Hormonal Update Volume 1 Number 7

HRT in Action

One of the most important new developments in hormonal medicine is individualized Hormone Replacement Therapy (HRT). For many years HRT has been prescribed in one-size-fits-all doses. While standard doses have worked well for some women, they have not worked as well for others. Because of advancements in hormone level testing, we now know that every woman’s hormone profile is as unique to her as her fingerprints. We also know that every woman absorbs and utilizes replacement hormones in her own individual way. This knowledge is changing the way hormonal medicine is practiced.

The best way to explain how individualized HRT works is to show it in action. In this bulletin we are going to discuss four case histories — each representing a woman’s personal experience with her healthcare provider and HRT.

Marilyn

Marilyn was experiencing irregular menstrual cycles. Sometimes she skipped a month entirely and, at other times, her cycles would come every two weeks. Marilyn was also having difficulty falling asleep at night, causing her to feel quite fatigued most of the time. In addition, she was feeling depressed, often for no reason. Marilyn, who is 42, believed she was too young to be menopausal. Her mother and sister went through menopause in their early fifties. Concerned there might be something wrong with her, Marilyn made an appointment with her doctor. Marilyn was asked if she would consider having her appointment with the nurse practitioner (NP) her doctor had recently added to his practice. The term “nurse practitioner” was unfamiliar to Marilyn. The receptionist explained that a nurse practitioner is a registered nurse who has been educated and certified to provide primary healthcare to women. She assured Marilyn that the nurse practitioner was well-versed in women’s hormonal medicine. Marilyn decided to give her a try.

 During Marilyn’s appointment the NP explained that her symptoms indicated she was in perimenopause, the time in a woman’s life that precedes menopause. Perimenopause is defined by the unpredictable fluctuation of hormone levels accompanied by many of the same symptoms as menopause. Marilyn’s nurse practitioner suggested a saliva hormone test to assess whether or not Marilyn was a candidate for HRT. Marilyn’s test results revealed that while her estrogen level was normal for a cycling woman, her progesterone level had declined considerably. 

Based on Marilyn’s saliva progesterone level, the nurse practitioner prescribed 100 mg. of oral micronized progesterone to be taken twice daily during the last two weeks of her menstrual cycle. She scheduled Marilyn to be re-tested in one month to make sure the dosage was just right. Marilyn filled her prescription and began taking her progesterone. Almost immediately her symptoms were relieved and she felt like her old self again. After Marilyn had been taking her progesterone for three months, her menstrual cycles were coming quite regularly again. 

Virginia

Virginia, 60, had not menstruated for many years. She experienced her menopause with minimal symptoms. In fact, her occasional hot flash did not affect her quality of life. However, because her mother died of a heart attack at 55, Virginia was concerned about her increased risk for heart disease. In addition, she had been reading a great deal about the benefits of estrogen for bones, even if taken later in life. She wanted to take every precaution regarding her health. Virginia decided to discuss HRT with her doctor. 

Virginia’s doctor agreed that because of her mother’s heart condition Virginia was at increased risk. He was also a proponent of taking estrogen for prevention of osteoporosis. He prescribed a standard dose of Premarin®, for Virginia’s heart and bones, and Provera® because she still had her uterus. Virginia began taking her prescription but within two weeks she was suffering from bloating, tender breasts, fatigue, irritability and depression. Virginia called her doctor to report how she was feeling. He reassured her that she was merely experiencing a period of adjustment and that she would get used to her new hormones if she continued taking them. Virginia tried for two more weeks but her symptoms were too uncomfortable. It didn’t seem worth it to feel poorly all the time. Virginia stopped taking her hormones. 

A friend of Virginia’s suggested that she consider seeing another doctor before abandoning hormone replacement entirely. Virginia’s new doctor tested her saliva hormone levels and discovered that her estradiol and progesterone levels were indeed well below the target levels considered protective. He explained that the standard HRT prescription that Virginia had been given was problematic for her for two reasons. First, the Premarin dose was too strong and elevated Virginia’s estradiol level too high. Second, she did not respond well to the synthetic Provera. Virginia’s new doctor prescribed bio-identical estradiol and progesterone in dosages suited specifically to her needs. When Virginia began taking her new hormone prescription she experienced no side effects. More importantly, she enjoyed peace of mind. She was minimizing her health risks in the best way she could. 

Natalie

Natalie, a perimenopausal 49-year-old, had not had a menstrual cycle for six months. Her hot flashes were so severe she was waking up in the middle of the night drenched in sweat. Natalie was also experiencing dramatic mood swings and a complete loss of her sex drive. In addition, Natalie had always been very active — now she didn’t have the energy or the enthusiasm to do much of anything. She didn’t know whether it was hormonal changes or lack of sleep causing her additional symptoms. She tried taking herbs, restructuring her diet and increasing her exercise regime, but nothing seemed to help. Natalie decided she wanted to try natural hormone replacement therapy and made an appointment with her doctor. 

Natalie’s doctor was fairly certain that Natalie needed hormone replacement but decided to determine precisely what she needed by requesting a saliva hormone panel. Natalie’s test results confirmed his suspicions and even gave him some additional information. Natalie’s estrogen and progesterone levels were predictably low but so was her level of testosterone, the hormone responsible for sexuality. Natalie’s doctor consulted with a pharmacist well-versed in individualized HRT who recommended capsules containing estradiol and micronized progesterone to be taken cyclically, and natural testosterone to be taken daily. In no time Natalie was back in full swing, enjoying her life. When she was re-tested a month later Natalie’s results showed that her supplemented hormone levels were well within her target range. 

Glenda

Glenda, 46, was still menstruating fairly regularly, only occasionally missing a cycle. She was, however, experiencing more symptoms, particularly around menstruation. Moody, irritable and anxious for two weeks before her period, Glenda was also having difficulty sleeping. In addition, at work she found herself forgetting things more frequently. This periodic memory loss was particularly disturbing to Glenda because her mother was an Alzheimer’s patient. 

When Glenda described her symptoms to her doctor, he was not convinced that what she was experiencing was hormone related. He felt Glenda was too young to be in menopause and thought it might be stress. Admittedly Glenda did have stress in her life, but she wanted to know for sure whether or not this was ‘the change’. 

Glenda’s doctor ordered tests for FSH and LH. FSH (follicle stimulating hormone) and LH (luteinizing hormone) stimulate estrogen and progesterone production by the ovaries and regulate a woman’s monthly menstrual cycle. Then, as estrogen and progesterone levels rise, during a normal cycle, FSH and LH levels drop. During perimenopause, when ovulation is occurring more erratically, estrogen and progesterone levels become unpredictable. As a result, FSH and LH can go into overdrive in an attempt to maintain the status quo, and FSH and LH tests may give artificially high or low results. In Glenda’s case, even though she was cycling irregularly and very symptomatic, her FSH/LH levels were low. Therefore, Glenda’s doctor did not believe she was in menopause. He sent her home without a prescription. 

Glenda’s symptoms were so uncomfortable she decided to get a second opinion. Her new doctor measured her saliva hormone levels. The results showed that Glenda’s progesterone and testosterone levels were both well below the level considered beneficial for a woman her age. Once Glenda began taking her hormones, in dosages formulated to suit her needs, she began feeling great again. 

The Future of HRT

As our knowledge of hormones increases, our understanding of their importance in our health increases as well. In addition to providing welcome relief from uncomfortable symptoms, replacement hormones also provide important protection against serious diseases. HRT can be the key to a healthier, longer and more vital life.