What Menopausal Women Need to Know About Estrogen—the New Basics!

Part 1 in a 5 Part series on the Major Hormones of Menopause.

ESTROGEN

What is estrogen? Why is it important?  How do I know if I am in menopause? Why won’t my doctor test my hormone levels?  If they won’t test, how do I know “where I am at”? I see bioidentical all over the internet, what does it mean? How long does it take to work? How long do I stay on it? What are the side effects? Will it cause Breast Cancer?

These are only a few of the most common questions asked about this hormone. So make a cup of tea, settle in and let’s get your most pressing questions answered:)

This is not your mother’s menopause. And thank goodness for that. Some very unfortunate reporting of a very controversial study called the Women’s Health Initiative (WHI) put a generation of women into a world of hurt.  Fortunately, after 20 years of reanalysis of WHI data and accumulating new data, very different recommendations are being made.

As you approach the menopause transition, AKA perimenopause, your ovulation becomes more erratic. This means your estrogen, a hormone released from your ovaries, fluctuates.  And when I say fluctuate, I mean rollercoaster fluctuate not sway back and forth fluctuate.  The root cause of this is no more known than the root cause of when labor will start.  How long it lasts is also variable, just like the length of labor.  We are all different!  Generally though, the symptomatic menopause transition may start in your mid 40’s and can last 2-10 years (or more).  Often, you follow what mom or your sisters did, which can give you a little predictive insight.  But even that is not terribly reliable. Menopause is defined as a year without a period. Most commonly around age 51.

Usually, in medicine we prescribe estrogen to alleviate the vasomotor symptoms (these are the hot flashes and night sweats).  And usually this is done based only on the severity of symptoms and perhaps a blood test (FSH) to “prove” you are in menopause. I find this fraught with difficulties at the individual level.  You are often symptomatic when you are perimenopausal not only when menopausal (defined as 1 year without a period). You see, you can still be experiencing vasomotor symptoms when your estrogen is still present (fluctuating) and your period may only be irregular. At this point in perimenopause, adding estrogen at “standard starting dosing” won’t do a thing for vasomotor symptoms ( and could cause more distress from exacerbating estrogen dominance—bloating, weight gain, breast tenderness, headaches, anxiety and worsening premenstrual syndrome-PMS).

It’s the sudden change in estrogen levels that cause the vasomotor symptoms, especially if not balanced by progesterone which is also fluctuating and eventually dropping (wait for the Part 2 of this series for more on progesterone).   Most doctors are not trained in how to order and interpret levels. Further, many women do not need levels checked, but many actually do. Cost and response to therapy will play into this shared decision.

Starting estrogen at this time, to prevent the lowest levels from getting too low, may help prevent (or at least postpone) the many chronic diseases of aging that rear their ugly heads at menopause transition: Diabetes, cardiovascular disease and certain types of cancer.  Defining this window for timing estrogen therapy has been been referred to as “the timing hypothesis.” Estrogen replacement is preventive and also very safe during this perimenopausal/early menopausal time period.  This implies that estrogen will have different effects at different times in your life.

Let's be clear about risk. Your own estrogen is not going to kill you.  You have had estrogen in your body since birth. It is not an evil or even a scary hormone.  But let’s look at how replacing estrogen may be different.

Compelling reinterpretation of evidence has brought on a paradigm shift from thinking that estrogen causes breast cancer, to an understanding that estrogen prevents breast cancer! The practice of medicine (hopefully) dictates following the clinical evidence. The Women’s Health Initiative study (the same study that said estrogen caused breast cancer back in 2002), now with 20 years of follow up, compels a completely different finding.  Exposure to estrogen alone (in women with a hysterectomy) prevents breast cancer!  

But do keep in mind that nothing is 100% preventative. Not even maintaining a normal weight, abstaining from alcohol, not smoking, eating whole foods, minimizing exposure to toxic people and exercising regularly. There is simply risk in being alive.

Also with this paradigm shift, we now see that the risk with estrogen/progesterone combination therapy is much less than originally stated!  This means overall an absolute risk going from 4 in 1000 to 5 in 1000. But more on this is Part 2-Progesterone (next week).

That said, lets us expand our thinking on how complex and little understood estrogen really is. This is important because it keeps us humble and in awe of being a human female.

Estrogen does seem to play a role in breast cancer for some women.  Having one's ovaries removed (thus removing a major source of estrogen) lowers the risk of breast cancer in at risk women (women with breast cancer or a high genetic predisposition).

As I mentioned, there is quite a bit of variability among human females that dictates our response to hormones…

Perhaps there is variable risk from the different types of estrogens (estrone, estradiol, estriol).

Perhaps there is variable risk in how we are exposed to estrogens outside of what our bodies make- called xenoestrogens, which are chemicals in the environment that act on estrogen receptors- ie. some plastics and pesticides.

Perhaps there is variable risk in how we metabolize or break down estrogen.

Perhaps there is variable risk in how different cells in our body respond to different types of estrogen metabolite signaling. 

I believe it is all of this and more…it's complicated and humbling. 

You will find that the complexity of being a human female is a recurring theme in a holistic view of menopause. I am challenging you to think about your health more broadly.  Menopause management demands more than a hammer and nail approach. There is just too much going on.  Adding to the complexity, estrogen is just one piece of the menopause puzzle.  Aren’t we amazing?

For clarity, estrogen is not the root cause of the development of breast cancer, but something about estrogen may stimulate cancer growth if the cancer is present in a susceptible woman.  This is why we do not prescribe hormone replacement therapy to women with breast cancer nor to women who carry a strong genetic risk for breast cancer.  Most other women would be appropriate candidates at least from the breast cancer issue.  While estrogen replacement therapy or ERT, remains the most effective treatment for the vasomotor symptoms (hot flashes and night sweats), there are multiple other options to help take the edge off the severity of symptoms.

To summarize, we now know that estrogen alone does not cause breast cancer. In addition, we also know know that estrogen alone may prevent breast cancer in normal risk women.

Most women who are candidates for estrogen therapy would benefit from estrogen therapy.  However, I believe  in a Goldilocks approach. Your choice of product and dosing should be “just right” and this can change and will change over the course of therapy.  Trial and error, as well as repeated testing can be quite useful for some.  Perhaps early on you need a tiny dose to prevent the lows from getting too low, then you need a higher dose the year your estrogen plummets and symptoms escalate. But gradually, as your body adjusts, you can bring your dosing back down to eventually an amount to help protect your bone health and protect from developing some of the chronic diseases of aging. You are dynamic. Being open to therapy adjustments as well as continuing to optimize your lifestyle to support your body will make all the difference.

Let's talk bioidentical… 

Bioidentical estradiol is currently your best option for treating vasomotor symptoms.  In particular, transdermal bioidentical estradiol.   

If you are daydreaming, make another cup of tea and come back to me, this is important!  You see, bioidentical has somehow become a marketing term and raised the ire of many physicians.  Bioidentical (the term) is not fringe.  I am referring to pharmaceutical bioidentical products, covered by insurance and readily available by prescription in both oral and transdermal patches at various doses.  Bioidentical simply refers to plant-derived hormones that are identical in chemical structure to hormones in your body.

I do recommend to stick with the transdermal patch (vs pills) to avoid problems with liver metabolism, which may impact risk of clotting and stroke risk.  This has to be individualized with the oversight of your doctor.  Make sure you talk about this. Your risk of blood clots and stroke should be part of your decision making discussion.

Don’t be confused by bioidentical compounded transdermal creams or pellets.  While I think they (the cream, not the pellets) are a wonderful option for some women, they probably are not first line choice for most women due to cost more than anything.  When a compoounded cream is provided, Biest is usually given which typically contains 80% estriol & 20% estradiol (by weight) and dosed for a particular patient’s needs.  These falls under the category of a supplement and do not require a physician prescription.  Hence, the mistrust of many doctors. The concern is not overtly misplaced,  as often these products lack data on purity, potency and efficacy.  Often the products are not batch tested for safety.  There are, however, compounding pharmacies that are accredited by the Pharmacy Compounding Accreditation Board (PCAB). More expensive but you get what you pay for. Thank goodness they exist, especially for patients with certain allergies like peanuts or adhesives or when a different dose is required than what Pharma provides. Accredited compounding pharmacies can make a product to fit your needs.

Testing hormone levels when on compounded estrogen cream is sometimes more complicated and expensive. Saliva or urine tests are advised and usually quite frequently.   The testing is a challenge as saliva testing is highly variable even for the same woman who is not taking estrogen. Even more variable when hormones are given exogenously (ie taking hormones). Saliva contains a far lower concentration of hormone than blood serum.  Contamination with blood, mucosal cells and bacteria can also alter results.  Urine testing may be getting around some of these limitations in testing. Testing methods are improving which is great.  Being able to test from your own home is also great. But cost remains an issue. Stay tuned.

I’m not saying never consider compounded products, just that currently there are easier, cheaper, more evidence based ways of managing symptoms for most women. I am completely open to changing my mind on this. Especially as we learn more on the beneficial effects of different types of estrogens and home testing improves. Recent studies are intriguing on this front and compounded products may be the only way to access the different types of estrogens.  For now, the pharmaceutical products will suffice for most women, especially in early menopause.

So what is a woman to do?

Give estrogen therapy some consideration.

Understanding the role of estrogen and how it changes during this phase is crucial for making informed decisions about your health. Whether you choose estrogen replacement therapy or opt for natural approaches, your healthcare provider can guide you on the best path to manage menopause's effects on your body and well-being. Remember, menopause is a unique journey for each woman, and with the right information and support, you can embrace it with confidence and grace.

I encourage you to talk to your doctor about this!   If you are low risk but symptomatic, under 60 and within 10 years of your last period, it would be worth the discussion.  You could potentially feel better in as little as 2 weeks! If you have had a hysterectomy, no progesterone is required but progesterone may contribute to your overall well being depending on your age and timing of your surgery. If you have a uterus, you will need progesterone therapy.  Which leads us to the next hormone in this series—Progesterone!

To continue this dive into menopausal hormones, I encourage you follow next week’s blog : Part 2 Progesterone replacement therapy!

Wellness always,

Integrative Menopause MD

Clearly, this post is for general information only!  This is not medical advice. No physician/patient relationship is formed. Utilizing any of this information is at the reader's own risk.   This content is not a substitute for personalized medical advice, diagnosis or treatment. Seek advice from your personal professional provider who knows you and your current medical needs.