Happy Thanksgiving week! Today, I'm grateful for my health, my family, sunshine, ....and the ability to serve and connect with my colleagues who also love functional medicine!
I covered progesterone last week, sharing some learning tid-bits from a conference I recently attended (the 4th organization from which I have received education on hormone replacement therapy).
This week, the topic is estrogen therapy. An outline of today’s email:
- Estrogen FYI
- “Nevers”
- Prescribing tips
- My takeaways
***Most of the following information is per Dr. Pam Smith's certification course - not sure I am completely on board with all this information yet; still reviewing the research and slides from the conference
1: Estrogen FYI
- Remember, OCP is not considered hormone replacement therapy
- Estriol is not FDA approved in U.S., is only available in cream form via compounding pharmacies, and it's primary function that we know of is to protect against breast cancer
- In perimenopausal women who are still cycling: When low estrogen is found (per cyclical saliva testing), treat the cause of low estrogen (since estrogen will fluctuate a lot in perimenopause, and giving estrogen without frequent follow up salivary testing can increase risk for estrogen-dominant cancers and affect endogenous production of estrogen; there are also very few studies on the safety of using estrogen in these women). Only exception to using estrogen in these women = worsening menstrual migraines.
2: Estrogen “Nevers”
- Never give estradiol (patches or transdermal) without estriol (E3) (per the conference...still evaluating my stance on this)
- Never give estrogen without progesterone in a menopausal woman, even in a woman without a uterus (again, per the conference...still evaluating this)
- Never use serum testing to evaluate dosing of estrogen (I am finding soooooo many high hormone levels after I started doing this a few months ago, so I am completely on board with this)
3: Estrogen Prescribing Tips
- After 6 months of use, always initiate a hormone holiday to maintain brain health, since neurology studies show negative effects on the brain if the brain is constantly exposed to exogenous hormones. With transdermal Biest + oral progesterone, this just looks like skipping the hormones one day a week. If using a patch, have to remove the patch for 4 days (which is why Dr. Smith doesn’t use patches)
- Always evaluate cortisol (via saliva or urine testing) and fasting insulin BEFORE initiating estrogen therapy. If insulin or cortisol are out of balance, this will negatively impact HRT metabolism.
- Always do follow up testing via saliva to determine appropriate dosing (every 3 months until 2 consecutive tests are in optimal ranges, then every 6-9 months)
- There is an increased risk of breast cancer in women using only oral or transdermal estradiol (including bioidentical) beyond 5-10 years; unsure if these included those without a uterus (didn’t get that far into reading some of the studies, and I found studies for and against this...to mitigate these risks, include estriol when prescribing)
4. My Takeaways
From this conference, the main changes I will be making to my practice when I prescribe estrogen include:
- Add estriol cream for anyone on patch-based estrogen therapy or estradiol-only therapy (due to mixed studies on the risks of using these beyond 5-10 years).
- Use saliva testing to make sure I am not overdosing my patients.
- Highly encourage any of my patients with hormone imbalances to start with a 10-14 days “liver cleanse” before initiating therapy. My go-to is the one from Metagenics (but I hadn't thought to use this before initiating HRT).
Bonus
Some references to consider reviewing. I perused these (and have around 10 others to read through), but didn't get around to looking into the proportion of HRT that was transdermal, and how many women had had a hysterectomy:
- 2006 Danish study on 2700+ women over age 50 with breast cancer who had used estradiol (similar risks in oral vs transdermal when used more than 5 years)
- Lancet 2019 meta-analysis
- 2011 analysis of 133,000+ postmenopausal women
Thank you for reading! This is a very complex topic, and requires constant questioning of what we are taught and doing our own reading. My focus is always on safety WITH symptom improvement, and my practice continues to evolve with new information that I come across.
Best in health,
Meg
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