Physician Directed Age Management and Hormone Replacement for Men and Women

Hormone Replacement Therapy in Women

Menopause typically occurs in females around age 51. However, hormone related sx frequently present in the perimenopausal state, 1-2 years before the cessation of normal menstral cycles. Women who have their ovaries removed are considered menopausal regardless of age. The use of hormone replacement therapy (HRT), is highly effective for improving the quality of life of women suffering from acute menopausal symptoms, such as hot flashes, night sweats, insomnia, increased fatigue, irritability, memory loss, headaches, depression, skin changes, vaginal dryness and incontinence. HRT provides protection against cardiovascular disease, at least in women who use HRT within 10 yrs of menopause. HRT also reduces osteoporosis, colon cancer and may reduce the incidence of dementia/alzheimers. Women in the perimenopausal state are candidates for HRT, this may be the best time to consider treatment. Both estrogen and progesterone have proved to be beneficial in treating the symptoms of menopause. Low doses of testosterone, DHEA, pregnenolone and melatonin have also been very beneficial in women with hormone deficiencies.

Improved Quality of Life
The major benefit of HRT cited by most women is the improved quality of life and relief of symptoms. Quality of life cannot be quantified in a study. There is no doubt that taking hormones around menopause has direct beneficial effects on mood and behavior, and therefore on the quality of life.

Relief of Hot Flashes
The relief of hot flashes is the most significant benefit patients perceive soon after starting HRT. Estrogens are the most effective treatment in eliminating this symptom. Hot flashes can occur during the day or at night, as "night sweats," and can cause sleeping disturbance. HRT brings relief from hot flashes, night sweats and an improvement in overall sleep.

Improved Mental Outlook and Mood
Studies have shown conclusively that estrogen improves the mood of women who had lost ovarian function. The actual reasons for the mood-elevating effects are not fully understood, but it is known that estrogens have many effects within the brain and the nervous system. This mental tonic effect of estrogens, which is perceived as a feeling of overall well-being, goes beyond the fact that the hot flashes have been relieved. Women often describe a feeling of revitalization, which translates into better performance of daily duties, improved confidence and motivation and greater enjoyment of life. Women on HRT often feel more alert and better able to function.

Reduces Mild Depression
Estrogen reduces the minor depression that some women experience after menopause. Major, chronic depression requires a more complete workup and treatment plan. Reduction in Anxiety/ Increased relaxation/Progesterone Progesterone, in particular, has been helpful to women who experience anxiety during and after menopause. Bioidentical progesterone (or micronized progesterone), unlike synthetic progesterone (Provera), has not been shown to attenuate some of estrogen's benefits. Progesterone, which declines even earlier than estrogen, is a relaxing hormone and may improve sleep, mood and mental function in addition to its anti-anxiety effects. Progesterone has been shown to have anti-cancer properties and it is necessary in reducing the risk of endometrial cancer in patients on HRT. Progesterone also helps estrogen build bone strength.

Enhanced Quality of Sleep:
Studies at Harvard confirmed that estrogens enhanced the quality of sleep. We know that halting night sweats for women suffering hot flashes improve their sleep. Women without night sweats experienced an improvement in REM/deep sleep. This improvement occurred for all the women on HRT. There was a deterioration of REM sleep in women deprived of HRT.

Improved Short-Term Memory Improved short-term memory is a distinct advantage of HRT. A study performed at King's College Hospital, London, England found a distinct difference in short-term memory between women who had active ovaries or were on postmenopausal HRT as compared to menopausal women without ovaries or HRT. Other studies have confirmed these findings, and continue to provide evidence that when women take estrogen their short-term memory improves. Many women's health experts also believe estrogen reduces the risk of dementia and along with other lifestyle modifications, helps to slow long term memory loss.

Combats Osteoporosis: Stronger Bones

Estrogen therapy is the most successful method of combating osteoporosis. Estrogen increases bone mass by inhibiting the function of osteoclasts, the cells that eat old bone so that new bone can be laid down. Long-term estrogen use (10 or more years) may be required to prevent postmenopausal bone loss. Estrogen helps bones absorb the calcium needed to stay strong. While estrogen decreases osteoclast activity, thus increasing bone mass, it has no effect on osteoblast activity (it doesn't build new bone). In contrast, exercise and progesterone therapy increase osteoblast activity. So, estrogen and progesterone both contribute to bone strength. Most bone is lost before menopause even begins. A low-fat, low-protein diet rich in fiber and green leafy vegetables, regular exercise, and the avoidance of smoking, alcohol, and carbonated beverages (high phosphate level in the carbonated drinks displaces calcium from bones) is the best strategy for maintaining healthy bones throughout the life cycle.

Reduces the Risk of Cardiovascular Diseases (CVD) in some women
Since heart disease develops about ten years later in women than in men, and risk increases postmenopausally, low estrogen levels have long been considered a risk factor. Premenopausally, women have higher levels of HDLs (good cholesterol), and lower levels of LDLs (bad cholesterol) than men. After menopause, a woman's total cholesterol level increases, HDLs drop and LDLs rise. In the 2002 WHI (Women's Health Initiative) study, Estrogen was shown to reduce heart disease in women aged 50-60. Estrogen also slightly reduced heart disease in the estrogen only arm. Unfortunately, it may have been the synthetic progestin that blocked some of estrogen's cardioprotective effects for women over age 60, unlike results from previous studies. The Kronos study, started in 2006, may provide more insight. There have been small studies that indicate bioidentical hormones may be more beneficial, safer and better tolerated but there is no consensus yet. More studies on non-synthetic, bioidentical hormones are needed.
One prominent study showed after 15 years of estrogen replacement, risk of death by CVD was reduced by almost 50 percent and overall deaths were reduced by 40 percent. We may assume that estrogen is cardioprotective at least for women aged 50-60 and probably for women who haven't already developed cardiovascular disease. It's important to remember that the vast majority of studies prior to the WHI showed HRT reduced heart disease. Estrogen maintains HDL and LDL at their healthier, premenopausal levels through its interaction with proteins in the liver. Estrogen also directly affect the blood vessels.

Another study that which shows a reduction in CV risk is the Nurses' Questionnaire Study, based on statistics gathered from over 48,000 nurses. An article published in the New England Journal of Medicine indicated that risk of death from heart disease was 39 percent less in nurses currently using hormones and 17 percent less for former hormones users compared to nonusers.
Most studies do show a small increase in stroke and deep vein clots, ehich is important to consider.

Reduces Colon Cancer Risk
A study published in the Journal of the National Cancer Institute supports one of estrogen's benefits: a reduced risk of colon cancer. In this study of more than 2,300 postmenopausal women, researchers found that women who used estrogen alone or with progestin within the previous ten years had a significantly lower risk of developing colon cancer than those who had never taken hormones. A 2009 study reported in Cancer Epidemiology, Biomarkers & PreventionCancer Epidemiology, demonstrated a 17-40% reduction in the incidence of colon cancer in women who used HRT. The findings support those from the Women's Health Initiative (WHI), which showed a 44% reduction in colorectal cancer risk in women taking estrogen plus progestin.

Enhances Sexuality
Estrogen is an important hormone for maintaining female sexuality. Estrogen can produce increased awareness, sensuality, desire, and enjoyment of sexual activity in addition to enhancing physiologic conditions of the genital tissues. If women have deficiency, low dose testosterone increases sex drive and genital responce.

Slows some signs of Aging
Estrogens cannot prevent aging. Aging is a natural process of evolution. However, estrogen slows some of the aging processes of your body, just like other hormones. A good example is the skin.
The skin is the largest organ of the body. It undergoes many changes related to menopause and has many positive responses to HRT. After menopause, women notice that their skin is thinner, dryer, and that more body hair falls out. These changes typically improve with HRT. Within six months, skin usually appears thicker and softer because of increased oil secretions from the sebaceous glands. As the skin plumps up, wrinkles diminish, giving a somewhat younger appearance. Estrogen also enhances collagen and elastin in the skin making it more taught and youthful.

Bladder/Pelvic Floor
Sex hormones also maintain the firm tone of the pelvic muscles. When estrogen dwindles, muscle tone diminishes and the uterus, bladder, and vagina can drop to varying degrees. This condition is called prolapse. Estrogens improve the muscle tone of the pelvic floor and may enhance sexual pleasure.

Restores Breast Firmness
Many women feel changes in their breasts during their normal monthly cycle. These changes are a result of the changing levels of their sex hormones. Loss of hormones can result in chronically smaller breasts. Estrogen and Progesterone treatment may restore breasts firmness. All patients should have regular breast checkups and mammography to screen for breast cancer.

Estrogen and HRT May Increase Survival Rates
In the midst of the continuing debate on the benefits and risks of HRT, some women are left confused. A study published in Obstetrics and Gynecology looked at one single outcome—death. The scientists concluded that women who use estrogen "can substantially reduce their risk of dying prematurely."
The study demonstrated a 46 percent reduction in the risk of death, mostly from cardiovascular causes, seen over a two-decade period among users of estrogen supplements. Another important observation was that women taking lower doses of estrogen (0.625mg/day) had the lowest risk of death, and as the dose went up, the benefit declined. In light of the WHI finding that CV disease was slightly increased in the oldest women (70 and over), many experts believe HRT must be started early, before vascular disease occurs. Thus, when it comes to estrogen, more is not necessarily better; more may simply increase the possibility of experiencing the negative side effects of hormone-replacement therapy without decreasing risks.

HRT Protects Teeth
A study showed that taking estrogen supplements within five years of menopause can slow down periodontal disease.
The study, found in the Journal of Periodontology, says estrogen supplements can lower gingival inflammation in menopausal women who have osteoporosis, or low bone density, a growing problem for older women. Dr. Richard Reinhardt, of the University of Nebraska College of Dentistry, says for women at risk for osteoporosis -- which makes them more vulnerable to rapid periodontal bone loss -- "this may be yet one more reason to be on estrogen."

Benefit Summary

  • Enhances quality of life
    • Mental tonic (mood lifting) effect
    • Improved sleep
    • Improved short term memory
    • Reduced stress & anxiety in some patients
    • Improved Body Composition
  • Prevent osteoporosis and bone fractures
  • Prevent heart disease, at least in women who start HRT within 10 years of menopause
  • Improve cholesterol
  • Eliminate hot flashes, night sweats, headaches, and nausea associated with menopause
  • Improvement in short term memory and possible decrease in long term dementia/Alzheimers
  • Enhance sexuality
    • Enhanced genital sensation and bloodflow
    • Increased of vaginal epithelium/tissue
    • Improved pelvic floor muscles
    • Reduction in local irritative symptoms related to intercourse
    • Increased libido (sex drive)
  • Slower overall body deterioration
    • Smoother, more resilietnt skin
    • Tauter bladder/pelvic floor muscle tone
    • Firmer breasts
    • Improved muscle tone
    • Small Reduction in overall bodyfat

What are the risks of hormone therapy?

The Women's Health Initiative found that women taking the combination synthetic estrogen-progestin (Prempro) used in the study had an increased risk of developing certain serious conditions. According to the study, over one year, 10,000 women taking estrogen plus progestin compared with a placebo might experience:

  • Seven more cases of heart disease in women over the age of 60.
  • Eight more cases of breast cancer
  • Eight more cases of stroke
  • 18 more cases of blood clots
Based on these numbers, the increased risk of disease to an individual woman is small.
For women taking estrogen alone (Premarin), the WHI found no increased risk of breast cancer or heart disease. But researchers found that over one year, 10,000 women taking estrogen compared with a placebo might experience 12 more cases of stroke and six more cases of blood clots in the legs. These risks may not apply to bio-identical estrogen/progesterone combinations. Synthetic progesterone has been shown to have harmful effects in vitro.
Women on HRT may also experience: breast tenderness, bloating, weight gain, and increase in gallstones. These symptoms often depend on dose.