Once, as I entered the exam room, a woman in menopause looked at me and announced cheerily, "Give me hormones or give me death!"
We both got a good laugh out of that one, and I certainly appreciated her forthrightness and humor. So, realizing that sometimes a woman has a better quality of life with wise use of hormones, let's give you the information you need to make your decision.
Natural forms of estrogen
Section titled “Natural forms of estrogen”Estrogen is the name given to the feminizing hormones. The actual names of the feminizing hormones are estrone, estradiol and estriol. The ovary chiefly makes estradiol which is then converted into estrone and finally into estriol. They are numbered
- E1 - estrone
- E2 - estradiol
- E3 - estriol
Although each of these hormones has a feminizing effect, they are not the same in their activity. For example, there is some concern that estrone has a carcinogenic effect. And, according to an article in the Journal of the American Medical Association(1978;239:29) entitled Estriol, the Forgotten Estrogen, "there has been a growing suspicion if not a conviction that estriol may not only not be carcinogenic but indeed anti-carcinogenic." Ethnic groups who have less breast cancer than North Americans seem to have more estriol in their system than we do. In animals, high levels of estriol seem to protect against the carcinogenic effects of estradiol and estrone. There is even some evidence that oral estriol might turn around already-existing cancer.
Choices in estrogen replacement
Section titled “Choices in estrogen replacement”Estriol alone
Estriol is the most benign and perhaps even beneficial of the estrogens.
A study in the Journal of the American Medical Association (1978;239:1638) showed that in 52 women with menopausal symptoms, estriol in doses from 2 to 8 mg a day was effective in relieving symptoms without causing adverse side-effects. Our experience is that other forms of estrogen are usually more effective. Estriol is usually ineffective for a woman who has been used to taking Premarin.
Tri-est
A woman, left to her own devices, will produce 10% estradiol, 10% estrone, and 80% estriol. Clever chemists can coax these hormones from soybeans into a form identical to human hormones. They are safe for those allergic to soybean. This combination in the 10% E1, 10% E2, 80% E3 ratio is commonly called "Tri-est."
Bi-est
Since estrone has an easier time getting into trouble than the other estrogens, we will often use a combination of estradiol (20%) and estriol (80%).
Estradiol
Estrace is a commercial brand of estradiol of plant origin.
Comparative prices and strengths
Section titled “Comparative prices and strengths”The different estrogens have different biological potencies in the body. Equivalent potencies are listed below.
| type of estrogen | usual dose and range | price usual dose (per 25 day month) |
| Tri-est | 1.25 to 2.5 topical | $18 |
| Tri-est | 2.5 to 5 mg oral | $25 |
| Estrace | 2 milligrams (1 to 2) | $13 |
| Premarin | 0.625 milligram (0.3 to 1.2) | $9 |
Prices correct as of June 1994 and are for comparative purposes only.
Progesterone
Section titled “Progesterone”Estrogen without progesterone can be harmful.
Progesterone is an important hormone responsible for pregnancy. Lack of enough progesterone can lead to PMS and, some doctors believe, to osteoporosis. Most physicians will prescribe a synthetic progesterone called medroxyprogesterone along with estrogen to prevent cancer of the uterus.
We prescribe identical-to-natural progesterone as it causes less side effects and is safer. When this progesterone in combined in the capsule with the three identical-to-natural estrogens, the cost is about $25 per month. This product is available at reduced cost from Women's International Pharmacy (800-279-5708), about $18 per month. Premarin and synthetic progesterone is about $19 per month. (1994 prices)
Side-effects of oral progesterone
Oral progesterone can sometimes increase symptoms in people with candidiasis or digestive problems.
Testosterone
Section titled “Testosterone”Although women make less of it, testosterone is as important to them as it is to men. Many women will find after a hysterectomy or after menopause that they lose their enjoyment of sex. After a hysterectomy, the blood flow to the ovaries is disturbed, and they often do not function as well as they did previously. And of course after menopause, the ovaries produce less hormones of all kinds, which includes testosterone. Most of the time a woman's libido returns when she takes a small amount of testosterone.
This is not news to the pharmaceutical companies. For many years they have sold various types of estrogen mixed with methyltestosterone. Not entirely natural, but often effective.
How to take hormones
Section titled “How to take hormones”Hormones may be taken by mouth or applied to the skin. When taken by mouth, some of the hormone is destroyed in passing through the stomach and liver. For this reason, some people prefer to use hormones applied to the skin. Lower doses are required and sometimes the effect is more prolonged.
In addition, some women will take their hormones in a cyclic manner; other women are not able to tolerate a few days without them. The dosing, timing, and best route of administration is best determined individually.
3/4/04