“I can’t stand it any longer! The hot flashes, I could tolerate, but my husband says if I can’t get my mood swings under control.”
Brenda’s voice trailed off. A 47-year-old woman, she first went through menopause 2 years earlier. The problem was, she did so with the help of Premarin hormone replacement therapy.
Perceived Risks of HRT
“I just won’t take that stuff any longer,” she continued. “Why didn’t they tell me it came from horses?”
It was not the way the drug was made that bothered Brenda the most, though it didn’t help that Premarin stands for “Pregnant Mare’s Urine”. It was a published study showing the medication increased the risk of breast cancer. Though no one in her immediate family ever had breast cancer, a good friend of hers did. She immediately stopped her hormones and the menopausal symptoms returned.
I empathised. “I agree with you. You do not have to take artificial hormones, but you do not have to suffer with these symptoms either. We just have to find a better way. There are other options for menopause, we just have to figure out what you want.”
During our consultation, Brenda relayed her history. She had been reasonably healthy her entire life, except for a partial hysterectomy for fibroids. At age 45 she started having night sweats and mood swings. That was when her gynecologist tested her blood and diagnosed her with menopause. She initially resisted the idea of hormones, but when her bone density test showed that she was already losing some bone, she accepted the prescription. Every year after, she had her annual pap and pelvic exam, and was handed prescriptions for a mammogram and Premarin.
“Did your doctor ever explain to you why he prescribed Premarin?” Brenda shrugged. What happened over the next half-hour is what medicine used to be about. The word, ‘doctor’ means ‘to teach’. With shortened HMO visits, this part of the visit often gets left out. As a private practice physician, I am lucky to spend more time with my patients. “I think now is about the right time for us to go over the three reasons why we should treat your menopause. Do you know what they are?”
Easing the Symptoms of Menopause
“The first one is obvious, it’s these hot flashes. I feel like I’m going out of my mind!”
“Menopausal symptoms can begin months or even a few years before periods stop. Even though they left your ovaries, the surgery chopped off half their blood supply. That’s why you went through menopause a bit early, and that’s one of the reasons your symptoms are so bad. Don’t worry, we will find a way to make them go away.”
Combating Osteoporosis and Weight Gain
“I also know the second, osteoporosis. My gynecologist already warned me about that one. But what’s the third reason?”
I smiled, “Well, when your hormones are balanced properly, you just feel better. Though Premarin has been associated with water retention and weight gain, the proper balance of natural hormones can cause some weight loss. I have also seen other symptoms such as headache, insomnia, and even libido improve.”
“I think any woman would like to lose some weight, but I don’t think I have to worry about libido right now. Where do we start?” “I want to talk to you about your diet. We should find some ways to get you to eat more soy. Do you ever eat tofu?”
Brenda asked, “Like the stuff that floats in Miso Soup?”
“Exactly, but I call that Tofu Lite’. There are many other ways to eat soy foods. And there are many different types of tofu to buy. Some are hard, while others are softer. You can prepare soy dozens of different ways. When you go to the health food store, ask the grocer how to buy tofu. He might even have a good recipe to share.”
“That is a good idea, but I need to do something now. With these flushes, I’m not sleeping, and that makes me irritable, and then I scream at Frank. Is there something I could take, but is safer than those hormones?”
I reflected a bit. It’s true that in an ideal world, everyone would eat perfectly and they wouldn’t need any medicines at all. But Brenda’s world was far from perfect. Though her children were grown and out of the house, she had a husband and a house to take care of, as well as a part-time job outside the home. It might be a while before she took enough cooking classes to find the 60 grams/day of soy needed to impact her symptoms.2 “I think that adding some supplements is definitely needed, especially now when your symptoms are the worst. Let’s start with vitamin E. Though the RDA is only 15 IU (international units) per day, there is some research that doses of up to 3,000 IU / day can be very effective.”3
“Whoa! That seems like a lot. I don’t want to get toxic on vitamins!”
“You’re right. Too much of anything can be bad. I prefer to start low, and go slow. Perhaps you should just try 400-800 IU of the natural form of vitamin E. It’s better. And don’t forget to leave it in the refrigerator. Just like mayonnaise, vitamin E is a fat and can go bad if you leave it out on the counter.”
“This seems like a good start, but what about herbal medicines? I saw something about them on the news a while back.”
“These might be a good option for you. Black Cohosh has been studied quite extensively. Remifemin is one standardized product that has been used in Germany since 1956.4 Dong Quai has also been used for many ‘female’ problems including menopause.” I wrote down the dosages of each.
I continued, “I can’t let you go so quickly. Though you might not have osteoporosis now, your bones are already getting thin. We need to do something to prevent further loss. I want to talk to you about hormones.”
Brenda protested, “I’m sorry, I’m not ready to hear about them. You know my friend Sue has breast cancer.”
Education and Seeing What Works
“I understand. How about we start with these things first, but in the mean time, can I ask you to learn how to make your bones stronger? There is a book I’d like you to read called ‘Preventing and Reversing Osteoporosis’ by Dr. Alan Gaby. It talks about everything from calcium to exercise. There are even a few chapters on natural hormone replacement. When you’re ready, we can talk more then.”
Brenda returned 4 weeks later after trying the vitamin E and Remifemin. Though she was having some trouble convincing her husband to eat “Tofu Burgers”, she seemed quite pleased. “My flashes are all gone, and Frank doesn’t seem to complain about my moods anymore. But I want to talk to you about my hormones. I think I am ready to try those natural ones you mentioned.”
The first book I recommended sparked an interest in her. In the time since her last visit, she had read two other books on natural hormone replacement, spoke to a compounding pharmacist, and found out that one of the girls in her women’s group was taking them. We decided to start with low dosages of both natural estrogen and progesterone as her next step in achieving balance.5 Though I often titrate doses of medicines based upon my patients’ symptoms, this is one condition I feel it is important to do serial testing to make sure her hormones were in a safe but therapeutic range.
Though it may be too soon to tell how well this therapy will work for Brenda, there is definitely a difference in her comfort level. “I am no longer scared about hormones, at least, not these hormones.”
REFERENCES: 1 WHI Study Group. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA. 2002;288:321-333. 2 Albertazzi P, et al. The effect of dietary soy supplementation on hot flushes. Obstet Gynecol. 1998;91:6-11. 3 McLaren HC. Vitamin E in the menopause. BMJ. 1949:1378. 4 Liske E. Therapeutic efficacy and safety of Cimicifuga racemosa for gynecological disorders. Adv Ther. 15:45-53, 1998. 5 Follingstad AH. Estriol, the forgotten estrogen? JAMA. 1978;239:29.
This is an updated version of an article published in 2002. Health information obtained from Performance Body Works is for informational purposes only and is not a substitute for seeking clinical advice or treatment relating to any medical condition. If you have a concern about your health, promptly consult a licensed healthcare provider.