Menopause & HRT
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Menopause & HRT

Menopause is when menstruation stops and the body goes through changes that no longer support pregnancy- a natural event that normally occurs at age 45 to 55 (MedlinePlus,  2014). Menopause is complete when a period has not occurred for 1 year (MedlinePlus). 

The discomforts of the transition through menopause can exist many years before (peri-menopause) and after (post-menopause) menstruation ceases.  Common discomforts are hot flashes, night sweats, difficulty sleeping, amenorrhea or irregular menstrual cycles & bleeding patterns. The risks for osteoporotic hip fractures and coronary heart disease (CHD) inherently increase with diminishing estrogen during menopause. The goal is to support the transition by decreasing discomforts & health risks. There are a few ways to do this:

Hormone Replacement Therapy (HRT) 
HRT with low dose combined oral contraceptives (COC) reduce mild to moderate discomforts (Edmunds & Mayhew, 2013, p. 634). Combination estrogen: progestogen drugs are prescribed for women with a uterus: estrogen-only drugs for those without a uterus. The amount of estrogen and progesterone in OC is 4 to 5 times greater than that used in HRT. 

There are benefits, risks & side effects associated with the use of COC for menopausal symptoms. Progesterone levels fall dramatically (more than estrogen) during menopause, causing a relative estrogen excess (or unopposed estrogen). The progestogen in HRT/OC is therefore essential to prevent the risks associated with unopposed estrogen.

Complementary & Alternative Modalities [CAM]
CAM can support the liver & adrenals before, during, and after the transition through menopause. A sluggish liver does not effectively clear hormones and hormone metabolites. Foods-as-medicine such as cruciferous vegetables, and Chinese & Western herbs can support the liver. Food & nutrition, herbs & supplements also support the adrenals. However, adequate rest & relaxation are essential because the adrenals are a source of a maintenance estrogen after menopause. (See menopausal chart). Thirty minutes of daily aerobic exercise is also shown to decrease the vasomotor discomforts of menopause. Exercise also reduces weight; important because obesity is associated with an increase in the conversion of testosterone to estrogen [estrogen excess]. 

Conversely, low testosterone is associated with low libido. Pregnenolone is a precursor to testosterone, as well as estrogens, progesterone, and DHEA. DHEA level is a marker for adrenal fatigue. Pregnenolone can supplement many hormones along the steroid hormone cascade].

One of the most notable estrogenic essential oils is Clary Sage. Sclerol is unique to Clary. Sclerol has a chemical structure similar to estrogens, which enables it to loosely dock onto estrogen receptor sites and illicit the same physiological response. 

Vitex (Agnus castus) or Chase Berry is a beneficial herb when there is relative estrogen excess due to progesterone deficiency. It is indicated for hot flashes, and irregular bleeding patterns. 

Osteoporosis
Virtually all women lose 5-10% of their bone mass during the first 5 years after menopause, with another 1% loss per year thereafter. There are a few research studies on the efficacy of using a Chinese herbal formula called Gui Lu Er Xian Jiao for osteoporosis in menopausal women. In one study, taking the formula (5g twice daily) for 1 year resulted in a 3.4% increase in bone mass density (BMD) without side effects. This is in comparison to a 4-5% increase in BMD in those taking Fosomax for 3 years. 

The Fosomax group experienced side effects such as brittle bones, femur fractures, and osteonecrosis. Gui Lu Er Xian Jiao, on the other-hand, enhanced bone mass density without side effects for safer longterm use. Osteoporosis is mainly due to decline of the kidneys jing, which this formula specifically addresses. Weight bearing exercise is also important to preserve bone mass density, and many women further supplement with calcium and vitamin D.

Lab Tests 
Certain tests establish baselines, safety, and/or rule out pathology that may be a contraindication to the use of COC for menopausal symptoms:

Pregnancy Test: HRT with COC is not abortifacient, and will not disrupt an already implanted pregnancy. But there is increased risk for ectopic pregnancy with progestin-only OCs. Women who become pregnant shortly after discontinuing OC may have a greater risk for birth defects due to low folate levels. Not all peri-menopausal women want to necessarily avoid pregnancy given the wide range of age at which peri-menopause can exist, and especially if due to premature ovarian failure (POF). Chinese medicine has proven very beneficial to women with fertility issues due to POF. See ABROM.

Complete Blood Count (CBC), Blood Chemistry, Lipid Profile: The estrogen in COCs can cause decrease glucose tolerance. The progestin increases glucose resistance. Women with diabetes type 1 or 2 may want to choose an alternative form of HRT or OC. Progestin can also deceases HDL and increases LDL. An Estrogen increases triglycerides. And there is increased risk for gallbladder disease and hepatic lesions (rare) with COC.
 
Pelvic Exam, PAP Smear & Mammogram: There may be an increased incidence of cervical cancer with COC. Unopposed estrogen increases the risk for endometrial hyperplasia and uterine cancer. Opposition with progesterone decreases uterine hyperplasia and risk for uterine cancer. COC may increase or decrease risk for breast cancer, but are generally contraindicated with history of any estrogen-dependent cancers.

Menstrual Cycle Chart: For the peri-menopausal woman, estrogens can increase dysmenorrhea and menstrual flow, and OCO may exacerbate PMS and fluid retention. Progestin-drospirenone is recommended. For the child-bearing woman, the nature of an existing menstrual cycle should be assessed because irregular bleeding is a positive sign associated with the effectiveness of progestin-only OC [POC]. POC normally cause irregular break through bleeding during the first 3 months of starting them. This indicates that ovulation is not occurring- EFFECTIVE BIRTH CONTROL. If bleeding is normal, it indicates that ovulation is occurring- IN EFFECTIVE BIRTH CONTROL. This assessment also determines when to start certain OCs (before during or after a menstrual cycle), and when to use a back-up method if a pill is missed.

Follicle Stimulating Hormonelevel reflection of age and/or disease processes. For example, high FSH on day 3 of the follicular-phase of the menstrual cycle indicates ovarian insufficiency/ failure in a young woman (abnormal), or the beginning of menopause in older women (normal):

  • FSH 2.4-9.3 UL indicates premenopausal-follicular
  • FSH 0.6-8.0 indicates premenopausal-luteal
  • FSH FSH 31 -134 UL indicates postmenopausal 
(ZRT Lab, 2014). 

Sex Hormone Binding Globulin (SHBG) binds and transports sex hormones to target tissues. A deficiency profoundly effects the balance between testosterone & estrogen, especially in obese women.

Benefit vs. Risks Assessment- Disease & Conditions: 
Estridiol, estriol, and estrone are the main ones measured during menopause. But there are over 30 different types of estrogens in the female body. Naturopathic or Functional medicine practitioner focus in on the type of estrogen(s) that is most likely to be of harm or benefit during different phases of a woman's life. Some estrogens are contraindicated in vascular disease associated with lupus, and history of thrombus (blood clots).  

A history of asthma, migraines, and renal disease may be aggravated by COC (progestin-drospirenone is recommended). COC may change tolerance to wearing contact lens. Depression is an adverse reaction associated with HRT/OCs. Estrogen and progestogen affect thyroid function. Vitamin C decreases the effectiveness of estrogen OCs. Anticonvulsant medication (e.g. Gabapentin) may increase failure rate of COCs. 

The major risks associated with COC are related to CHD status and estrogen-related cancers. The benefit/risk ratio is favorable and does not seem to increase CHD risk when treatment is initiated within the following parameters, (1) age 50 to 59, or (2) within10 years of menopause, (3) at onset of menopause, or (4) 5 or more years post menopause. The benefits are a decrease in  vasomotor discomforts (hot flashes and night sweats), vaginal dryness & dyspareunia; and decreased menopausal bone mass loss (osteoporosis). In general: 

  • Estrogen increase coagulability and risk for thrombosis, especially in women who smoke (the risk increases if over 35 years old). 
  • HRT/OC may increase blood pressure and risk for MI & stroke. 
  • Weight gain of 5 to 16 lb. with Depo-Provera injection is not an issue with HRT/OC.
  • HRT/OC may increase or decrease risk for breast cancer, but are generally contraindicated with history of estrogen-dependent cancers. HRT/OC may decrease the risk for colo-rectal cancer.
  • unopposed estrogen increases the risk for uterine hyperplasia and uterine cancer. Progesterone has the opposing effect.
  • HRT/OC may increase the risk for dementia.


INTEGRATIVE  MEDICINE  TIP:  In Chinese medicine, it is advised to start fortifying the Kidney yin & yang (and jing) before the onset menopause in order to ease the transition through menopause. In this way the discomforts of menopause will not be severe and/or treatment will not be refractory if initiated at the time that signs & symptoms appear. This is the same treatment principle used in Naturopathic medicine, which supports the adrenal glands before, during & after menopause.


References
Edmunds, M. W. & Mayhew, M. S. (2013).  Pharmacology for the Primary Care Provider  (4th ed).  St.
       Louis, Missouri: Elsevier Mosby.
MedlinePlus. (2014). Menopause. Retrieved from  
ZRT Labs. Sample test reports: Fertility profile. Retrieved from
     file:///Users/lorikelsey/Downloads/Fertility_Sample_Report%20(1).pdf

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