7. Hormone Replacement

I recommend that every person over 50 should have their hormone levels checked and consider hormone replacement with bioidentical slow-release pellets if their levels are low, or low normal. There has been hesitancy in the medical community to consider this because of misinformation that made doctors believe that estrogen causes breast cancer and that testosterone causes prostate cancer. This is simply not true. I am not an expert on this very complicated topic, but I have become convinced by several books on this topic that there may be great benefits for most people by replacing deficient hormones. I suggest you educate yourself by reading some of these books yourself and consulting an expert in hormone replacement to see if this is best for you.

Both men and women gradually start producing less of the natural sex hormones testosterone, estradiol, and progesterone around 40 years of age. The details of this process vary considerably between individuals. The process of testosterone loss in men is so gradual that most of us just don’t notice it (1% /year after age 30).

In women testosterone starts decreasing around 40, then progesterone, and finally estradiol (a natural form of estrogen) at around 50. When estradiol loss occurs in women, dramatic symptoms recognized as menopause make this obvious. Therefore, the process in women has been much more commonly studied and treated. Treating the symptoms of menopause has been controversial because some of the treatments have led to higher risks of serious problems such as blood clots, cardiovascular disease, and cancers of the uterus and breast.

It has long been suspected that the loss of these hormones speeds up the aging process. Replacing them to slow some of the effects of aging has been a highly controversial subject. I have become personally interested in this topic when I noticed on several occasions, postmenopausal women on bioidentical triple hormone replacement acting and looking much younger than their stated age. Unfortunately, one of the loudly proclaimed results of the famous Women’s Health Initiative (WHI) study was that oral synthetic (horse) estrogen (Premarin) causes breast cancer, therefore I was surprised to see several women from different parts of the country being treated long-term with hormones and apparently thriving. One of these women referred me to some reading material on these topics.

The Women’s Health Initiative (WHI) was the study that convinced many doctors that hormone replacement in women was a bad idea. Reanalysis and independent review of the data has found many of the initial conclusions to be faulty. The WHI was a randomized controlled study whose organizers claimed they were studying “healthy” women, but actually they were studying women of average American poor health (70% overweight or obese, 50% past smokers, 35% treated for hypertension, average age 63). The hormones received were synthetic oral (horse) estrogen and progestins (not bioidentical subcutaneous estradiol and progesterone). Their conclusions must therefore be viewed with caution.

I have come to the conclusion that the advantages of hormone replacement with bioidentical hormones probably far outweigh the risks for most aging adults. Therefore, if you are over 40 or have the symptoms of menopause or andropause (male symptoms after losing testosterone), I would suggest that you consult a hormone/antiaging specialist and have your hormone levels checked. Gynecologists, endocrinologists, and urologists rarely are up to date on the use of bioidentical hormones.

Bioidentical hormones refer to those that are identical in chemical structure to our natural ones and are typically delivered by slow-release pellets into subcutaneous fat every 3 months (estradiol, progesterone, testosterone). They cannot be delivered orally because they are destroyed in the stomach. An unnatural copy of estrogen is Premarin, and unnatural copies of progesterone are called Progestins (Aygestin, Provera). These have the advantage that they can be delivered orally but it turns out that most of the problems encountered with hormone therapy in women was due to these chemically altered forms of these hormones and how they were delivered orally. Most studies including the WHI are based on oral hormones. Even these less healthy versions have many benefits, but the bioidentical versions are clearly superior and eliminate several of the negative drawbacks of the oral versions.

Most medical doctors still erroneously believe that female hormones cause breast cancer, blood clots, and cardiovascular disease. 90% of breast cancers are cured with modern treatment. Many more women die of cardiovascular disease than breast cancer, twice as many at age 40, and 20X as many at age 80. The same number of women die of osteoporotic hip fractures as breast cancer annually, and many more suffer from chronic pain due to spine compression fractures.

It turns out that the increased risk of breast cancer is due to oral progestin (Provera, Aygestin), not oral or bioidentical estrogen. Even the WHI showed no increased risk with oral estrogen alone, but only a slightly increased risk if Progestins were added. Other studies have shown that the risk of breast cancer is actually reduced if women receive testosterone in addition to estrogen. The risk of blood clots was due to oral estrogen in the WHI and other studies but has not been found with various versions of bioidentical estrogen supplied non-orally.

Oral testosterone has been linked to liver cancer, but bioidentical testosterone injection, transdermal cream, or pellets do not cause this problem. The other big cancer controversy has been prostate cancer in men being supposedly caused by testosterone. This has been debunked. Testosterone does not cause either benign prostatic hypertrophy or prostate cancer. In fact, there is now some evidence to suggest that men with abnormally low testosterone levels are at a higher risk for developing prostate cancer.

There is also no evidence that testosterone causes atherosclerosis (heart attack, stroke, etc.) but may even protect against this. Estradiol in women reduced the risk of heart disease by 30-50% in numerous studies, but the WHI study that claimed an increased risk really only found a short-lived 1-year time period of slightly increased risk in women who start treatment greater than 20 years after menopause begins. Again, the WHI was used to exaggerate the harm of estrogen.

Another study has found an increased risk for one year in women with known heart disease. The most commonly prescribed preventative medicine for heart disease is statins, but they do not change cardiac risk at all (except in men with a previous heart attack); estrogen in most women reduces the risk by 30-50%.

The other major advantage of estrogens is its positive effect on bones. It is known that women dramatically lose bone mass in menopause. Replacing estradiol and testosterone reverses this. In men, a more gradual loss of testosterone causes a more gradual loss of bone mass. As a result, older women have more problems with osteoporosis and subsequent fractures than men do.

Fractures can lead to morbidity; spine fractures cause a hunched-over appearance and chronic low back pain after they have healed. Hip fractures require surgery and are associated with a 30% 1-year mortality after the fracture. The same number of women die of hip fractures annually as breast cancer. Bisphosphonates and other bone-building drugs can now reverse osteoporosis with low associated risks (reflux, ulcer, late atypical fractures, osteonecrosis of the jaw), but estradiol and testosterone can also prevent and reverse this problem in a more natural way.

The effect of hormones on dementia is controversial. Twice as many women as men develop dementia. Women lose all estrogen at menopause. Men have a more gradual decline in estrogen. Testosterone in men declines gradually and testosterone is converted to estrogen by aromatase, thus aging men have higher estrogen levels than women. Estrogen seems to have protective effects on the brain. This may explain why women are more prone to dementia. A woman has twice the risk of dementia beyond 60 as she does for breast cancer. Breast cancer is cured in 90%, while no effective treatment exists for dementia. People typically live 4-10 years after the onset of dementia.

The WHI found no greater risk of dementia in those taking estrogen and a slightly higher risk in women with preexisting mild dementia or those starting oral estrogen after age 75. Women who were already taking estrogen before entering the WHI study had a 50% lower risk of developing dementia during the study. Numerous other studies have shown positive effects on brain health and function with estrogen.

A woman without a uterus requires only estradiol and testosterone; with a uterus, progesterone is needed to prevent uterine cancer. Progesterone given as a buccal troche (tablet that dissolves in the mouth) at night helps with sleep as well. Some women who do not have a uterus may also choose to add progesterone in this fashion to help with sleep and mood stabilization. Testosterone also prevents sarcopenia, the gradual loss of muscle mass that occurs with aging in both men and women.

On balance, it appears that there are numerous health benefits of hormone replacement in men and women. Bioidentical pellets are typically administered by a hormone specialist who measures hormone levels before treatment and monitors them during treatment to ensure that you receive the normal physiologic levels that young people have. Slow-release pellets placed under the skin every three months are the best method for most people. This treatment results in:

Men

If your T-level is below 500ng/L (or free T is <15pg/mL) non-oral bioidentical testosterone results in:

• Improved energy and vigor motivation and mood
• Improved sexual desire and function
• Improved bone density
• Loss of fat, improvement of diabetes (metabolic syndrome)
• Improved muscle mass
• Increased skin thickness
• Less generalized joint pains
• Increased hemoglobin
• Decreased heart disease
• Decreased risk of dementia
• Improved immune system
• Possibly a reduced risk of prostate cancer; Even in men with prostate cancer, there is no evidence that cancer growth is increased.

The lab reported a “normal” total testosterone level is 200-800 ng/dL. Under 500ng/L is only “normal” for old men who have lost their testosterone level. Free testosterone should be greater than 15 pg/ml. I am replacing my level to get above 500.

Please read the book “Testosterone for Life” by Dr. Abraham Morgentaler and give a copy to your doctor if he/she advises you against hormone replacement.

Women

Non-oral Bioidentical testosterone, estradiol, and progesterone

Testosterone levels of 30-60ng/dL are normal before age 40 for women. This is about 10% of the normal male testosterone level and about 5X the normal estradiol (estrogen) level in women. Replacing testosterone to normal provides the same benefits as in men listed above. Normal young women have all 3 sex hormones. Replacing your testosterone after you lose it at age 40 does not make you into a man. It restores your well-being to that of a younger woman. (Of course, aging cannot completely be reversed.)

Please read “The Secret Female Hormone” by Dr. Kathy Maupin to understand the critical need for testosterone for aging women to maintain their health and well-being. This book also provides a practical guide to understanding how triple hormone replacement is done. The story about estrogen and progesterone is more complicated. First, we must debunk the myths believed and propagated by most of the medical establishment.

Nonoral Bioidentical estradiol DOES NOT:

• cause breast cancer. There is a slight increased risk of breast cancer with the use of oral progestins (WHI 2002).
• cause blood clots. Only oral synthetic (horse) estrogen increases this risk.
• cause cardiac disease. Only women first starting estradiol at age 75 have a slight TRANSIENT risk of cardiac events. Estradiol is actually otherwise cardioprotective.
• Cause dementia. Only in women starting estrogens over age 75 or those with preexisting dementia. It is probably preventative of dementia otherwise.

Non-oral Bioidentical estradiol (estrogen) is the best and healthy way to take estrogen. The problems associated with hormone replacement in women are all linked to oral synthetic estrogen and oral progestin (fake progesterone). Normal estradiol levels should be 60-250 pg/ ml, and FSH (follicle-stimulating hormone) should be less than 23 MIU/ L. If FSH is elevated, this means that your body is trying to get your ovaries to make more estradiol.

Please read “Estrogen Matters” by Dr. Avrum Bluming who debunks the myths surrounding female hormone replacement.

Please read “Stay Young and Sexy with Bioidentical Hormone Replacement” by Jonathan Wright who explains clearly the differences between bioidentical (human) hormones and the abnormal horse estrogen and fake progesterone usually prescribed for women.

• Resolution of menopausal symptoms: migraines, hot flashes, night sweats, sleeplessness, arthritis, anxiety/ depression/mood swings, memory loss, difficulty concentrating, vaginal dryness, painful intercourse, decreased libido, thinning hair, abdominal weight gain.
• Decreased cardiac risk (except a transient increase in risk for women starting estradiol after age 75)
• Improved bone density (lower risk of hip and spine fractures)
• Decreased risk of colon cancer by 30%
• Increased life expectancy by 3 years
• Probably decreased the risk of dementia

Non-oral bioidentical progesterone is required in women who still have a uterus and receive estrogen supplementation in order to prevent uterine cancer. Women who have had a hysterectomy or uterine ablation are not at risk for uterine cancer. Progesterone also acts as a mood stabilizer for many women. For example, women with severe PMS are often substantially helped by progesterone therapy.

If you are interested in bioidentical hormone therapy, please read the suggested books, and consult a hormone/antiaging specialist. In Columbia, SC, I would recommend Dr. Rachel Hall.