by Ray D.
Strand M.D., Bionutrition.org
(Click on this link to visit Dr. Strand's Website)
pictured at left: Dr. Ray & Elisabeth Strand, and Kathy Corwin
Therapy in retrospect
Ive heard it said that you know youre a veteran physician
when you have seen the pendulum make a broad sweep and come back
again. In my 30 years of practice this has certainly proven true
with Hormonal Replacement Therapy (HRT).
When I started my medical practice in the early 1970s, the
belief was widely held by physicians that women should be placed
on HRT. However, in the late 1970s, studies began appearing
in our medical journals reporting that women who still had their
uterus and were taking estrogen alone had a significantly increased
risk of developing uterine cancer. Physicians quickly responded
by discontinuing estrogen prescriptions for all menopausal women.
If they could not get their patients off the estrogen, they were
forced to schedule annual endometrial biopsies to make certain their
women patients were not developing early signs of uterine cancer.
This obviously discouraged most physicians, including me, to stop
recommending HRT for menopausal women.
In the early 1980s, however, research results demonstrated
that women who took HRT actually decreased their risk of developing
osteoporosis. Along with these studies, other clinical studies were
showing that if women took progestin (a synthetic progesterone)
with estrogen, they could actually decrease the risk of developing
uterine cancer. Estrogen builds up the tissue in the uterus and
progestin tears it down. It was believed that only the so-called
"unopposed" estrogen truly increased the risk of uterine
By prescribing a combination of estrogen and progestin for the
menopausal woman, the risk of developing osteoporosis was decreased
while the risk of uterine cancer was not increased. The pendulum
again began swinging back to the side of the overwhelming majority
of physicians recommending HRT.
By the 1990s, many reports began to emerge claiming further
health benefits of taking hormone replacement therapy. The most
well-publicized benefits were apparent decreases in the risk of
developing heart attacks and strokes. The FDA allowed these claims
to be promoted because of what is known as "secondary findings."
Although studies showed that HRT had a positive effect on the patients
cholesterol levels, there were no studies that truly showed that
these patients suffered fewer heart attacks. Women taking HRT experienced
a drop in their total cholesterol and LDL or "bad" cholesterol,
while at the same time they showed an increase in the HDL or "good"
cholesterol. Since elevated cholesterol levels were a known risk
of cardiovascular disease, this allowed the pharmaceutical companies
to make the claim that "HRT reduces the risk of heart attacks
and strokes." A short time later, studies further showed the
promising effects of HRT also reducing the risk of developing Alzheimers
Again physicians began pushing the use of HRT so aggressively that
it could be even considered malpractice if one did not recommend
HRT to each and every patient entering menopause. It should come
as no surprise then that Premarin became the number one "most
prescribed medication" in the world. This is really impressive
when you consider that Premarin is used only in women who had entered
Pharmaceutical companies had done a great job in convincing all
of us the fountain of youth awaited those who took HRT. Physicians
began treating menopause as a disease, requiring life-long medication.
The public, were soon convinced this was the right thing to do and
women all across the world faithfully began taking their HRT, simply
trusting their physicians were right.
The Bubble Begins to Burst
All seemed well until in the mid 1990s several studies began
appearing in main-line medicaljournals regarding a significant increased
risk of developing breast cancer in patients whod been taking
HRT. This risk developed after patients had been on HRT for a period
of greater than five years and was significantly higher the longer
the patient had been taking HRT. Combining the results of several
of these studies, researchers felt the risk of developing breast
cancer was 40% greater in those women whod been taking both
estrogen and progestin for longer than 10 years.
I vividly recall a full-page add that appeared in the USA Today
(the day following the release of the study just mentioned) showing
all of the benefits of taking estrogen; however, there was absolutely
no mention of the increased risk of breast cancer. Pharmaceutical
representatives would come into my office trying to convince me
that the benefits of HRT far outweighed the increased risk of breast
cancer. Though in the minority, I was not convinced.
It was at this time I quit recommending HRT except for short-term
use to aid patients through difficult times around menopause. I
would mainly recommend natural hormones produced by compounding
pharmacists, which were becoming popular. "Compounding"
means the pharmacist would make hormones the "old fashioned
way"from scratch using natural estrogen and natural progesterone.
Natural hormones are marketed independently of synthetic ones because
drugs must be synthetic in order to gain approval through the FDA.
Natural products cannot obtain a patent and therefore offers no
financial incentive for pharmaceutical companies to produce them.
(See my recommendations at the end of the newsletter.)
Unfortunately, medical journals continued to publish negative reports
regarding HRT. There was increasing evidence that women taking HRT
had an increased risk of developing ovarian cancer, gall bladder
disease, blood clots, and pulmonary emoblism. Of course, the news
was not always bad for HRT. Some evidence of decreased risk of colon
cancer in patients taking HRT was also found. Studies continued
to support the benefit of decreasing the risk of osteoporosis and
physicians remained convinced of the associated decreased risk of
developing a heart attack and stroke in their patients who were
The Womens Health Initiative (WHI) and
the Heart and Estrogen/progestin Replacement Study (HERS)
Since the health benefits of HRT were still uncertain, the government
funded two major studies to determine once and for all whether there
was truly a decreased risk of cardiovascular disease in women who
were taking HRT and whether the health benefits were significant
enough to outweigh all risks. These two studies were known as the
Womens Health Initiative (WHI) and the Heart and Estrogen/progestin
Replacement Study (HERS).
These studies brought immediate concern. During the first year
of both studies, a marked increase became apparent in the number
of heart attacks and strokes in the patients taking HRT compared
to the control group of women who were taking nothing. Researchers
originally believed this was just a fluke and that in time they
would begin to see a decline in the actual risk of developing a
In the summer of 2002, the Journal of the American Medical Association
(JAMA) reported the 5-year results of these two studies. Not only
was there no evidence of decreased risk of heart attack or stroke
in women taking HRT, there was strong evidence that it could possibly
increase the risk of heart attack or stroke, especially in the first
year of its use. These studies showed a decreased risk in the development
of hip fractures and colon cancer. However, there was also an increased
risk of invasive breast cancer, ovarian cancer, pulmonary embolism,
heart attacks, and strokes.
Researchers concluded that the overall health risks of Hormone
Replacement Therapy exceeded the benefits. The use of HRT was recommended
by the researchers to be discontinued for the primary prevention
of chronic diseases. In fact, these two clinical trials were terminated
three years early because it was obviously placing patients in the
HRT study group at too great of a risk.
Why Were Physicians so Surprised by these Results?
For years physicians passionately recommended HRT to their patients
believing in its far-reaching benefits. Since HRT actually decreases
total cholesterol and LDL cholesterol, while at the same time increasing
HDL cholesterol, this should decrease the patients risk of
have a cardiovascular riskright?
Unfortunately, this logic has been proven wrong in the case of
HRT. It has been known for years (although just now becoming public
knowledge) that heart disease is NOT a disease of cholesterol, but
instead an inflammatory disease of the artery. In fact, over half
of the patients who suffer heart attacks, have normal cholesterol
levels. Studies indicate that checking for the amount of inflammation
in the artery, especially in women, is a much better predictor of
heart disease than is cholesterol. Inflammation in the arteries
can be measured very effectively and inexpensively by doing a test
called a highly-sensitive C-Reactive Protein (hsCRP). Although HRT
lowers cholesterol levels, studies reveal that C- Reactive Protiens
(CRPs) increased by 80% in women who take hormone replacement
therapy. This explains why women who begin taking HRT actually have
an increased risk of a heart attack or stroke. Although HRT has
a positive effect on cholesterol it also causes a significant increase
in the inflammation of the arteries. Any benefit of decreasing cholesterol
is easily overwhelmed by the increase in inflammation of ones
Where Does This Leave You?
There are two sides of the coin when it comes to hormone replacement
therapy. The first is possible symptomatic relief of your menopausal
symptoms. The second is the question of whether you should use HRT
in order to prevent or reduce your risk of osteoporosis other degenerative
diseases. The pendulum has now definitely switched back to the side
of not using HRT for preventative measures for osteoporosis. The
risks are undoubtedly greater than the benefits. However, on the
flip side, careful use of hormonal replacement will still be recommended
for those women trying to relieve menopausal symptoms. Still, you
need to know safer and better choices are available.
Menopause is a difficult time in almost every womans life.
In fact, I have found that the 3 to 4 years before a woman actually
stops having her periods (called the perimenopausal time) is the
most difficult time for some women. You see, your ovaries dont
just quit working one day. They actually "sputter" and
the hormonal output can vacillate up and down significantly during
this time, creating emotional instability, mental fogginess, hot
flashes, night sweats, and vaginal dryness. Some women simply need
hormonal support during this perimenopausal time and following actual
menopause (ovarian failure). However, there is a safer approach
than simply taking synthetic estrogens/progestins. I would like
to detail a simple, logical approach, which can help the overwhelming
majority of women during this most difficult time.
First Step: I find that many of my patients can get needed
relief by taking phytoestrogens. Phytoestrogens occur naturally
in our foods and in some herbs and have the ability to "bind
an estrogen site" within the body without having any estrogen
effect. Clinically, they have been shown to reduce many menopausal
symptoms while at the same time proving very safe. Some of the most
common and best-studied phytoestrogens are:
* Soy isoflavones
* Black Cohosh
* Licorice Root
* Dong Quai
You can get these from your local health food store and you should
take the recommended amounts found on the bottles.
Second Step: If the phytoestrogens do not provide adequate
relief, I recommend a trial of natural progesterone cream. Unlike
the synthetic progestin drugs, natural progesterone has been shown
to decrease breast cancer and while still possibly helping to preserve
bone and possibly increase bone density. Many women do not ovulate
during the last year or two before menopause. Because the follicle
produced following ovulation is where the progesterone is produced,
this means these women are not making any progesterone at this time.
This may explain many of the perimenopausal symptoms. By using one
of the natural progesterone creams (such as yam cream), many of
these symptoms may be relieved. These natural progesterone creams
are also available form your local health food store.
Third Step: I still have patients whose perimenopausal and
menopausal symptoms are not relieved with steps one and two. In
these cases, I recommend using a natural estrogen and natural progesterone
cream or drops. These need to be prescribed by your physician and
are produced by a compounding pharmacist. Many local pharmacists
are actually starting to do this. Some of the larger facilities
currently providing this service are:
* Belmar LabLakeview, Colorado800-525-9473
* Womens Health CenterMadison, Wisconsin800-279-5708
* Rx Compound CentreColumbia, TN931-388-399
What if I am Already Taking Estrogen/Progestin?
Many women have long passed the menopausal time but are still taking
synthetic estrogens and progestins with their doctors insistence
that significant health benefits are being provided. For the past
seven years, I have encouraged my patients to get off synthetic
hormones and all hormones if possible. This is not necessarily an
easy task, however. Premarin, for instance, is so potent that women
can suffer dramatically if they stop taking it abruptly. I literally
anticipate six months to slowly wean my patients off estrogen/progestin.
I am now seeing many patients who want me to help them get off HRT
because they know Ive been able to help many of their friends.
Similarly, switching patients to natural estrogen and progesterone
creams can sometimes be difficult. I have found that patients do
well by slowly decreasing the dose of the synthetic HRT while at
the same time adding natural Triest or Biest creams along with natural
progesterone. If my patients seem to be transitioning smoothly,
I then take them off synthetic HRT as quickly as possible.
During the past six months, Ive been prescribing Estrogen/Progesterone
/Testosterone drops (EPT drops) produced by the Rx Compound Centre
listed above. These drops are absorbed amazingly well and are potent
enough to compete with synthetic HRT. I have actually been able
to simply switch my patients from their synthetic HRT to the EPT
drops. Once a day, patients place 1 to 4 drops (dose varies depending
on symptoms) on the inside of the forearm and then rub forearms
together (much like ladies do when trying a new perfume). After
the switch is made from synthetic HRT to EPT drops, women can slowly
start decreasing the dose and eventually just quit. This approach
has proven very effective in many of my patients. If you choose
this treatment, you will need a physician who is willing to order
these drops for you and then work with you until you have gradually
come off HRT.
The verdict is in. The potential harm of hormone replacement therapy
far outweighs its health benefits. If you are currently taking HRT,
you need to come off as soon as possible. Most physicians are having
trouble with this change and may resist your decision to quit. However,
the evidence is conclusive. Once you are through your change of
life, I feel strongly that you should discontinue all hormone therapy.
I cant state strongly enough: synthetic HRT should be avoided
entirely due to the increased risk of a heart attack and stroke
in the very first year of HRT. In addition, the increased risk of
invasive breast cancer becomes stronger with each passing day you
are on hormone replacement therapy.
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* Writing Group for the Womens Health Initiative Investigators.
"Risks and Benefits of Estrogen Plus Progestin in Health Postmenopausal
Women." New England Journal of Medicine, 288 (2002), 321-333.
* Lacey, J. V.; P. J. Mink, et al. "Menopausal Hormone Replacement
Therapy and Risk of Ovarian Cancer." New England Journal of
Medicine, 288 (2002), 334-341.
* Zhang, Y.; et al. "Bone mass and the risk of Breast Cancer
among menopausal women." New England Journal of Medicine, 336
* Steinberg, K. A., et al. "A meta-analysis of the effect of
estrogen replacement therapy and the risk of breast cancer."
JAMA 265 (1991): 1985-1990
* Grady, D., et al. for the HERS Research Group. "Cardiovascular
disease outcomes during 6.8 years of hormone therapy: Heart and
Estrogen/progestin Replacement Study Follow-up (HERS II)" JAMA
288 (2002): 49-57
© 1999, 2000, 2001, 2002 Ray D. Strand M.D. USED BY PERMISSION
(Click on this link to visit Dr. Strand's Website) All the materials
published in this article are the property of Ray D. Strand, M.D.
Copyright 1999, 2000, 2001, 2002. All rights are reserved. The materials
and information contained herein cannot be edited, altered, or used
in any other format.
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CLICK HERE FOR FREE HEALTH AND NUTRITIONAL INFORMATION