Progress In Safety Of Hormone Delivery

Women depend on their reproductive hormones in many ways. During the reproductive years, estradiol, the most powerful of the estrogen family, is produced largely by the ovaries. While it is important for menstrual cycles and pregnancy, we now know that estradiol plays a key role in keeping your body in an uninflamed state. Estradiol accomplishes this by depressing the ability of your fat cells and immune cells to produce a number of inflammatory proteins that are linked to many of the menopausal symptoms women describe. Even in the several years leading up to that one year without a menstrual period (a window of time called the Menopause Transition), fluctuations in ovarian production of estradiol cause the release of these inflammatory proteins. These fluctuations explain why mood swings, hot flashes, skin changes, and loss of libido may be encountered, even as the menstrual periods still are occurring.

If reductions in estradiol lead to many of these menopausal symptoms, should reintroducing estradiol into the body early in menopause combat these changes? Progress in safety of hormone delivery has helped here.

In the 1992 Women’s Health Initiative (WHI), designed to study if hormone replacement in menopause could prevent cardiovascular disease, the average age of the participant was 62 years. Moreover, Premarin® (a mixture of estrogens extracted from the urine of pregnant mares), combined with the synthetic progesterone, medroxyprogesterone, was administered as Prempro®. We now know that it was the wrong age group to study this question. Moreover, oral estrogen, with its first pass through the liver after intestinal absorption, increases the risk of blood clots and stroke.  And the synthetic progesterone used may well have contributed to the increase in breast cancer observed in the Prempro® group since women receiving only Premarin® in that study actually showed a reduction in incidence and deaths from breast cancer.

Most hormones currently provided by compounded pharmacies and pharmaceutical companies are called bioidentical hormones. They are identical in structure and function to your own hormones but are derived from plants. When administered as a patch applied to the lower abdomen once or twice a week, depending on the brand, estradiol is introduced at a low, steady rate through the skin directly into the bloodstream exactly as the ovaries provided estradiol to your body during the reproductive years. There is no first-pass phenomenon as is seen with oral hormones. For women who still have a uterus, progesterone is needed in order to prevent uterine cancer caused by estrogen stimulation.

Today, the benefits of transdermal estradiol during menopause far exceed the risks identified during the Premarin® era. Moreover, initiating hormone replacement earlier in menopause actually decreases cardiovascular and bone risk while benefiting common menopausal symptoms. 

Knowledge in the field of menopause medicine is rapidly improving. Through books, the internet, and care provider contact, educated patients today can have a more sophisticated conversation about this important chapter of their lives. Together, we can make menopause not just tolerable but part of a better you.

By James Woods, M.D. and Elizabeth Warner, M.D.
Dr. Woods treats patients for menopause at the Hess/Woods Gynecology Practice.

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James Woods | 9/14/2015