The Perimenopause – Reverse Puberty
The Perimenopause is that transitional time that can began as early as 10-15 years before actual menopause and continues until after the menopause is well established. For many women, this will typically be early to mid 40’s until age 60 or older. At it’s best; one can have little to no symptoms and a very smooth progression. On the other hand, many women will experience some very troubling symptoms including significant menstrual irregularity, hot flashes, night sweats, and even anxiety/depression.
There are also potentially some changes related to inadequate vaginal estrogen, such as dryness, sensitivity and bladder weakness. In women who have surgical menopause related to the removal of the ovaries, these changes could be more abrupt. In women who have had a hysterectomy, the lack of periods can make the changes confusing. It is important to realize that everyone is different and especially in the premenopause or climacteric, hormonal swings occur throughout the day and variations may be noticed with no real predictable pattern. For these reasons, there are no exact hormone tests that offer meaningful information in most cases.
The best advice for everyone is to realize that each woman has a very individual situation that benefits greatly by good general health and prevention, diet, exercise and guidance from a knowledgeable healthcare expert. In addition, the situation is constantly progressing, and current options continue to evolve, new information is accumulated and people and attitudes also change. This means that effective help must be re-evaluated on an ongoing basis, at least annually and often much more frequently.
Nutritional and Herbal Therapy have been used in place of and in addition to hormonal treatment for many years. The potential benefit of healthy and “natural” ingredients is attractive to many people. These treatments have generally not been as well studied and researched as products from the major pharmaceutical companies. There is however a growing body of evidence to suggest the safety and benefit of many non-prescription and herbal products, especially those from well-known and reputable companies. When the choice is to try these products, our advice is to start conservatively using small dosages and proceeding cautiously. A simple regimen or formula is probably safer than a complex mixture. There are several well-accepted herbs and supplements currently in the market and many different brand products. If initial success with these products is not adequate, we can offer additional advice and suggest additional steps to take.
“Natural hormone” replacement therapy suggests that the chemical makeup of the product is bio-identical or exactly the same as what the human body produces. Most pharmaceutical company products are actually derived or processed from natural sources. Premarin estrogen product, for example, is processed from the urine of pregnant mares. Many other estrogen products are processed by pharmaceutical companies from plant sources. There is a small industry that has been created by some pharmacists who produce a custom-made formula with a doctor’s prescription, using any of a variety of ingredients in any chosen dosage. The benefit here is that a custom product can be created for each individual patient and adjusted accordingly. This offers significantly more choice in designing a supplement for a particular purpose. The disadvantage is that a particular formula may not have any clinical research backing or testing and the patient and the physician must have trust in the pharmacist who is actually compounding the product in their store or lab. There may be much more variation in one batch to the next and certainly from one pharmacy to the next.
Pharmaceutical company factory-made products are known for their consistency and standardization although there is not as much variety and choice in ingredients. Certainly patients can consider both options and may actually find success with compounded formulas if traditional store-bought products are not effective or cause side effects. It is important to know that these hormones have many of the same potential risks as products made by the pharmaceutical companies and the benefits are not as well documented.
A variety of dosage forms can be developed by these specialized pharmacists to meet the specific needs of each woman. Options include: 1) Transdermal or through the skin dosage forms such as gels, troches, or suppositories, 2) Capsules containing micronized particles for improved oral absorption, 3) Unique ingredients and “lesser” hormones which are not always available in commercial products and may be better suited to an individual woman’s specific needs.
We can currently recommend specific pharmacies for compounded hormones and products. Locally there is Family Pharmacy, 3644 Webber Street, Sarasota, Florida 34232 (941) 923-7558. We can also provide information for quality mail order pharmacies.
Patients not on hormone therapy need to be more watchful of long-term low hormone effects such as vaginal sensitivity, dryness, bladder frequency/ urgency and osteoporosis. These patients may also notice dry skin, thinning hair and changes in sexual response or libido. Some patients also notice a decrease in energy levels and sleep quality. If symptoms or signs become too troublesome, a plan involving restarting some form of hormone therapy may be advised for consideration. Bottom line is that unless contraindicated, if a woman feels significantly better on hormones than off, then we suggest starting back on a customized program under physician guidance is usually recommended.
Various levels of hormone support treatment
The Classic Step-wise Approach to any treatment involves trying the simplest and often safest therapy before moving to stronger and often a more intensive strategy. Still, some patients may opt for an aggressive strategy if symptoms are creating major disruptions. For most patients, a carefully chosen prescription hormone supplement used over a relative short term has a high benefit and low risk profile. Once severe symptoms have been stabilized over a period of time, patients may want to try a lower dosage program or slowly stop prescription hormones completely. Some research studies have suggested higher risks for certain types of cancers and cardiovascular events in certain patient groups. Whether there really are any newly identified increased risks or not, caution should be exercised with the use of any prescription (and non-prescription) medication or products.
First Step for Hormonal Support:
1) Increase supplemental Vitamin E to 800-1000 units daily. This is generally safe and effective (Check blood pressure periodically). There are generally believed to be vitamin E benefits for cardiovascular and breast problems as well.
2) Increase nutritional Soy-based foods and even consider Soy protein supplements if absolutely necessary (see food source list under phytohormones). Soy protein has been proven helpful for cardiac health and is safe in diet form.
Second Step
Nutritional -Herbal products can be added to a high soy protein and vitamin E program. Over the counter choices include Promensil, Remifemin or Estroven. These are all brand names of Black Cohosh, Don Quai or Evening Primrose Oil. Another alternative is Progest or wild yam cream. All of these products are “hormone boosters” and relatively safe though not as well tested as the prescription products. Any health concerns including hormone risk factors should be discussed with us prior to using these products.
The highest quality combination formula available is Women’s Isoguard.. It can be mail-ordered by fax or phone from Clinician’s Choice/ American Health Sciences in Vienna, Virginia.. You can request more information on these products from our office or online at www.sworcare.com or at www.MDchoiceVitamins.com
Third Step
4) If the other products are not adequately solving the menopausal issues or if severe symptoms warrant aggressive action, then a temporary trial of prescription medication can be offered. Non-hormonal drug therapy can be attempted for specific symptoms, such as mild anti-depressants, sleep aids or “hot flash” meds.
5) If hormonal therapy is desired, then a formulated therapy can be prescribed or “off-the-shelf” prescription hormones can be used.
Standard hormone therapy should be begun at lowest effective dosages and then there is a choice of monthly injection, weekly patches, 3 month vaginal ring or vaginal creams or suppositories.
With the recent media blitz on controversial hormone study findings, there has been even more interest in discontinuing or avoiding hormone therapy. Many women ask about a specific program of going off hormonal therapy. This is usually customized for individuals, but here is a generalized plan:
Weaning off or stopping hormone therapy
If the plan involves going off or stopping hormones, then typically this should be a gradual process over a period of time. Our most common recommendation is as follows:
1. Reduce estrogen daily dosage to next lower level every 2-4 weeks until the lowest dosage is reached.
2. If symptoms of lower estrogen become significant, then maintain current dosage for several weeks and, if necessary, increase to next highest dosage for 2-4 weeks.
3. Once the lowest dosage is reached, then alternate days on treatment and off treatment.
4. For patch wearers, the last patch can be followed by no treatment.
5. While weaning or stopping, use non-hormonal alternatives if possible…these include vitamin E and soy protein foods and, if necessary, herbal supplements such as Women’s Isoguard, Progest cream, Promensil, Estroven or Remifemin.
6. Discuss other options for bone health, cardiovascular health and non-estrogen hormones such as progesterone and androgens for a customized plan of hormone health. A high quality calcium supplement is important if less than 1500mg is obtained in daily diet.
