans are affected, with 30,000 committing suicide each year.

Brain cells communicate with one another via neurotransmitters. A deficiency of the neurotransmitters, serotonin, dopamine, norepinephrine, and glutamate is involved in depression. Signs of serotonin deficiency are depression, over eating, and being overwhelmed. An excess of dopamine causes excitement, whereas low dopamine causes fatigue. Newer evidence is pointing towards unhealthy nerves in the part of our brains that control emotion, not the lack of neurotransmitters, is what is causing us to be depressed. The stress hormone, cortisol, is elevated in people with depression. Overexposure to cortisol has been shown to inhibit the growth of nerve cells in the brain. Part of the reason why antidepressants work is that they stimulate the growth of new nerve cells. Drugs in the future will probably focus on repairing damaged nerves in the part of the brain that controls emotion. Drugs that diminish the stress response are currently being studied. From what we learned about cortisol in the last chapter, it is apparent that depression can have serious effects on our health. Depression is a serious risk factor for heart disease.

The treatment of depression is centered upon making the neurotransmitters, especially serotonin, available for use. Neurotransmitters are mostly made from amino acids, the building blocks of proteins. Tryptophan, an amino acid, is a direct precursor of serotonin. Tryptophan is available by prescription only, but supplemental 5-hydroxytrptophan will increase serotonin levels as well. The amino acids phenylalanine and tyrosine are precursors of dopamine, epinephrine, and norepinephrine. Brain chemistry is still not completely understood, but it is believed that by increasing individual amino acids in the diet, levels of neurotransmitters will increase as well, preventing or relieving depression. There are some theories indicating that the longer one is depressed, the harder one is to treat. It is important to seek treatment sooner than later. There is some evidence that prolonged severe depression can result in early ovarian decline.

Initially the treatment of depression was with psychoanalysis thanks to the work performed by Sigmund Freud. Ever since the tricyclic antidepressant drugs became available in the 1960's, psychoanalysis has been used less and less. The tricyclics increase the activity of serotonin and norepinephrine, thus increasing euphoria. The side effects are blurred vision, dizziness, and sleepiness. In 1987 Prozac was the first selective serotonin reuptake inhibitor (SSRI) available in the U.S. SSRIs only increase the availability of serotonin and not norepinephrine, so side effects were less severe. The SSRI's include Prozac, Celexa, Luvox, Paxil, and Zoloft. Side effects from these medicines include insomnia, loss of sex drive, nausea, and restlessness. Lexapro is the newest SSRI and it has been touted to relieve anxiety as well as depression. The monoamine oxidase inhibitors (MAOIs) are less commonly used than the SSRIs because they have more dangerous side effects. Marplan, Nardil, and Parnate are MAOIs and they can cause a hypertensive crisis, dizziness, weight gain, constipation, and headaches. MAOIs cannot be used with other medications to treat depression and people must eliminate the amino acid, tyramine from their diet. The use of MAOIs might be back on the rise, because the FDA just approved an MAOI patch. This will result in fewer side effects because most of the serious side effects from MAOIs were secondary to oral administration. Wellbutrin is another commonly prescribed drug for depression, but its exact mechanism of action is unknown. There seems to be less sexual dysfunction on Wellbutrin, and Wellbutrin SR (sustained release) is the same drug as Zyban, used for smoking cessation. Some of the above antidepressants have increased suicidal thoughts in teenagers, as well as adults. It is important to watch for signs of increased irritability, anxiety, hostility, or restlessness, especially in the first few weeks of treatment. When antidepressants are stopped it is important to decrease the medication slowly. Stopping cold turkey can cause dizziness, fatigue, nausea, headaches, anxiety, and depression.

There are also natural agents which are used for depression. St. John's Wort has been used for hundreds of years and it is one of the most studied herbs. The studies show that it is as effective as standard drugs for treating mild depression. Omega-3 fatty acids are being extensively studied. The nervous system cannot grow and regenerate without omega-3 fatty acids. Docosahexaenoic acid (DHA), an omega-3 fatty acid, is the main component of cell membranes in the brain. GABA and glutamate are natural occurring molecules, which can also be taken as a supplement. They are the primary neurotransmitters in the brain, and as a result they can affect all activities in the brain. Testosterone supplementation has been shown to improve mood in a study involving men, so the same hormone may have the same effect on women. DHEA, an over the counter hormone, has been used for depression and mood elevation as well. SAMe, ginkgo biloba, phenylalanine, and 5-HTP are also used to treat mild depression. Adequate levels of vitamin B12 have been shown to be important in treating depression. People who respond best to medical treatment have higher concentrations of vitamin B12. Exercise is also important because of the release of natural endorphins, which elevate mood.

Unfortunately stress is a big part of a women's life and it can have negative effects on health. Like depression, women suffer from anxiety much more than men. In addition to having a career, women are usually responsible for taking care of the children, cooking and cleaning, which leaves little time for other interests. It is very important to find time to channel this stress out of your body. In a stressful situation cortisol and epinephrine (adrenaline) are secreted from the adrenal glands and secreted into the bloodstream. Epinephrine causes the heart to pump faster and stronger, getting ready for the “fight or flight” response. Too much epinephrine over time can lead to hypertension and damage to arteries. After the stressful situation is resolved, cortisol remains elevated, which is responsible for an increased appetite for sugar. This results in impulse eating and is responsible for the majority of diet breakdowns. Cortisol also increases insulin levels, causing fat storage, especially in the abdomen. Chronic exposure to cortisol has multiple deleterious effects. It can be responsible for heart disease, hypertension, stomach ulcers, overeating, impaired immune response, sleep impairment, memory impairment, and depression. High levels of cortisol can lead to osteoporosis because cortisol interferes with the bones' ability to absorb calcium. Cortisol levels naturally increase with age, and as a result it is the hormone that is strongly implicated in the aging process. Hostility and impatience has shown to double the risk of hypertension, obesity, and depression.

Serotonin calms the stress response and thus has the opposite effect from cortisol and adrenaline. Serotonin is responsible for the “stop eating signal” and thus when levels of serotonin are normal we have less cravings for sweets and carbohydrates. Serotonin levels naturally decrease with age. Exercise increases levels of serotonin and vitamin B6 is necessary to produce serotonin.

It is important to eliminate chronic stress. Whenever a stressful situation arises we need to channel that negative energy elsewhere. Stress increases heart rate, blood pressure, muscle tension, and respiratory rate. Living a healthy lifestyle has been shown to prevent stress. When the body is relaxed it produces more nitric oxide, which counterbalances cortisol. Eating properly, routine exercise, yoga, pilates, meditation, and a healthy sex life are helpful for preventing stress. Meditation and yoga share the same philosophy concerning relaxation and the control of breathing. It is very difficult to remain anxious when breathing slowly and deeply in a regular pattern. Relaxation techniques lower blood pressure, heart rate, and respiratory rate. Meditation has not only been shown to reduce stress, but can improve chronic pain, elevate mood, increase circulation, and improve digestion. Exercise is important because endorphins are released which counterbalance cortisol.

Many women say they have never had chronic stress or anxiety until they reached their forties. The reason for this is that anxiety is much more common after perimenopause. In perimenopause, progesterone is deficient for the first time in their lives. Progesterone has calming properties, so when the progesterone is supplemented, the anxiety often diminishes.

The most common headaches are classified as migraine or tension-type. The cause of headaches is not completely understood, especially why certain people have a higher predisposition toward getting them. Women are three times more likely to suffer from chronic headaches than men. Allergies are the most common triggering source for headaches. The second most common cause of headaches is a hormonal imbalance. An excess or deficiency, in almost every hormone, can be related to headaches. Hormones are what cause us to perceive pain. The hormones serotonin and histamine act as neurotransmitters and induce pain responses at nerve endings. Endorphins block these neurotransmitters and prevent the sensation of pain. An overproduction of prolactin has been linked to headaches. Too much or too little thyroid production has also caused headaches. The most common hormones associated with headaches in women are the sex hormones. Headaches are very common when sex hormones are fluctuating. They are common in puberty, perimenopause, menopause, and postpartum. They also are common in women on oral contraceptives and with women who suffer from PMS. Most cyclical headaches occur in women right before their menses or during their menses. Fluctuating estrogen levels are what is usually responsible for these headaches. It is the sudden drop in estrogen that is most symptomatic. Women experience a drop in estrogen prior to menses, and estrogen levels are at their lowest point during menstruation. Women on oral contraceptives make very little of their own estrogen, secondary to the high doses of synthetic hormones they are taking. I have found estradiol cream, balanced with progesterone, to be very effective in treating headaches. Every woman responds differently to her individual hormones, so the same treatment does not work on everyone.

It is amazing that thoughts on nutrition are constantly changing. For years we have known what foods are healthy or unhealthy. Scientists have known since the 1960's that the saturated fat in red meat and dairy products can raise cholesterol and lead to coronary heart disease. Initially these findings were downplayed to appease the cattle and dairy industries. The synthetic fats were invented to replace saturated fats, but scientists determined that the newer fats are more detrimental to health than saturated fats. These fats are still being used by the food industry because they are inexpensive and increase the shelf life of processed foods. Nutritionists have always known about the perils of simple sugars, yet their prevalence continues to grow. There is a constant debate whether a low-fat diet or a low-carbohydrate diet is better for you. Asking your doctor for their opinion has always been a poor option because nutrition is very rarely taught in medical school.

The calories we get from food either come from protein, carbohydrates, or fats. A gram of protein or carbohydrate gives us four calories, whereas a gram of fat gives us nine calories. When food was not as plentiful as it is today, it was imperative for us to consume as many calories as possible, so the craving for fatty foods was an important inherited trait. Now food is plentiful but unfortunately we cannot reverse our evolutionary desires. Today Americans eat too much, and as a result, more than one half of Americans weigh too much. We need to eat smaller portions.

Carbohydrates enter the bloodstream as glucose and glucose is an instant energy source for all tissues in the body. Carbohydrates can be subdivided into “good” carbohydrates and “bad” carbohydrates. “Good” carbohydrates consist of fruits, vegetables, and unprocessed starches (whole grain breads and cereals, brown rice, whole wheat pasta). “Good” carbohydrates provide dietary fiber and some essential vitamins and minerals. Fiber is the structural part of fruits and vegetables that cannot be digested. Fiber is important in preventing constipation and colon cancer. Societies that have the highest percentage of fiber and grain have the lowest incidence of colon cancer. Fiber also gives us a sense of fullness, which helps us from over eating. Fiber removes bile acids from the small intestine, resulting in lower cholesterol levels.

The main difference between “good” and “bad” carbohydrates is the glycemic index. Glycemic index measures how fast a food we eat releases glucose into the bloodstream. The “good” carbohydrates have a low glycemic index. When glucose enters the bloodstream a surge of insulin is released from the pancreas. Insulin is the hormone that enables the glucose to enter the cells within the muscle and other tissues. At times of activity, glucose is immediately consumed by muscle cells. This is why carbohydrates are an excellent source of fuel during exercise, especially high glycemic carbohydrates. At times of rest insulin still causes cells to absorb glucose, but the glucose is stored away in fat and muscle cells. The intake of carbohydrates, especially “bad” carbohydrates, needs to be limited at times of inactivity. Whole grains and fruits are broken down much slower in the digestive tract compared with “bad” carbohydrates so the surge of glucose and insulin is not as drastic.

“Bad” carbohydrates consist of simple sugars, refined pasta, white rice, and white bread. These are the most important items to be removed from our diets. They have a high glycemic index. These foods give the surge in glucose, which then cause the surge in insulin. The surge in insulin can also cause us to over eat because after the insulin surge our blood glucose falls increasing our craving for more glucose. Increased insulin levels also decrease the ability for the body to metabolize fat. Not only does this cause us to gain weight but cells become resistant to insulin, which can lead to diabetes. High insulin levels inhibit the activity of glucagon. Glucagon is a hormone that is responsible for releasing stored fuels when blood sugar is low. Without glucagon our body cannot self regulate its blood glucose level, causing the hunger signal to set in. Eating another high glycemic snack results in a continuous cycle of high blood sugars followed by low blood sugars, then the craving for sugar again. The simple sugars consist of anything sweet; sodas, cookies, candies, cakes, etc.

Proteins are made up from combinations of the twenty amino acids. There are eight essential amino acids that the body needs through nutrition. The remaining amino acids can be synthesized from the eight essential amino acids. Protein is important for building muscle mass. All protein sources are good for you but some have a higher percentage of fat in them. The low fat sources of protein are: turkey and chicken breasts, dry beans, most fish, shell fish, egg whites, tofu, reduced fat dairy (cheese, yogurt, milk). Proteins with a higher fat content are: red meats, liver, sausage, bacon, hot dogs, ribs, poultry leg and thigh, egg yolks, dairy products. A diet that is excessive in protein can put stress on the kidneys, resulting in kidney stones or renal failure.

Fats role in heart disease led to the fat phobia. Fats are nutritionally very important. Fat is essential for the growth and maintenance of the nervous system. Fat is also integral in proper functioning of the fat soluble vitamins, vitamins A, D, E, and K. Fats can be broken down into saturated and unsaturated fats. Saturated fats are solid at room temperature, whereas unsaturated fats are in a liquid form at room temperature. Saturated fats are bad for us because they are dangerous to the heart and they increase the bad cholesterol, LDL. Saturated fats also promote insulin resistance. Saturated fats are found in fats from animals (dairy products, poultry, red meat) and tropical oils (coconut and palm oils). Unsaturated fats are better for us and they consist of monounsaturated and polyunsaturated fats. Unsaturated fats can lower cholesterol and are felt to be protective to the heart. We should never eat foods deep-fried because even if it is fried in unsaturated fat, the heat can break the double bonds of unsaturated fat, changing it into a saturated fat. The oils in olives and peanuts are monounsaturated. Polyunsaturated fat sources are the oils that come from corn, soybean, sunflower, and safflower. Monounsaturated fats are slightly better for our bodies than polyunsaturated fats. Omega-3 fatty acids are polyunsaturated fats and are protective to the heart. Foods that are rich in omega-3 fatty acids include tuna, salmon, mackerel, walnuts, flax and canola oils. It is still smart to eat good fats in moderation because of their high caloric content. Additionally, the body easily stores dietary fats as body fat. Trans-fatty acids are synthetic fats that are common in processed foods, labeled as “partially hydrogenated” or “vegetable shortening”. Like saturated fats, trans-fatty acids raise LDL cholesterol and lower HDL cholesterol, leading to heart disease and strokes. It is best to avoid these fats as well.

In the 1980's the general population was not only becoming aware that we got more than twice as many calories from fat, but that saturated fats were partially responsible for heart disease. As a result came the fat free diet. Products were coming up overnight with their “fat free” or “low fat” slogans and they were a huge economic success. Unfortunately these products were loaded with simple sugars and as a result had nearly as many calories. These products had a psychological effect on people as well because we felt we could eat more than the usual serving because they were good for us. Instead of losing weight, people gained weight by eating these products. A lot fat diet is good for us, as long as high glycemic foods are not replacing the fat calories. Dean Ornish, M.D. has shown that a low fat diet and exercise can reverse heart disease. The Atkin's diet is very popular, and it is essentially a carbohydrate-free diet.

Today we are seeing low-carbohydrate products saturating the food industry, similar to the fat free gimmick of the 1990's. The problem with this diet is that one can eat unlimited amounts of fatty meats, butter, and cheese. Though this diet has been successful for weight loss, it does not promote healthy eating. This diet is high in saturated fats and causes the body to go into ketoacidosis, a disturbed acid balance. This diet can also cause bone loss and increased uric acid levels, leading to gout. The Atkin's diet causes rapid early weight loss, but most of this is water and some lean muscle weight. After one year, people regained more weight on the low carbohydrate diet compared to those on low fat diets. The problem with a lot of diets is that they are very hard to adhere to. I prefer diets for lifelong health, not short-term weight loss. The key to this is giving up processed foods in favor of natural foods. Boyd Eaton, M.D. wrote Paleolithic Prescription in 1988 with the philosophy that farming made us fat. His solution is to eliminate processed grains from our diet and replace them with fruits and vegetables favored by our early ancestors. He also advises against mass produced meats and favors lean free-range animals like those hunted by our forebears. Not only are the meats we buy in the supermarket fatter, but they are usually injected with hormones to make the animals grow bigger. I also recommend trying to eliminate milk products, such as butter, cheese, and cream. Milk products are high in saturated fats. We are the only mammals who continue to use milk products after weaning from breast milk.

Exercise is important for everyone, even if weight loss is not an issue. It is important for maintaining cardiovascular health, and cardiovascular disease is the leading cause of death in both men and women. Exercise lowers blood pressure, cholesterol, and triglyceride levels. Exercise has been shown to lower the risk of hypertension, diabetes, and some cancers. Overweight women who exercise have less heart disease than thin women who do not exercise. Exercise also has an anti-aging effect by lowering cortisol and increasing endorphins, dopamine and serotonin. By increasing endorphins, dopamine, and serotonin, exercise might be more effective than traditional antidepressants in treating depression. Endorphins neutralize the effects of cortisol, giving a post exercise calming effect. This result can prevent anxiety and insomnia and possibly help with hot flashes. Exercise improves metabolism and fat oxidation. Exercise builds muscle and muscle dictates metabolism. It not only burns fat but most importantly it burns intra-abdominal fat. It is the intra-abdominal fat that puts women at increased risk for heart disease and diabetes. Exercise improves bowel motility and digestion. It improves the endocrine (hormone producing) and immune systems. Exercise protects from osteoarthritis by strengthening the muscles within the joints and increasing the flexibility of the ligaments and tendons within the joints. Weight bearing exercise improves bone strength, improving or preventing osteoporosis.

SAMe (S-Adenosylmethionine) is a combined product of ATP and methionine. It is not a vitamin because the body produces all that it needs. In order to produce SAMe the body needs adequate levels of methionine, folate and vitamin B12. As a supplement it is used primarily for depression. It works by enhancing the impact of the neurotransmitters serotonin and dopamine. It is also used to alleviate the symptoms of arthritis and it is being studied to see if it slows the progression of arthritis. Researchers have found SAMe as effective as pharmaceutical agents for pain and inflammation. SAMe is also felt to regenerate the liver, so it can be helpful for people who drink too much or have other liver conditions.

Melatonin is primarily used for insomnia and jet lag. Melatonin is a hormone produced by the pineal gland but only in the absence of sunlight. As soon as the sun rises the pineal gland stops the production of melatonin and instead makes serotonin. Melatonin is what triggers sleep. Higher melatonin levels produce a deeper sleep. It decreases stress by decreasing cortisol levels and stimulating GABA. It is a strong antioxidant, protecting against free radicals, thus protecting against cancer. It is felt to be anti-aging because of its effect on stress and cancer protection. Woman who work at night have less melatonin production and as result they have an increase in breast and colon cancers. It also improves thyroid function by enhancing the production of T3.

Coenzyme Q10 is beneficial for people with congestive heart failure and other forms of heart disease. It has also been used with limited results to enhance athletic performance. The body naturally produces CoQ10 but it can become deficient if cholesterol-lowering drugs are being used.

Glucosamine is derived from glucose and is a key component for making cartilage. It is used to treat osteoarthritis. Not only does it alleviate symptoms but also it slows progression of the disease by regenerating cartilage.

Chondroitin sulfate, like glucosamine, is used to treat and protect against osteoarthritis. It is naturally produced in the body like glucosamine but additional supplements are beneficial. Like glucosamine, chondroitin is a major component of cartilage.

Creatine is responsible for bringing ATP to muscle cells. It is used to increase athletic performance. Muscles use ATP for energy, so creatine can make muscles work harder and longer while training and then recover faster.

Isoflavones are hormones that plants produce. Phytoestrogens are isoflavones because they are plant hormones that have an estrogen like effect. They bind to the same receptors as estrogen, and can actually prevent estrogen from binding, blocking estrogen's influence. Our bodies do not have the enzymes to convert phytoestrogens into estrogens, so our levels of estrogen will not go up by taking phytoestrogens. Isoflavones have been shown to lower cholesterol. Soybeans are the most common source of isoflavones.

Ipriflavone is a synthetic isoflavone. Since it is synthetic it will not be obtained in our foods, and can only be obtained through a supplement. It was synthesized for preventing and treating osteoporosis. It gives an estrogenic effect only on the bones and does not prevent hot flashes or act on other tissue like the heart, breast or uterus. Ipriflavone most likely works by inhibiting bone breakdown, similar to estrogen's effect on bone.

5-hydroxytryptophan (5-HTP) is a precursor for serotonin. Serotonin deficiencies are common in depression, so supplemental 5-HTP may increase serotonin levels. 5-HTP is also used to help with anxiety, insomnia, fibromyalgia, weight loss, and chronic headaches.

The three main estrogens produced by the human body are estrone (E1), estradiol (E2), and estriol (E3).

Estrone accounts for 10% of the circulating estrogen in a reproductive female. Estradiol and estrone can be converted to one another in the body by enzymes. In addition to being produced by the ovary, estrone is also formed from androstenedione in fatty tissue. Androstenedione is in the androgen family of hormones like testosterone. After menopause, when the ovary stops producing estrogen, a woman's only source of endogenous estrogen comes from the peripheral conversion of androstenedione to estrone; hence estrone accounts for the majority of estrogen in a menopausal woman. Estradiol accounts for another 10% of the circulating estrogen in pre-menopausal women. Most traditional prescriptions of estrogen have either estrone or estradiol. Premarin has estrone, as well as thirty other equine estrogens. Estrace and estrogen patches consist of estradiol.

Estriol accounts for the remaining 80% of circulating estrogen. It is the weakest and most benign of the estrogen family. It is also the predominant estrogen in pregnancy. It is felt to be protective by counterbalancing the aggressive effects of estrone and estradiol. Some studies show it has a protective effect against breast cancer. Vegetarians and Asian women have higher levels of estriol and lower levels of breast cancer. Women with breast cancer were found to have lower levels of estriol relative to estrone and estradiol. Sisters and daughters of women with breast cancer were found to have lower than normal levels of estriol. One of the reasons why an early pregnancy is protective against breast cancer is possibly because of high estriol levels. Estriol is extremely effective in preserving the lower genital tract. As a vaginal cream it is very effective at alleviating vaginal atrophy, preventing urinary and vaginal infections, and preventing urinary incontinence. Estriol has not been shown to be protective to the heart or bones. Vitamin E can increase estriol levels. Estriol is often referred to as the forgotten estrogen because it is rarely prescribed. Although research on estriol is limited, all evidence points to its protective nature, so I believe it is a mistake not to prescribe it with the other estrogens.

Women who take supplemental estrogen should take either Biest or Triest. Triest is an exact ratio of the hormones described above. It consists of 10% estrone, 10% estradiol, and 80% estriol. Biest is 20% estradiol and 80% estriol. The theory behind using Biest instead of Triest is that estrone is the most aggressive of the estrogens and menopausal women already have enough estrone in their bodies. In reality, estrone and estradiol are readily converted to one another so whether you take one or the other, both estrone and estradiol are going to be in the body.

There are several ways to take estrogens; the most common way is oral administration. Swallowing a pill is very easy and oral administration improves the cholesterol profile more than other routes of administration. Oral estrogen reduces insulin-like growth factor-I (IGF-I) and increases growth hormone. The downside of oral estrogens is the “first pass liver effect”. Anything we ingest immediately goes to the liver. When the liver processes the hormones, it makes steroid hormone binding globulin (SHBG). SHBG binds hormones, making them unable to perform their functions. The liver also is responsible for making clotting enzymes, and oral estrogen leads to a greater production of these enzymes. Oral estrogens increase the risk for gallbladder disease and raise triglyceride levels. Oral estrogen showed a reduction in lean body mass and an increase in fat mass, when compared with transdermal estrogen. I prefer transdermal, via creams or gels, or sublingual (under the tongue) administration of estrogen. This causes the estrogen to go right into the bloodstream without the “first pass liver effect”. When the ovary produces estrogen, it immediately gets into the blood stream via the ovarian vessels. The transdermal and sublingual routes closely resembles this physiologic process. Transdermal application of estrogen does not increase the risk of gallbladder disease or raise triglyceride levels like oral administration does. Transdermal estrogen also is less of a risk factor for blood clotting because the estrogen does not initially go through the liver.

Despite what recent studies have led many physicians and women to believe, estrogen is protective to the heart. The American College of Obstetrics and Gynecology (ACOG) now recommends that women no longer take HRT for cardiovascular protection. This is based on the findings from the Women's Health Initiative (WHI) study, but only the effects of synthetic hormones on older women were studied. See the chapter on research on HRT. More than 40 observational studies have shown that menopausal women receiving estrogen have less heart disease than menopausal women not on estrogen. We cannot just ignore the other studies. Heart disease is the leading cause of death in women and they usually do not develop heart disease until after menopause, when estrogen is deficient. In multiple studies, estrogen also has been shown to prevent artherosclerosis. It does this by lowering total cholesterol, lowering low density lipoprotein (LDL) cholesterol, raising high density lipoprotein (HDL) cholesterol, and lowering lipoprotein (a), homocysteine, and C-reactive protein (CRP). Estrogen also has direct vascular effects. It increases vascular dilatation by relaxing the smooth muscle cells within the vessel wall. Estrogen increases endothelial cell growth, increases insulin sensitivity, and decreases coagulation factors. It also decreases uptake of LDL cholesterol in the coronary arteries and inhibits the oxidation of LDL. This results in a decrease in artherosclerosis and an overall protection to the coronary arteries.

Nothing is better than estrogen at preventing osteoporosis. The majority of bone loss occurs in the first five years of menopause without estrogen supplementation. Without estrogen women lose approximately 3-5% of their bone mass per year for the first five years, and then approximately 1% per year thereafter. Not only does estrogen prevent osteoporosis by reducing bone resorption, studies have shown that it helps to rebuild bone mass as well. Estrogen has also been shown to reduce the chance of a fracture in weaker bones. Menopausal women have a 15% chance of developing a hip or wrist fracture, and a 20% chance of developing a vertebral fracture. When long-term estrogen replacement is complemented with adequate calcium intake, hip and wrist fractures are reduced by 55% and vertebral fractures are reduced by 80%. Hip fractures are so serious that approximately 20% of women hospitalized because of a hip fracture die within a year.

Colon cancer is the third leading cause of cancer deaths in women, after lung cancer and breast cancer. The risk for developing colon cancer is reduced by 50% with estrogen use. The longer one uses estrogen, the more protection they receive. This risk reduction is maintained for approximately ten years after discontinuation of estrogen. The WHI did not see as great as a result, but patients were observed for only five years. Between 1960-1990, mortality rates from colon cancer rose in men by 16%, whereas in women they fell by 21%. This time period is when women started using more estrogen replacement, so estrogen could account for these findings.

Studies on estrogen and the risk of Alzheimer's disease have shown mixed results. The Manhattan Cohort Study showed that estrogen reduced the chance of Alzheimer's disease by 60%. It also showed that of those women who get Alzheimer's disease, women on estrogen get it later in life than women not on estrogen. The Leisure World Cohort Study showed that estrogen reduced the risk of Alzheimer's disease by 35%. It also showed that women on larger doses of estrogen and longer duration of use had even more of a reduction in risk. The results of the Women's Health Initiative Memory Study (WHIMS) were published in July 2003. This study evaluated the chance of developing Alzheimer's disease among 4500 women older than 65. Over a five-year period twice as many women on Prempro developed dementia compared with a placebo. Prempro is Premarin and Provera (See the chapter on Reaserch on HRT) and it may be the Provera that was responsible for the increase in adverse outcomes. Provera has been shown to increase the incidence of strokes; thus the memory of the women could have been affected by transient strokes (transient ischemic attacks) within the brain. The WHIMS found no significant increase or decrease in Alzheimer's disease in women taking only Premarin. Additionally, the women studied were much older than the women in previous studies. This might suggest that older women do not get the same protection from hormones as younger women. It is quite possible that estrogen receptors in the brain are down regulated after prolonged absence of estrogen. One of the first things most women notice after estrogen depletion is short-term memory loss and “brain fog”. In many women this is reversed with estrogen supplementation.

The biggest fear of women who use estrogen is breast cancer. Among women surveyed, 40% felt that the leading cause of death in women is breast cancer, where as in reality it is 4%. Whether or not estrogen causes breast cancer is still not known. Prior to the WHI study, there were more than fifty case control and cohort studies with mixed findings; thus the findings have been inconclusive. If there is an increased risk, the risk must be small. (See the chapter on research on hormone replacement therapy.) The largest cohort study looked at 46,355 women who were evaluated for 15 years in the Breast Cancer Demonstration Project. There were 2082 incidents of breast cancer. Women taking estrogen alone had a 1.2 fold increase in breast cancer, whereas women taking estrogen and a progestin had a 1.4 fold increase in breast cancer. Progestins (synthetic progesterone) have recently been shown to be more responsible than estrogen in the rising incidence of breast cancer. These risks are shown to decrease after stopping HRT, and are almost nonexistent five years after stopping.

These studies only looked at unnatural hormones, so the hormones a woman naturally produces have not been properly evaluated. Unnatural estrogens have been shown to increase density and mitotic activity in breast tissue. It is unclear if natural hormones have the same effect. Studies have shown that women who take HRT have a greater chance of surviving breast cancer. The breast cancers in women who use HRT are more likely to be lobular in origin. As a result, there is a 40-60% reduction in mortality when compared with women who developed breast cancer without a history of HRT. Unfortunately studies on bioidentical hormones are limited regarding breast cancer. Estriol has been postulated to be protective but doctors are not using it, so studies will continue to be limited. Every baby a woman has lowers her chance of breast cancer by 7%. It very well could be the high levels of estriol during pregnancy that is responsible for this protection.

Macular degeneration is a major cause of vision loss in the elderly. Because the average age of the population continues to increase, macular degeneration will be more of a concern in the future. Multiple studies have shown that estrogen use decreases the incidence of macular degeneration.

Estrogen has many other benefits. First of all, it is the hormone that makes women feminine. Estrogen is what makes a woman feel like a woman. Estrogen increases libido, preserving sexuality. Estrogen prevents hot flashes and night sweats. Woman lacking estrogen have difficulty sleeping and estrogen restores sleep. It increases stamina, giving a woman more energy. Estrogen keeps the vagina young and healthy by preventing vaginal atrophy. Vaginal atrophy is thinning of the vaginal tissue and shortening and narrowing of the vagina. Vaginal atrophy can result in decreased vaginal secretions and painful intercourse. There are more estrogen receptors in the vagina and urogenital tract than anywhere else in the body. As a result, estrogen protects from bladder and vaginal floor problems such as urinary incontinence and pelvic organ prolapse. Estrogen is also beneficial to the skin. Skin collagen is affected by loss of estrogen. Skin collagen is responsible for keeping the skin youthful by making it more elastic and thicker, which leads to fewer wrinkles. As women age the skin thins and estrogen prevents this thinning. Estrogen also keeps hair and nails youthful. Adequate estrogen levels also can prevent migraine headaches.

Progesterone is produced by the corpus luteum in the ovary after ovulation and by the placenta during pregnancy. After ovulation (approximately day 14), the corpus luteum starts producing progesterone. The corpus luteum is the remainder of the egg left behind in the ovary. The second half of the cycle is thus called the luteal phase; it is the progesterone dominant phase of the menstrual cycle. Progesterone peaks approximately 6-8 days prior to the next menses, which occurs around day 21-22 of the cycle.

Progesterone is responsible for stabilizing the thickened endometrial lining in the uterus.

If conception occurs, the corpus luteum continues to produce progesterone until 6 weeks after conception. The placenta then takes over the production of progesterone. If conception does not occur, the corpus luteum regresses, causing the progesterone level to fall. When the progesterone level gets back to its initial baseline, menstruation sets in and a new cycle is started. If ovulation fails to occur, progesterone is not produced. In perimenopause, ovulation is sporadic, so progesterone levels begin to decline. In menopause, progesterone is completely absent.

Rarely do menopausal women take progesterone; instead they are prescribed a synthetic progestin. There are many different synthetic progestins invented and patented by pharmaceutical companies. Hormones act on receptors and that receptor is looking for a specific molecule. The molecular structure of progesterone is not exactly the same as that of a synthetic progestin. The synthetic hormone can bind to the receptor but it does not fit exactly right, causing a different effect. Progestins also have been accused of tying up the receptor, not giving a pure progesterone response, causing estrogen dominance in tissues throughout the body. Synthetic progestins have a different effect on breast tissue, the cardiovascular system, and the brain when compared with progesterone.

Provera is a synthetic progestin, not progesterone or even close to it. Provera attenuates the benefits of estrogen. Provera raises LDL and total cholesterol, and lowers HDL cholesterol. As a result, it is damaging to the vascular system. A study published in the Journal of Reproductive Medicine showed that progesterone did not negatively affect estrogen's positive effect on the heart, whereas Provera did. In another study progesterone, but not Provera, enhanced the beneficial effect of estrogen on exercise induced myocardial ischemia (lack of oxygen to the heart). In several other studies, Provera was shown to constrict coronary arteries, causing vasospasm and myocardial infarction (heart attack), whereas progesterone dilated coronary vessels in primates. It is felt that natural progesterone has a direct impact on reducing platelet aggregation through its ability to enhance endothelium-derived nitric oxide. Progesterone also increases HDL cholesterol, making it even more protective to the heart. The data from these studies demonstrate that progesterone has a different effect on the body compared to Provera.

Provera also increases the risk of breast cancer. Studies looking at estrogen versus estrogen and Provera show an increase incidence of breast caner in the latter. Studies have shown no increased risk when natural progesterone is added to estrogen. It is believed that progesterone is cancer protective by counterbalancing the aggressive effects of estrogen.

Critics of this philosophy state that both progesterone and Provera act on the same receptors, thus they should elicit the same response. These molecules are completely different from one another and thus elicit different responses. Provera has been shown to cause bloating, breast tenderness, mood disturbances, somatic complaints, and lowers core body temperature. One reason why women stop taking HRT is because of the side effects of Provera. In contrast, women enjoy the way they feel on natural progesterone. Instead of causing bloating, it is a natural diuretic. It also reduces irritability, anxiety, depression, and raises core body temperature. With such different effects on the same receptor, it is readily apparent that these two hormones are not interchangeable. Additionally it is felt that Provera may provide insufficient balance for estrogen, making a woman estrogen dominate causing the diseases above.

After the WHI study, progesterone is now thought of as a dangerous hormone because of the increase in disease seen with Prempro. If progesterone is so dangerous, we should see disastrous events during pregnancy because this is when progesterone is at its highest. We should also see complications in younger women when they are naturally producing progesterone. We do not see either of these.

Initially when women were started on HRT, they were only given estrogen. Physicians started to see an increase in endometrial cancer (cancer of the uterus) secondary to the unopposed estrogen in the uterus. Instead of prescribing progesterone, they started prescribing synthetic progestins. If a woman has had a hysterectomy, only an estrogen is prescribed. The philosophy behind this is that if a woman no longer has a uterus she cannot develop endometrial cancer and thus does not need progesterone or a progestin. Progesterone has many positive effects in the body besides protecting the uterus. Progesterone is responsible for counterbalancing estrogen in all organ systems.

Progesterone is cancer protective. Progesterone reduces the mitotic change in endometrial and breast tissue. It reduces cell proliferation; it enhances natural killer cells, interleukin-2, and the p53 molecule. Natural killer cells and interleukin-3 are important components of the immune system. Molecule p53 coordinates the actions of more than 60 genes that prevent damaged cells from turning cancerous. Progesterone increases apoptosis, cell destruction before damaged cells are converted to malignant cells. Several studies have shown that the higher a woman's progesterone level, the less likely she is of developing cancer cells.

Additionally, progesterone is a calming hormone. It reduces anxiety, irritability, and depression. This is why progesterone should be the first line treatment for PMS. Progesterone is helpful for insomnia as well. It prevents osteoporosis by aiding in bone formation. Adequate progesterone helps prevent uterine fibroids, ovarian cysts, and fibrocystic breast disease.

It is usually recommended to take progesterone for two weeks a month, replicating the natural menstrual cycle. I often prescribe progesterone daily because it is less confusing this way and women generally feel better when on progesterone. If women are still menstruating, I recommend using it for two weeks starting on day 14 of the menstrual cycle so their menses stays regular.

Half of the testosterone produced in women is made by the ovaries; the other half comes from the adrenal glands. Testosterone is important for maintaining muscle mass, strength, and endurance. It is important for proper vitality and energy levels. Adequate testosterone levels have been shown to improve memory and mood. Testosterone is important in burning fat, especially in the abdomen. It is also important for preserving libido and enhancing orgasms. It protects from osteoporosis and cardiovascular disease. It lowers the risk of heart disease by lowering cholesterol and triglyceride levels and normalizing blood clotting.

Artherosclerosis increases as testosterone levels decrease. Testosterone reduces blood glucose levels by increasing insulin sensitivity, resulting in less abdominal fat. Testosterone has also been thought to increase creativity and confidence. Testosterone helps preserve the integrity of the skin by increasing skin tone. Synthetic testosterone, such as methyltestosterone, does not have all of the same benefits and may even cause damage to the heart by increasing LDL cholesterol and decreasing HDL cholesterol.

Unlike estrogen and progesterone, a woman's ovaries continue to produce testosterone after menopause. Most of this testosterone is converted into estrogen and this is where the majority of a menopausal woman's endogenous estrogen comes from. Testosterone peaks around age 25 and its production, like most hormones, diminishes with age. Supplemental testosterone is important for most women, and if a woman has had her ovaries removed, it is especially important. Testosterone levels are highest around ovulation, which is responsible for increasing libido at the proper time for fertilization. The first signs of too much testosterone are acne and facial hair.

DHEA (dehydroepiandrosterone) is produced by the adrenal glands. DHEA is the most abundant hormone in the bloodstream. It peaks at approximately age 25, and after that we lose approximately 2% per year. The majority of testosterone in a woman comes from the peripheral conversion of DHEA. DHEA is an anti-stress hormone; it reverses the effect of stress on the immune system. It improves mood and acts as an antidepressant. It also improves memory, energy, and stamina. Brain cells have been found to degenerate more rapidly when DHEA is low. DHEA is felt to be beneficial to the cardiovascular system. It has been shown to improve artherosclerosis and reduce platelet aggregation. It also has been shown to prevent osteoporosis.

Pregnenolone is produced by the adrenal glands and it is the first hormone sythesized from cholesterol. If there is not an adequate supply of pregnenolone, the production of other hormones becomes deficient because pregnenolone is the precursor for other hormones. Pregnenolone functions in cellular repair, especially in the brain and nervous system, thus preserving brain function. It can help to improve memory, alleviate stress, improve intelligence, improve energy, and improve mood.

The thyroid gland is a bi-lobed gland that is found on both sides of the trachea (windpipe). It is responsible for producing the hormones thyroxine (T4) and triiodothyronine (T3). These thyroid hormones control metabolism. They also regulate body temperature and energy levels. Women are more likely than men to develop a thyroid disorder. A deficiency in thyroid hormones is termed hypothyroidism. The most common cause of hypothyroidism is Hashimoto's disease, which is an autoimmune disease where antibodies destroy the thyroid gland. The most common symptoms of hypothyroidism are weight gain, fatigue, constipation, hair thinning, and intolerance to cold.

Many other conditions can cause these same symptoms, so laboratory analysis of thyroid hormones is also appropriate in the diagnosis. The most common test is to measure thyroid stimulating hormone (TSH), but there are often inaccuracies with this test alone. Many women who have hypothyroidism have normal TSH levels. Measuring T4, T3, and TSH, as well as a good clinical history will more accurately diagnose thyroid disorders.

Hyperthyroidism is when the thyroid is over producing thyroid hormones and typically has the opposite symptoms as hypothyroidism. The most common symptoms of hyperthyroidism are weight loss, diarrhea, heart palpitations, intolerance to heat, poor memory, and muscle weakness. The most common cause of hyperthyroidism is Grave's disease, which is a condition where antibodies stimulate the thyroid gland to produce more thyroid hormones. Women are nine times more likely to develop hypothyroidism than hyperthyroidism. Approximately 10% of women have an undiagnosed thyroid condition. The basal metabolic rate drops 5% every decade of life, which is why hypothyroidism is very common in women over the age of sixty.

The endocrine hormones respond to each other and abnormal levels of hormones affect other hormones. Too much or too little thyroid hormone affects the menstrual cycle, which can result in ovulatory problems, causing infertility. Ovulatory problems also change bleeding patterns, resulting in irregular bleeding or amenorrhea. Thyroid disease can also be responsible for miscarriages. Estrogen dominance can also cause hypothyroidism, by inhibiting the uptake of thyroid hormones. Estrogen dominance is common in anovulatory states such as perimenopause. Estrogen dominance can be treated with natural progesterone. There is good evidence that hypothyroidism is responsible for causing artherosclerosis, leading to heart disease.

The thyroid gland can become enlarged, forming a goiter. Most thyroid goiters do not affect the amount of thyroid hormone released from the thyroid. All thyroid goiters need to be evaluated by a physician because a significant percentage of them are cancerous.

The underlying disorder of hypothyroidism is usually not curable. In order to treat hypothyroidism, thyroid hormone must be replaced. The most common treatment is with levothyroxine (Synthroid). Synthroid is synthetic thyroxine (T4). The problem with synthroid alone is that some people are not able to convert T4 to T3; T3 is the most active thyroid hormone. Another problem is that some people only convert T4 to reverse T4. Because of this it is also important to treat women with T3. Cytomel is a prescription form of T3. Some practitioners prefer Armour thyroid. Armour thyroid is derived from pig thyroid and contains T3 as well as T4. I prefer prescribing bioidentical T3 and T4 from a compounding pharmacy.

Taking too much thyroid hormone is dangerous because it can cause heart problems and osteoporosis. Hyperthyroidism is usually treated with radioactive iodine, which destroys the thyroid gland. After treatment, most of these women are now hypothyroid and need thyroid supplementation for the rest of their lives.

The Women's Health Initiative (WHI) is the largest study to date on the risks versus the benefits of hormone replacement therapy (HRT). It was stopped three years early on July 9, 2002. This made headlines across the world because the study was stopped early due to the belief that the risks of HRT outweighed the benefits. Many studies have been done looking at the risk/benefit ratio of hormone replacement therapy, but most of these studies were smaller observational studies. The WHI involved 27,000 women in multiple cities, which was sponsored by the National Institute of Health (NIH). This study was a randomized, doubly blind study. The patients were randomized to hormones or a placebo (sugar pill) and neither the patient nor the doctor knew which arm of the study they were on. This is the gold standard when looking at research. The purpose of the study was to assess the long-term risk/benefit ratio of HRT in disease prevention. The study evaluated the incidence of heart disease, strokes, breast cancer, osteoporosis, and colon caner. The study was supposed to last eight years until 2005.

Two different studies were undertaken. 16,608 women without a hysterectomy were in the study involving Premarin/medroxyprogesterone acetate (Prempro), which was the study that was stopped in July, 2002. Per 10,000 women per year taking Prepro instead of a placebo they saw 8 more cases of breast cancer, 8 more strokes, 8 more incidents of pulmonary embolism, 7 more heart attacks, 6 fewer cases of colon cancer, and 5 fewer hip fractures. Only 2.5% of the women on Prempro had these adverse health problems. Even the authors of the WHI stressed that this increased risk should not be a cause for major alarm.

This study has many faults. First of all quality of life was never evaluated. Ever since the results of this study were published, millions of women have gone off of their HRT. After stopping their hormones, many women are suffering, and are fearful to go back to taking hormones. If a study concludes that the relative risk of a drug is only slightly elevated, the difference in quality of life must be evaluated.

There have been multiple observational studies prior to the WHI with no conclusive evidence that estrogen replacement therapy increases the risk of breast cancer. The relative risk for developing breast cancer on Prempro in the WHI study was 1.26. A relative risk of 1.0 is considered of no risk and many doctors do not consider a drug to be a risk until the number reaches 2.0. In contrast, the relative risk of developing lung cancer from smoking is 29.0. There are also numerous other risks for breast cancer that are greater than taking Prempro; night shift work (RR 1.36), not having children (RR 1.40), left handedness (RR 1.42), having your first pregnancy after 29 years old (RR 1.48), obesity (RR 1.60), an average of two alcoholic drinks a night (RR 1.7), greater than 13 years of education (RR 1.79).

Most women are convinced that taking HRT is going to cause them to develop breast cancer. It takes approximately seven years to diagnose breast cancer once it develops, so we cannot say that Prempro causes breast cancer because these women were only evaluated for five years. It raises the question that perhaps Prempro promoted the growth of pre-existing breast cancers. Many breast cancers have estrogen and progesterone receptors, so taking HRT will make a lot of these cancers grow more rapidly and thus they are diagnosed earlier.

Though this study was short lived, the Provera in Prempro has been shown to increase the risk of breast cancer in earlier studies. Studies looking at estrogen versus estrogen and Provera show an increase incidence of breast caner in the latter. Studies have shown no increased risk when natural progesterone is added to estrogen. Additionally, it is felt that Provera may provide insufficient balance for estrogen, making a woman estrogen dominant, causing an increase in breast cancer. The WHI found a decreased incidence of breast cancer in the group taking Premarin without Provera, though it was not statistically significant.

Seeing an increased incidence of heart disease was very distressing, because physicians have been giving HRT to women for years, telling them that it was good for their hearts. This was not surprising for the practitioners who have looked at the previous studies involving Provera. Provera is a synthetic progestin, not progesterone or even close to it. Provera attenuates the benefits of estrogen. Provera raises LDL and total cholesterol, and lowers HDL cholesterol. As a result, it is damaging to the vascular system. A study published in the Journal of Reproductive Medicine showed that progesterone did not negatively affect estrogen's positive effect on the heart, whereas Provera did. In another study progesterone, but not Provera, enhanced the beneficial effect of estrogen on exercise induced myocardial ischemia (lack of oxygen to the heart). In several other studies, Provera was shown to constrict coronary arteries, causing vasospasm and myocardial infarction (heart attack), whereas progesterone dilated coronary vessels in primates. It is felt that natural progesterone has a direct impact on reducing platelet aggregation through its ability to enhance endothelium-derived nitric oxide. Progesterone also increases HDL cholesterol, making it even more protective to the heart.

The Heart and Estrogen/Progestin Replacement Study (HERS) study was published in 1998. Previous studies like the PEPI study and the Nurses' Health Study suggested that HRT may provide cardio-protective benefits in women without coronary artery disease. The HERS study evaluated whether or not Prempro could prevent myocardial infarction in postmenopausal women with established heart disease. They saw an increased incidence of myocardial infarction in the first year of Prempro, but then a protective effect in years 2-4. They found similar findings in the WHI; the major risk was in the first year of treatment.
The data from these studies demonstrate that progesterone has a different effect on the body compared to Provera. Critics of this philosophy state that because both progesterone and Provera act on the same receptors, they should elicit the same response. These molecules are different from one another structurally and thus elicit different responses.

It was stated that the women in the WHI study were healthy. However, their average body mass index was 28.5, which is equivalent to 5'6”, 180 pounds . Fifty percent of the participants had a history of smoking, thirty-five percent had hypertension, 4.5% had diabetes, and 2% had a history of a heart attack. The biggest problem with the study was the average age of the women was 63, and only one third of the participants were in their fifties.

Only 25% of the women had a history of HRT use. We have known for a long time that the vasculature loses its estrogen receptors once artherosclerosis sets in. As a result, women no longer benefit as much from a cardio-protective standpoint when given estrogen at this time. It is also presumed that women start developing cardiovascular disease rapidly after menopause without the protectiveness of estrogen. Estrogens and especially medroxyprogesterone acetate (Provera) can cause embolisms in artherosclerotic arteries. An embolism is when a plaque in an artery dislodges and travels elsewhere. If an embolism occurs in the coronary arteries, it causes a heart attack. If an embolism occurs in the carotid arteries, it causes a stroke. This is why an increase in heart attacks was seen in the WHI and the HERS studies, especially in the first year of use. The HERS study was similar to the WHI in that these women started taking Prempro many years after menopause, after artherosclerosis had set in.

HRT should be started at menopause, not at age 63. To support this theory we should look at the studies involving birth control pills. Birth control pills (OCPs) have very large dosages of synthetic hormones, much larger than HRT. When perimenopausal women are given oral contraceptive pills (OCPs) there is no increase in heart disease or breast cancer. OCPs have actually been shown to decrease the risk of cardiovascular disease. The reason for this is that these women have not gone for a significant period without estrogen in their bodies.

Women in the WHI study with a previous hysterectomy were either given Premarin or a placebo. This study was halted in March 2004 because it was felt that Premarin did not have benefits over a placebo. It was determined that there was no increase or decrease in heart disease or breast cancer. Though there was a 9% reduction in heart attacks and a 23% reduction in breast cancers in women on Premarin; these numbers were not statistically significant. There were significantly fewer colon cancers and cases of osteoporosis in women on Premarin. There was a statistically significant increase in strokes in women on Premarin. This again can be attributed to unhealthy women being given estrogen after many years of not having its protectiveness. There was not an increase in strokes in women in their fifties on Premarin.

Of the forty observational studies evaluating estrogen and cardiovascular disease, almost every one has shown that estrogen has a protective effect. We cannot dismiss what we know about hormones based on one study. Estrogen decreases total cholesterol, increases HDL, and decreases LDL. It does raise triglyceride levels. It also lowers lipoprotein (a), homocysteine, and C-reactive protein (CRP) levels, giving additional cardiovascular benefits. Estrogen also has direct vascular effects. It increases vascular dilatation by relaxing the smooth muscle cells within the vessel wall. Estrogen increases endothelial cell growth, increases insulin sensitivity, and decreases coagulation factors. It also decreases uptake of LDL in the coronary arteries. This results in a decrease in artherosclerosis and overall protection to the coronary arteries. It's no wonder that heart disease is much less common in women prior to menopause before estrogen levels decline dramatically.

Prempro and Premarin were used in the WHI study because they are the most widely used of all HRT. Although Premarin is not as harmful as Provera, it is still consists of foreign substances. Its name originates from PREgnant MARes urINe. It consists of 30 different equine estrogens and all except one are foreign to the human body. The only hormone that resembles a human hormone is estrone. Premarin is three times more potent than your own hormones and can exist in the body for more than six weeks after taking it. A study showed that one ingredient, 4-hydroxy equinlenin, causes single-strand breaks in DNA and oxidation of DNA bases. It is well known that damage to DNA can lead to cancers, such as breast cancer.

It is hard to believe that a woman would take potentially harmful synthetic or foreign hormones when she can take the exact replica of the hormones she produced her entire life. Pharmaceutical companies will not produce bioidentical hormones because they cannot patent them. But they can develop a synthetic hormone, patent it, market it, convince physicians to use it, and then make a lot of money. They then donate their drugs to be used in studies. The major limitation to the WHI was that it only evaluated two forms of HRT, Prempro and Premarin. Obviously larger studies need to be performed using bioidentical hormones. We would see much different results; it does not make sense for these hormones to be protective to a woman in her 40's but not in her 50's.

Another problem with the study is that it did not evaluate different routes of administration, such as transdermal application. It is shameful that all forms of hormones are grouped together as HRT as if they are all the same medication. I wish headlines would state “Prempro is bad for you” instead of stating “HRT is bad for you”. People need to understand that women are healthiest when their hormone levels are at their prime. It is not until hormones start declining and synthetic hormones are added that we start to see health problems. Instead of discontinuing Prempro, Wyeth pharmaceuticals recently introduced a lower dose of Prempro.

Hormones are found in the blood, saliva, and urine. The most accurate way to check hormone levels is to determine levels in the blood. Blood tests can determine both the level of the free hormone and the amount of hormone that is bound to its carrier protein. Blood tests can accurately determine deficiencies in the hormone, and can show if adequate replacement has been prescribed. The downside of a blood test is that hormone levels change from moment to moment and day to day. Thus the hormone level is being evaluated only at that particular time.

Proponents of saliva testing argue that only the free hormone is measured and, therefore, determines the level of active hormone available to tissues. A limitation of salivary testing is that when hormone levels are low, there may not be sufficient hormone in the saliva to measure. In addition, saliva levels can become contaminated if any blood is in the specimen. Many practitioners feel that saliva tests are extremely inaccurate and hormone levels in the saliva are not consistent with levels in the rest of the body.

Unfortunately, all hormone testing cannot measure what is happening at the receptor site or hormone levels in tissues. If proper hormone levels are not achieved, then the person is not getting the full benefit of the replacement hormone. Each person responds differently to a dose of hormones because absorption and metabolism of hormones varies among individuals. Additionally, hormone levels can be affected by the route of administration of the hormone.

If a woman is going to be prescribed hormones, I recommend checking a blood level before starting, and then again in two to three weeks after starting. It is important to take the hormone as prescribed when evaluating hormone levels. When hormone levels are checked, it is optimal to check the level approximately 2-6 hours after taking the hormone. This is when the hormone level is peaking. If patients are not feeling the desired effect of the hormone or are having abnormal symptoms, it is recommended to recheck the blood level of the hormone, so micro-adjustments can be made.

Estrogen levels can be drawn at anytime if a woman is menopausal because she is no longer making estrogen in a reproductive manner. In a reproductive woman, estrogen levels peak at day 12-13 and have a second peak between days 20-22. This is the optimal time to check estrogen levels. The same is true of progesterone. Menopausal women are not ovulating, so they are not producing progesterone. Timing of the blood draw is not critical in these women. If a woman is menstruating, drawing progesterone 4-12 days before the next menses, when progesterone is peaking, is the optimal time.

Bioidentical hormone therapy can help you  through the process of change women undergo as they go into  menopause.  Bioidentical hormone replacement therapy  provides some relief from some of the worst symptoms brought on by  the onset of hormone imbalance. A bioidentical hormone  doctor uses bioidentical hormones to improve your health and  provide an overall better quality of life during this trying  time.  Bioidentical hormones doctors highly recommend  their use because they do not produce the harmful side effects synthetic  hormones cause. The major benefit of bio identical hormone replacement  therapy is that it allows bioidentical hormone doctors to offer  different choices of drugs, different strengths, and a variety of dosage  forms.
Other advantages of bioidentical hormone  replacement are that it lowers cholesterol levels, decreases the risk  of osteoporosis, and decreases the risk of heart attack and stroke, among  others.
  So, if you believe you may be feeling any of the  symptoms commonly associated with menopause or hormone imbalance bio identical hormone replacement  may be the solution you seek. Consult your physician and read up on  bio identical hormone therapy.  Let bioidentical hormone  treatment give you the quality of life you  deserve.



Contact Kenton Bruice, M.D. with your questions about bioidentical hormone therapy.