Natural HRT offers major benefits, less side effects
Women seek natural ways to address menopause
Late in 1982, a middle-aged woman came to Tahoma Clinic in Kent, WA, with what seemed like a routine request: She was suffering from hot flashes, night sweats, insomnia, and joint pain. She wanted relief.
This was a classic case of menopause, thought Jonathan V. Wright, MD, medical director of the clinic, as he wrote out a prescription.
The patient, apparently able to read even a physician’s chicken scratches upside down, saw what he had written: Premarin.
"Premarin?" she asked. "Isn’t that made from horse urine? Don’t you have anything natural?"
That question and that patient’s request put Wright’s feet firmly on a new road toward finding the best possible hormone replacement therapy (HRT) for menopausal women. "It needed to be one that duplicated the hormones that women had 20 or 30 years earlier," says Wright, author of Natural Hormone Replacement for Women Over 45.
Horse estrogens are vastly different from human estrogens, and many practitioners who take a natural approach to medicine theorize that the differences in equine estrogens may be the underlying cause of increased risk of breast cancer and the well-documented increased risk of uterine cancer.
Wright’s first foray into the nonexistent world of natural HRT began with a search for a baseline estrogen level so he could formulate a hormone virtually identical to the human hormones. Calls to laboratories in search of baseline levels of circulating estrogens in healthy 30-year-old women who weren’t pregnant turned up absolutely nothing.
He was amazed to find no one had ever written about normal estrogen levels in healthy women.
Eventually, Wright tracked down a Canadian lab that could give him the information he sought: At the time, a healthy young woman had a circulating estrogen composed of:
- 80% estradiol;
- 10% estriol;
- 10% estrone.
More recent work shows those levels may be changing for some unexplained reason, says Wright, and, while he has not yet changed his formula, a 90%-7%-3% (estradiol, estriol, estrone) formula now seems to more precisely mimic the hormones of modern young women.
By comparison, equine hormones contain 40% estrone, the estrogen component that has been most closely associated with breast cancer, says Carol Petersen, RPh, managing pharmacist at Women’s International Pharmacy in Madison, WI.
Wright also thinks that a woman’s total hormonal makeup needs to be mimicked in order for the therapy to be the most effective, so he arrived at progesterone and testosterone formulations as well.
He and the compounding pharmacists and some "very clever biochemists" got to work and devised a formula based on soy and clover "that contains hormones never found in soy or clover, but are exactly and precisely the same as human hormones." Petersen says soy is used as a base because it has a steroidal chemistry similar to human cholesterol, which can be chemically altered to become identical with whatever hormone is needed.
Two months later, Wright had a prescription ready for the patient who sparked his investigation and his tri-estrogen formula was born. Eighteen years and 2,000 patients later, Wright is firmly convinced of the safety of what he calls his "bio-identical" tri-estrogen-based HRT. He’s refined his regimen until it is an art, even though it is a rather complex art.
"Each woman is different, and each needs to have a formulation that works specifically for her. This takes some time, but the results are worth it," says Wright.
His formula involves determining the length of a woman’s cycle when she was in her prime and then tailoring the hormones to match.
For example, says Wright, if a woman had a 28-day cycle and a five-day period when she was 30, he would have her on tri-estrogen for 23 days and five days off. He would prescribe progesterone from the date she would normally have ovulated (if she knows, or a random date between day 10 and 15 can be selected). This is continued through day 23.
"This is simply copying nature, as does the hormone replacement formula," says Wright.
The base natural hormones are available through thousands of compounding pharmacies nationwide. (For more information, see editor’s note at the end of this article.)
"Natural [HRT] is a remarkably safe alternative to equine-based treatments, which have been shown in a number of studies to increase risk of breast cancer the longer a patient is using them," says Shari Lieberman, PhD, a clinical nutritionist in New York City.
Recent negative reports about HRT have used only equine hormones, adds Petersen.
"The conclusions drawn in the popular press are misleading," says Petersen, whose compounding pharmacy specializes in custom-designed natural hormone replacement prescriptions.
All three clinicians say estrogen should always be used in combination with progesterone. "When I have a patient who has done some homework and says, I don’t need progesterone because I have had a hysterectomy,’ I ask her, Have you had your bones removed, too?’" says Wright.
Wright points out that progesterone is not only important to balance the estrogen cycle, but it is essential for maintaining bone density and rebuilding bones once bone loss begins. And there is evidence that balancing the estrogen protects against breast cancer.
"It’s hard to find someone with breast cancer who has been using progesterone," notes Petersen.
Wright says he thinks testosterone in low doses also plays a pivotal role in maintaining and regaining bone density.
Lieberman adds that lab tests frequently show women experiencing hot flashes and other symptoms of menopause have adequate levels of estrogen and even progesterone, but they are deficient in testosterone.
"I cannot emphasize enough how many women remain symptomatic even after a course of HRT," she says. "Many of these women [have been given routine HRT prescriptions] only to discover their estrogen levels are actually too high, while their progesterone or testosterone levels are abysmally low. Give them a few milligrams of testosterone, and their hot flashes disappear, their libido returns, and they feel healthy and rejuvenated."
Use androgen cautiously
However, Lieberman does caution clinicians. "Androgen therapy must be used cautiously because excessive quantities can lead to overgrowth of body hair and other metabolic problems. And to my knowledge, there’s no natural testosterone replacement."
"This is simply copycat therapy," says Wright. "All I did was figure out what a normal woman should have and copy it exactly."
Natural progesterone is "quite safe," says Lieberman, who adds her years of clinical experience to Wright’s. "I can’t prescribe natural HRT, but I recommend it to women all the time, and they take it to their doctors and get the prescriptions. I monitor it right along with the doctor," she says.
Follow-up testing is important because hormone levels fluctuate as a woman ages, say both Lieberman and Wright, although they disagree which is most desirable. Blood, urine, and saliva tests provide a profile of a woman’s hormonal cycles so dosages can be adjusted accordingly.
Wright particularly recommends testing for 2- and 16-hydroxyestrone (so-called "good" and "bad" estrogens) to determine risk of breast cancer. "In general, the more 2-hydroxyestrone and the less 16-hydroxyestrone, the better."
In addition, Lieberman and the American Thyroid Association in Nanuet, NY, recommend regular thyroid testing to determine specific hormone levels so prescriptions can be tailored to the patient’s individual needs.
Not a one-size-fits-all prescription
Petersen appeals to clinicians to use "the basic scientific education they have and take that to the patient. This is basic molecular biology. It’s demonstrably scientific, and you can test to ascertain its effectiveness both before and after treatment."
"HRT isn’t a one-size-fits-all approach," cautions Lieberman. "Women are increasingly aware of their bodies and the natural and safer alternatives available to them. Doctors need to learn about this and be able to answer questions intelligently if they don’t want to become dinosaurs."
[For more information:
- Johnathan V. Wright, MD, Medical Director, Tahoma Clinic, Kent, WA. Telephone: (253) 859-8700. Web site: www.tahomaclinic.com.
- For a list of compounding pharmacies, contact the Professional Compounding Centers of America. Telephone: (800) 331-2498. Web site: www.thecompounders.com.
- The Women’s International Pharmacy, a commercial compounding pharmacy with an additional mission of educating men, women, and health care professionals about natural hormone therapy, can be reached at (800) 279-5708.]
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