As more information is learned on the prevention of coronary artery disease, it becomes increasingly clear that women should be considered at similar risk as men, and should undergo equally as aggressive preventative measures. Coronary artery disease is the leading cause of death in women, accounting for 38% of deaths among women, according to the American Heart Association.
I’ve been getting a lot of questions recently about hormones and food. For example, “should I eat [or avoid] soy because it contains phytoestrogens?” “how much estrogen am I consuming if I eat conventionally raised dairy products?” “is additional estrogen good for my brain?” “does extra estrogen exposure add to my risk for breast cancer or blood clots?”
These are complex questions that have been investigated, with conflicting data, in many research studies. Studies of populations that eat lots of phytoestrogens (such as the high soy food consumption in Japan), women have lower risk of breast cancer and blood clots. However, when rats are given large amounts (30X a dietary amount) of isoflavones (an estrogenic component of soy), cancer risk goes up. To quickly review the data, I turned to one of my favorite sources, Michael Greger, MD at nutritionfacts.org. He’s a colleague from my research days and a trusted authority who does a much better job of blogging than me! Listen to his review here His review of the research confirms – soy FOOD is an excellent quality protein that is more protective than harmful and the risk of true allergy to soy is < 0.5%. Further, it increases bone density! So…unless soy is undigestible for you, the health benefit of a few servings per week is a good idea.
On the flip side of the estrogen conundrum is the question about how important is it to avoid the xenoestrogens in factory-raised cow products (dairy and meat). Again, Dr Greger has done the homework and his report is here. In short, the estrogens from cow products is at least 10-fold that of soy. Further, it is bioidentical and basically has no redeeming benefits. Not to mention, the additional hormonal burden you are eating, such as high levels of the stress hormone cortisol that is present in animals under stress, such as cattle.
If you are looking for a way to incorporate dietary principles such as these in an easy, practical way, check out vegan Chef Madelyn at Zest. She makes and prepares vegan meals for San Diegans that are so delicious and nutritious, I frequently “prescribe” them for my patients!
Hormonal health is all about balance – but achieving the right balance can be a challenge, particularly for women at midlife. Long before menopause, this dynamic is found in women whose estrogen and progesterone balance is off kilter. The wide range of resulting symptoms can be debilitating, and women can find themselves battling heavy periods, disruptive PMS, fatigue, weight gain, and many more symptoms.
How can balance be restored for optimum well-being? Let’s take a look at how hormones influence your health and how a healthy lifestyle can help.
Your body contains over 50 different types of hormones, and they all act as chemical messengers to other parts of the body. Hormones are secreted by endocrine glands, including the:
Pituitary gland
Pineal gland
Thymus
Thyroid
Adrenal glands
Pancreas
Testes
Ovaries
When hormones are released by endocrine glands, they travel to specific receptor sites, where they “lock in” and transmit a message to perform a specific action.
What does this mean in practical terms? Your hormones control almost every function in your body, including:
Maturity and growth
Metabolism of food items
Hunger
Sleep
Sexual function and reproductive health
Mood
Cognitive ability
Stress response
Appetite
Hormones also work in tandem with each other. A good example is the relationship between progesterone and estrogen, two hormones produced by the ovaries that work together to regulate the menstrual cycle.
Estrogen and progesterone have complementary functions. Estrogen is the more energizing of the two and helps with memory, libido, mood, sleep and many other functions. It helps protect bone density, youthful skin and hair, mental sharpness, and healthy cholesterol levels. Estrogen levels rise in the follicular phase, which is the first half of the menstrual cycle, up to the point of ovulation.
Progesterone is produced after ovulation occurs (the period called the luteal phase) and has a more calming function. Progesterone levels peak about midway through the luteal phase, then drop off before menstruation occurs. This sudden drop can contribute to symptoms of premenstrual syndrome (PMS). Progesterone helps regulate the effects of estrogen on the body. It plays a role in the growth of the uterine lining during menstruation, and helps regulate the timing of menstruation.
As you see, both hormones play vital functions in a woman’s body, but they must be balanced. Having inadequate levels of progesterone is not only problematic on its own, but estrogen doesn’t function as well with low levels of progesterone. When your levels of estrogen and progesterone aren’t balanced, estrogen dominance can occur.
Without the balancing influence of progesterone, estrogen’s influence on the body can lead to troubling symptoms. This is often the first pattern to occur because the ovaries fail to make enough progesterone to balance the estrogen. Women who previously hadn’t experienced trouble with their periods may find themselves bleeding far heavier than before. They may struggle with PMS or wonder where their wild mood swings came from. The symptoms of estrogen dominance include:
Heavy periods
Menstrual cramps
Fertility issues
Blood sugar problems
Weight gain, particularly around the belly
Thyroid problems
Higher risk of developing autoimmune diseases
Bloating
Fatigue
PMS
Mood disorders, including anxiety and depression
Anger management issues
Increased risk of breast, uterine, and ovarian cancers
Many factors can lead to estrogen imbalance, and it’s not uncommon for a woman to experience more than one cause.
Problems in other parts of the body can contribute to estrogen dominance, including poor liver function, since the liver helps eliminate excess estrogen.
Other hormones also influence estrogen and progesterone production, particularly insulin and cortisol, so when those hormones are disrupted, the effects can cascade.
Chronic stress can lead to harmful hormonal fluctuations.
A poor diet can also lead to hormonal problems, because magnesium, zinc, protein, and B vitamins help to metabolize estrogen. In addition, since fat cells produce estrogen, obesity can contribute to excess levels.
Normal age-related fluctuations in hormone levels can create imbalances, particularly during the perimenopause years. Women experiencing polycystic ovary syndrome (PCOS) are also vulnerable.
Interestingly, sometimes estrogen dominance isn’t caused by estrogen itself. Xenohormones are compounds that mimic the properties of estrogens. They can be absorbed by the body and trigger estrogen production, leading to further imbalances. Many common products contain xenohormones, including plastics (watch out for plastic food containers in particular), pesticides, factory-farmed meat, car exhaust, and emulsifiers found in shampoo and other beauty products.
Stress, particularly the chronic stress so common in our modern lives, impacts cortisol production, which in turn impacts other hormones, including progesterone. Stress reduction techniques such as meditation and yoga can help regulate stress and hormone levels. Sometimes, a simple attitude shift in attitude can slow the “flight or fight” response that produces cortisol. To do this, try considering a stressful event in a more positive light – perhaps as an opportunity to prove your strength.
Hormonal imbalances can cause sleep disturbances. At the same time, you need adequate sleep to maintain healthy hormonal balance. If this seems frustrating, it is! Start with the obvious sleep habits – no blue light, cool, dark room, empty stomach. If that isn’t enough, try listening to guided meditations or binaural beats using headphones. Low dose melatonin, herbal teas like SleepyTime and NightyNight, and Magnesium malate are some things you can try as well. If that doesn’t work, come talk to me or another healthcare provider.
Your liver metabolizes estrogen, so it’s imperative to maintain optimum liver health by reducing exposure to toxins and minimizing alcohol. In addition, your gut microbiome also plays a role in estrogen regulation. Probiotic supplements, fermented foods like kimchi and sauerkraut, and drinks like kefir help maintain the “good” bacteria in the microbiome. Fiber consumption triggers the production of more bacteria, so increase your fiber intake with a focus on whole grains and produce. High amounts of fiber can also lead to more bowel movements, which helps eliminate excess estrogen.
The traditional Western diet of highly processed, high-sugar foods is linked to higher estrogen production. In contrast, a Mediterranean diet has been shown to reduce estrogen levels. The Mediterranean diet centers around whole grains, brightly colored vegetables, olive oil, and fish. Green, leafy vegetables like kale and spinach are particularly beneficial.
Protein is essential for the production of amino acids, which are the building blocks of hormones. Some evidence shows that vegetarian sources of protein are the most effective in regulating estrogen – but the most important factor is to avoid meat from animals exposed to pesticides and artificial hormones.
Omega-3 fatty acids help regular insulin and cortisol production and reduce inflammation, which has a beneficial effect on estrogen. Foods high in omega-3 include chia seeds, avocados, many nuts, and fatty fish.
Dr. Erica’s hormone balancing App can be an easy way to eat this way. It includes menus, shopping lists, recipes, and more!
Some research shows that regular exercise can make your body more receptive to the messages carried by hormones. Plus, exercise can help reduce excess body fat, which carries estrogen.
The decision to start hormone therapy should be an informed one, with many factors to consider, including a woman’s age, health priorities, and health history. Those who try it often consider it a game-changer, but it isn’t for everyone.
If you do choose hormones, it is important that they are bioidentical hormones compounded for you in your unique optimal dose. Dr. Erica is California’s only Menopause Method certified/endorsed prescriber. This method involves formulating your hormones in an organic oil base. Traditional hormone replacement therapy (HRT) is synthetic, and standard bases contain parabens and preservatives.
If you recognize any symptoms of hormonal imbalance, we can help! Reach out to get a comprehensive assessment of your hormones and a customized plan for rebalance. You don’t have to live with an imbalance of hormones!
Paterni I, Granchi C, Minutolo F. Risks and benefits related to alimentary exposure to xenoestrogens. Crit Rev Food Sci Nutr. 2017;57(16):3384-3404. doi:10.1080/10408398.2015.1126547
Layman DK, Anthony TG, Rasmussen BB, et al. Defining meal requirements for protein to optimize metabolic roles of amino acids. Am J Clin Nutr. 2015;101(6):1330S-1338S. doi:10.3945/ajcn.114.084053
Sánchez-Zamorano LM, Flores-Luna L, Angeles-Llerenas A, Ortega-Olvera C, Lazcano-Ponce E, Romieu I, Mainero-Ratchelous F, Torres-Mejía G. The Western dietary pattern is associated with increased serum concentrations of free estradiol in postmenopausal women: implications for breast cancer prevention. Nutr Res. 2016 Aug;36(8):845-54. doi: 10.1016/j.nutres.2016.04.008. Epub 2016 Apr 26. PMID: 27440539.
Cano A, Marshall S, Zolfaroli I, Bitzer J, Ceausu I, Chedraui P, Durmusoglu F, Erkkola R, Goulis DG, Hirschberg AL, Kiesel L, Lopes P, Pines A, van Trotsenburg M, Lambrinoudaki I, Rees M. The Mediterranean diet and menopausal health: An EMAS position statement. Maturitas. 2020 Sep;139:90-97. doi: 10.1016/j.maturitas.2020.07.001. Epub 2020 Jul 15. PMID: 32682573.
Gorbach SL, Goldin BR. Diet and the excretion and enterohepatic cycling of estrogens. Prev Med. 1987 Jul;16(4):525-31. doi: 10.1016/0091-7435(87)90067-3. PMID: 3628202.
Sánchez-Zamorano LM, Flores-Luna L, Angeles-Llerenas A, Ortega-Olvera C, Lazcano-Ponce E, Romieu I, Mainero-Ratchelous F, Torres-Mejía G. The Western dietary pattern is associated with increased serum concentrations of free estradiol in postmenopausal women: implications for breast cancer prevention. Nutr Res. 2016 Aug;36(8):845-54. doi: 10.1016/j.nutres.2016.04.008. Epub 2016 Apr 26. PMID: 27440539.
What is Candida you might ask?
Candida albicans is a yeast, a type of fungus which grows within the mouth, intestines, and skin. In small amounts, this fungus is harmless to our body and leads to no symptoms.
The problems arise, however, when there is an overgrowth of Candida, which leads to infections. This is typically referred to as Candidiasis, which can be caused by a variety of factors:
Antibiotics: Sometimes antibiotics are necessary to fight an infection or kill unwanted bacteria in the body. However, antibiotics can also kill good bacteria, such as those responsible for controlling Candida levels. This causes Candida to grow out of control and can lead to serious symptoms.
Diet: The diet you consume has a significant impact on regulating levels of both good and bad bacteria in your gut. Sugar, refined carbohydrates, and alcohol are all substances that Candida feeds on, so overconsumption promotes Candida overgrowth.
Immune Weakness: People who have weakened immune systems are more likely to experience Candida overgrowth. At-risk populations include the elderly, infants, and those with HIV/AIDS or other autoimmune disorders.
Diabetes: Type 1 or Type 2 diabetes increases your chances of experiencing Candida overgrowth.
Stress: A healthy immune system can regulate your body’s good and bad organisms. Sometimes, however, stress can lead to a shift in the balance between Candida and healthy bacteria. When we are stressed, the immune system’s ability to fight off infections is weakened.
How can you tell if you have Candida overgrowth in your body? Here are the tell-tale signs to look out for:
Brain fog and Fatigue: This is one of the most common symptoms associated with Candida overgrowth and is likely due to nutritional deficiencies that accompany the condition. It also happens that having a weakened immune system leads to both fatigue and Candida, so the effects can be multiplied.
Oral Thrush: When there is too much Candida in your mouth, white, bumpy patches will appear on the tongue, inner cheeks, or throat. This is a tell-tale visual sign of Candida, and is most common amongst the elderly, newborns, and those with weak immune systems.
Digestive Issues: The balance of good and bad bacteria in the gut plays a large role in digestive health. As mentioned, small amounts of Candida can be present in the body and cause no problems. However, Candida overgrowth may cause various unpleasant gut-related symptoms, such as bloating, constipation, and diarrhea. Recent studies have connected Candida overgrowth with several gastrointestinal disorders such as Crohn’s and ulcerative colitis.
Yeast Infections and Recurring UTIs: Candida naturally exists in the vaginal tract, but an overgrowth can lead to vaginal Candidiasis, also called a yeast infection. Symptoms include redness, swelling, itching, painful intercourse, and a thick, white discharge from the vagina. Vaginal yeast infections are quite common, occurring in 75% percent of women at least once. Candida overgrowth can also cause urinary tract infections (UTIs). This tends to occur amongst the elderly and immunocompromised populations. UTIs can cause burning while peeing, a more frequent need to urinate, dark and cloudy urine, and discomfort in the lower abdomen.
Joint pain: When a Candida infection is left untreated for too long, the fungus can enter the bloodstream. This then affects the joints and can lead to arthritis. Candida can also affect the bones, causing infections or osteomyelitis. Bone and joint infections caused by candida are uncommon but can be difficult to eliminate when they do occur.
Hormonal imbalance: Scientists have noticed a correlation between increased estrogen levels and the overgrowth of Candida. The by-products of Candida, which can spread beyond the digestive tract, mimic estrogen, which can cause serious hormonal imbalance.
Treating Candida involves a thorough health assessment from your healthcare practitioner, followed by a strict elimination diet and Candida protocol as next steps.
Since food plays a crucial role in regulating healthy levels of bacteria in the gut, one of the main ways Candida overgrowth is treated is through diet. This means reducing consumption of sugars and carbs which Candida thrives on. High-lactose dairy products can also encourage Candida to grow and should be avoided.
Along with eliminating foods that can trigger Candida, focus on foods that have been proven to fight it and promote the growth of good bacteria. Try incorporating the following into your diet:
Garlic. Garlic has an antifungal property called allicin, which is known to fight against candida yeast.
Coconut oil. Due to its high lauric acid content, coconut oil can also reduce Candida.
Pomegranate. More research needs to be done, but initial research has found that the plant compounds found in pomegranate are helpful in reducing Candida.
Curcumin. Test tube studies show that curcumin has the ability to reduce the growth of Candida yeast and may even kill it.
Probiotics. Probiotics promote the growth of healthy bacteria in the gut and protect against candida. Lactobacillus is the recommended probiotic for fighting Candida overgrowth. Be sure to speak with a healthcare practitioner to guide you in the right supplements to choose for your condition.
Don’t let a Candida overgrowth run you down! It’s important to get the proper assessments in order to get to the root cause and a tailored plan to cleanse your body of it for good – we can help!
Sources
Irving G, Miller D, Robinson A, Reynolds S, Copas AJ. Psychological factors associated with recurrent vaginal candidiasis: a preliminary study. Sex Transm Infect. 1998 Oct;74(5):334-8. doi: 10.1136/sti.74.5.334. PMID: 10195028; PMCID: PMC1758140.
Kumamoto CA. Inflammation and gastrointestinal Candida colonization. Curr Opin Microbiol. 2011 Aug;14(4):386-91. doi: 10.1016/j.mib.2011.07.015. Epub 2011 Jul 28. PMID: 21802979; PMCID: PMC3163673.
InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Vaginal yeast infection (thrush): Overview. 2019 Jun 19. Available from: https://www.ncbi.nlm.nih.gov/books/NBK543220/
Cheng G, Yeater KM, Hoyer LL. Cellular and molecular biology of Candida albicans estrogen response. Eukaryot Cell. 2006 Jan;5(1):180-91. doi: 10.1128/EC.5.1.180-191.2006. PMID: 16400181; PMCID: PMC1360257.
Khodavandi A, Alizadeh F, Harmal NS, Sidik SM, Othman F, Sekawi Z, Jahromi MA, Ng KP, Chong PP. Comparison between efficacy of allicin and fluconazole against Candida albicans in vitro and in a systemic candidiasis mouse model. FEMS Microbiol Lett. 2011 Feb;315(2):87-93. doi: 10.1111/j.1574-6968.2010.02170.x. Epub 2011 Jan 10. PMID: 21204918.
Shino B, Peedikayil FC, Jaiprakash SR, Ahmed Bijapur G, Kottayi S, Jose D. Comparison of Antimicrobial Activity of Chlorhexidine, Coconut Oil, Probiotics, and Ketoconazole on Candida albicans Isolated in Children with Early Childhood Caries: An In Vitro Study. Scientifica (Cairo). 2016;2016:7061587. doi: 10.1155/2016/7061587. Epub 2016 Mar 14. PMID: 27051559; PMCID: PMC4808662.
Pai MB, Prashant GM, Murlikrishna KS, Shivakumar KM, Chandu GN. Antifungal efficacy of Punica granatum, Acacia nilotica, Cuminum cyminum and Foeniculum vulgare on Candida albicans: an in vitro study. Indian J Dent Res. 2010 Jul-Sep;21(3):334-6. doi: 10.4103/0970-9290.70792. PMID: 20930339
Kumar A, Dhamgaye S, Maurya IK, Singh A, Sharma M, Prasad R. Curcumin targets cell wall integrity via calcineurin-mediated signaling in Candida albicans. Antimicrob Agents Chemother. 2014;58(1):167-75. doi: 10.1128/AAC.01385-13. Epub 2013 Oct 21. PMID: 24145527; PMCID: PMC3910804.
Mailänder-Sánchez D, Wagener J, Schaller M. Potential role of probiotic bacteria in the treatment and prevention of localised candidosis. Mycoses. 2012 Jan;55(1):17-26. doi: 10.1111/j.1439-0507.2010.01967.x. Epub 2011 Jun 14. PMID: 21672043.
Good bone health requires more than just calcium – it requires a combination of key nutrients to build strong, non-brittle bones, activity stresses the bones in a healthy way, and balance exercises to ensure you don’t fall!
INCORPORATE THESE KEY FACTORS:
Calcium, magnesium, and trace minerals
1200-1500mg total calcium from food and supplements.
Calcium + D increases BMD by 1-3%, reduces fracture 30%, likely more with all trace minerals
We like Bone Up (Jarrow) & Botani-Cal (New Mark)
Vitamin D3
Dosed based on lab tests to reach serum 50-70ng/dl.
Increases BMD 1-3%
Strontium citrate
200-250mg – this is different than prescription strontium ranelate (SR) which is available Europe.
SR reduced fracture ~50% and increases BMD 3-7%
Vitamin K2
45mg (MK4 preferably, MK7 is an acceptable, less well studied form).
Increases BMD 3-5%, reduces fractures significantly; one study of MK4 showed 90% reduction.
Weight bearing exercise
Weighted exercise vests, walking with a small backpack with weights, or weight training in the gym all put healthy stress on your bones, causing them to remodel into stronger, less brittle bone. Weighted walking vests can be found on Amazon. Start with 6lbs and work up.
Good balance
Osteoporosis isn’t much of an issue if you don’t fall! If your balance isn’t great, start with well supported activities like chair yoga. T’ai Chi, Qi Gong, and Yoga are all excellent options to build balance.
AVOID BONE DEPLETING FACTORS:
Medications – Proton pump inhibitors, glucocorticoids,
Smoking – Depletes bone
Sedentary behavior – Minimize bed rest; begin physical activity and rehabilitation as soon as possible following surgery or illness.
Excess alcohol intake – Depletes bone
GET EDUCATED:
Read Lara Pizzorno’s book “Your bones” (2011)
Explore the FRAX tool to estimate your personal risk. https://www.shef.ac.uk/FRAX/tool.jsp
Please also see my companion blog post, Are Bioidentical Hormones Right for Me?
IF FURTHER TREATMENT IS NEEDED, DISCUSS THE RISKS AND BENEFITS SPECIFIC TO YOU:
Bio-identical hormone replacement therapy (estradiol, estriol, testosterone)
Reduces fractures, increased BMD 1-8%, Very slight ncreased risk of breast cancer, CVD, blood clots and stoke. Progesterone and DHEA appear to have no bone-related effects.
Bisphosphonates
Alendronate (Fosamax), Ibandronate (Boniva), Risedronate (Actonel), Zoledronate (Zometa, Aclasta)
Over 5 years, increases bone density 3-5%, decreases fractures 40-60%.
Overtime, decreases bone remodeling. This leads to adverse effects such as brittle-ness and osteonecrosis, cavitations, atypical fractures
Safe use requires a “drug holiday” after several years; 3-5 years on, 3-5 years off may be wise.
Selective estrogen receptor modulators (SERMs) i.e. Raloxifene (Evista)
Decreases fractures up to 35%, decreases breast cancer risk
Side effects consistent with estrogen-blockade – hot flashes, vaginal atrophy, cognitive function
Parathyroid hormone – Teriparatide (Forteo)
Best for glucocorticoid-induced osteoporosis, those who haven’t tolerated other therapy, or at high risk. Decreases fractures up to 70%, increased bone density 1-6%. It is given 3m on, 3m off for a max of 2 years. Lots of contraindicated conditions – ask your doctor. Must monitor calcium, PTH, and 25(OH)D
Calcitonin
Decreases fractures 30%, increases bone density 2%. Increases risk of malignancy, cannot be used long-term.
Denosumab (Prolia)
A monoclonal antibody treatment that affects bone remodeling. May be most appropriate for bone loss associated with auto-immune & inflammatory conditions like IBD.
To learn more, or to discuss which approaches are most relevant to you, schedule a consultation with Dr. Oberg.
Low bone density often sneaks up on otherwise healthy women. It is generally asymptomatic until it’s too late and a fracture occurs! Fortunately, non-invasive screening with a DEXA test can identify osteopenia and osteoporosis early. When detected early, a number of strategies can be implemented to regain lost bone density, or at least prevent further deterioration.
The conventional approach to osteoporosis inolves the bisphosphonate medications and selective estrogen receptor modulators, and calcitonin. More recently, immunomodulator denosumab has become available. Whether women have had intolerable side effects from medications, or simply don’t want to take a drug, I often point them towards bioidentical hormone replacement therapy as an option to build bone density (in conjunction with supplementation to ensure the necessary vitamins and minerals are available to make new bone).
Bioidentical hormone replacement therapy, specifically estradiol, is an evidence-based approach that is supported by research and guidelines, despite getting less attention than the drugs. When women pass into menopause, and estrogen levels decline, we see a rapid rate of bone loss that is most dramatic over the first few years of menopause. Estradiol is known to prevent this bone loss and in fact has an FDA approval for the indication of osteoporosis prevention (but not treatment). According to a 2021 review of best practices for endocrinologists, “not only [does] MHT [menopausal hormone therapy] prevent bone loss and the degradation of the bone microarchitecture but it significantly reduces the risk of fracture at all bone sites by 20-40%. It is the only anti-osteoporotic therapy that has a proven efficacy regardless of basal level of risk, even in low-risk women for fracture.1 Thus, some countries, such as the UK guidelines, also include recommendations for the use of HRT for osteoporosis. 2
So, knowing that hormone replacement therapy is a proven strategy for maintaining or improving bone density, how do women know if it is right for them? And if so, what type of hormone replacement should they use?
The first consideration is to weigh the potential risks and benefits of both using hormones and the risks and benefits of not using them. As is usually the case, the answer is not one-size-fits-all; it depends on the individual. In terms of bone protection, estrogen replacement has been shown beneficial in every study from the controversial Women’s Health Initiative study in the early 2000s to the present. The benefit is seen across delivery methods (transdermals, transvaginal, or oral), even at low doses. We’ll get into delivery methods below. Given that the lifetime risk of a woman to have an osteoporotic fracture is 1 in 2 (50%), protecting bone is a high priority for most.
The risk of breast cancer is often top of mind for women considering hormone replacement therapy, and research has been conflicting. Fortunately, a new huge study which included more than half a million women, provides reassurance. “It found that – in line with other evidence – the risks of HRT are generally low. Breast cancer risks were extremely low with oestrogen-only HRT, but this can only be taken by women who have had their womb removed (hysterectomy). Most women take combined HRT which contains oestrogen and progestogen. The type of progestogen in combined HRT made a difference: norethisterone was linked to the highest increases in risk of breast cancer. (That is a synthetic progestogen, which cannot be compared apples-to-apples with bioidentical progesterone). The researchers stressed that some women who had never taken HRT would still get breast cancer. For example, if a group of 10,000 women in their 50s had never taken HRT, 26 women would still get breast cancer in a year. If all 10,000 women had recently taken combined HRT for less than 5 years, 35 would get breast cancer. So, in this large group of women, the HRT is linked to 9 extra cases of breast cancer in a year. That is less than one in a thousand women”. 3
Other health factors that women may need to consider to understand their personal risk/benefit ratio include their risk of other diseases. Oral HRT is associated with a small increase in stroke risk, but transdermal HRT has a largely neutral, possibly protective cardiovascular effect (improves cholesterol ratios, relaxes hypertension). Additionally, HRT protects against colorectal cancer, dementia, and of course life-disrupting symptoms such as hot flashes, vaginal atrophy, insomnia, and mood changes. 4
Fine-tuning the decision to use HRT for osteoporosis can be made by choosing the delivery method associated the lowest risk. It appears transdermal application has less risk that oral estrogens which are associated with a variety of clotting issues such as deep vein thromboses & ischemic strokes. 5 Oral estrogens also negatively impact triglyceride levels and inflammatory markers and require much higher doses to achieve symptom relief. I never prescribe oral estrogens, nor do I recommend forms that are not bio-identical. Even amongst the topical transdermal application methods, there are options. I am one of California’s only certified Menopause Method prescribers, which is a system that uses organic oil as a base for the bioidentical hormones. I prefer this option as it further reduces the risks associated with exposure to parabens, phthalates and stabilizers in the cream bases. For some women, patches or vaginal rings are an option, although these are limited to estradiol (estriol combination is not available).
While every woman must make an informed decision based on her own situation, the majority of symptomatic menopausal women will both improve their quality of life, and reduce their risk of osteoporosis, dementia, and colorectal cancer with the use of bioidentical hormone replacement therapy. Please also see my companion blog post, Optimizing Osteoporosis, which reviews the lifestyle and dietary supplements that reduce the risk of osteoporosis – there are many easy things to implement beyond just hormone replacement therapy.
1 Gosset A, Pouillès JM, Trémollieres F. Menopausal hormone therapy for the management of osteoporosis. Best Pract Res Clin Endocrinol Metab. 2021 Dec;35(6):101551. doi: 10.1016/j.beem.2021.101551. Epub 2021 Jun 2. PMID: 34119418. 2 Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2022 Apr 5;17(1):58. doi: 10.1007/s11657-022-01061-5. Erratum in: Arch Osteoporos. 2022 May 19;17(1):80. PMID: 35378630; PMCID: PMC8979902. 3 https://evidence.nihr.ac.uk/alert/risk-of-breast-cancer-with-hrt-depends-therapy-type-and-duration/ 4 https://my.clevelandclinic.org/health/articles/16979-estrogen–hormones 5 https://www.naturalmedicinejournal.com/journal/bioidentical-hormone-replacement-therapy-postmenopausal-osteoporosis
Severe pain during your period, bloating, and painful intercourse shouldn’t be accepted as normal. Women experiencing these symptoms could have endometriosis, a condition affecting about 10% of females of reproductive age. Despite its prevalence, endometriosis can be difficult to treat, and it often worsens over time. As a result, endometriosis can have an ongoing negative impact on a woman’s life.But it doesn’t have to be that way!
Let’s take a look at the symptoms and causes behind endometriosis and some natural ways to treat it.
The endometrium is the lining of your uterus, which comes from the Greek word “endo” meaning within. When the endometrium grows outside of the uterus and spreads to other organs in the abdominal cavity like the ovaries, fallopian tubes, bladder, and rectum, it’s called endometriosis. This condition is fueled by estrogen levels and causes swelling, inflammation, and adhesions around the affected organs, essentially locking them in place.
The most pronounced sign of endometriosis is pain in the abdomen, often extreme and debilitating. Severely painful periods are a common symptom, but pain can also be felt in other areas, like the back, legs, and rectum.
Other physical symptoms include:
Painful bowel movements
Pain during intercourse
Diarrhea
Constipation
Heavy periods
Nausea
Fatigue
The pain from endometriosis is different from regular menstrual cramps. It’s often chronic, occurring at all times of the month, and regular pain relievers for cramps don’t have much of an impact.
Not surprisingly given the pain experienced, it can also have a large impact on a woman’s mental health. Many women with endometriosis also experience anxiety and depression. Insomnia is also common.
Endometriosis can also impact fertility. One study found that as many as 50% of women seeking treatment for infertility have endometriosis!
A healthy lifestyle that aims to reduce inflammation is the best approach to ending endometriosis. Be sure to include the following in your daily routine.
Prioritize whole foods. To reduce inflammation, choose whole foods, particularly foods high in antioxidants, like brightly colored veggies, and omega-3 fatty acids, found in fish, nuts, and eggs. Avoid overly processed foods.
Eat organic. Some research shows that pesticides and artificial colorings can contribute to endometriosis.
Go gluten free. Studies show many women’s symptoms improved after eliminating gluten.
Avoid red meat. Red meat is linked to the development of endometriosis. Women who replace red meat with fish experience fewer symptoms.
Use caution with dairy. A few studies show that dairy consumption actually reduces the risk of endometriosis, but some women do report it worsens their symptoms. Keep a food diary to see how dairy consumption affects you. If you do eat dairy, choose organic products whenever possible.
Drink ginger or green tea. If you experience nausea, some warm ginger tea will bring relief. Green tea has antioxidant properties to help with inflammation.
Focus on fiber. Your body eliminates excess estrogen in your stool, so boosting your fiber content is a good idea.It can also help with any constipation triggered by endometriosis.
Avoid alcohol. Alcohol is inflammatory and many women report it makes their symptoms worse.
Exercise has been found to be an effective natural way of managing pain and inflammation associated with endometriosis. While it might seem counterintuitive to engage in physical activity while experiencing pelvic pain, low-impact exercises like walking, yoga, and swimming can help reduce inflammation and ease discomfort.
Exercise stimulates the production of endorphins, which are natural painkillers that can alleviate the severity of menstrual cramps and pain caused by endometriosis. Furthermore, regular exercise can help improve blood flow to the pelvic area, which can reduce inflammation and help the body flush out toxins. Incorporating gentle exercise into your routine can provide a significant relief for endometriosis symptoms, although it’s important to consult your doctor before starting any new exercise regimen.
Some supplements that treat endometriosis include:
Bromelain. This enzyme, found in pineapple, can relieve symptoms.
Turmeric. An anti-inflammatory spice also available in supplement form.
DIM or diindolylmethane is a compound created when you eat cruciferous vegetables. It can improve the way estrogen receptors react to estrogen.
NAC or N-acetylcysteine can slow the growth of endometrial cells.
We can work together to create a supplement regime that matches your health profile. It’s always important to work with a professional, since some supplements can interact or may not be suited for your unique needs.
The pain associated with endometriosis can take a large toll on women’s health. It’s important to prioritize self-care. And, by building a relaxation routine, you could even slow the growth of endometriosis.
Living with endometriosis is stressful. Chronic stress worsens inflammatory conditions like endometriosis. It also disrupts hormonal balance and can lead to estrogen dominance. The end result is often a cycle of worsening symptoms.
Mindful meditation, yoga, and moderate exercise can help manage your body’s reaction to stress. Take the time for relaxing activities like warm baths and massages. Cognitive therapy can also help you develop strategies for coping.
We’re here to help you treat endometriosis the natural way so you don’t have to deal with the pain and other symptoms. Reach out today to get started.
SOURCES
World Health Organization, “Endometriosis”
https://www.who.int/news-room/fact-sheets/detail/endometriosis
Warzecha D, Szymusik I, Wielgos M, Pietrzak B. The Impact of Endometriosis on the Quality of Life and the Incidence of Depression-A Cohort Study. Int J Environ Res Public Health. 2020 May 21;17(10):3641. doi: 10.3390/ijerph17103641. PMID: 32455821; PMCID: PMC7277332.
Ball E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Res. 2020 Feb 4;9:F1000 Faculty Rev-83. doi: 10.12688/f1000research.20750.1. PMID: 32089831; PMCID: PMC7001750
Buggio L, Barbara G, Facchin F, Frattaruolo MP, Aimi G, Berlanda N. Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care. Int J Womens Health. 2017;9:281-293
Qi X, Zhang W, Ge M, Sun Q, Peng L, Cheng W, Li X. Relationship Between Dairy Products Intake and Risk of Endometriosis: A Systematic Review and Dose-Response Meta-Analysis. Front Nutr. 2021 Jul 22;8:701860. doi: 10.3389/fnut.2021.701860. PMID: 34368211; PMCID: PMC8339299.
Li Piani, L., Chiaffarino, F., Cipriani, S. et al. A systematic review and meta-analysis on alcohol consumption and risk of endometriosis: an update from 2012. Sci Rep 12, 19122 (2022). https://doi.org/10.1038/s41598-022-21173-9
A Qualitative Study on the Practice of Yoga for Women with Pain-Associated Endometriosis, Andrea Vasconcelos Gonçalves, Maria Y. Makuch, Maria Silvia Setubal, Nelson Filice Barros, and Luis Bahamondes Published Online: 1 Dec 2016 https://doi.org/10.1089/acm.2016.0021
Lete I, Mendoza N, de la Viuda E, Carmona F. Effectiveness of an antioxidant preparation with N-acetyl cysteine, alpha lipoic acid and bromelain in the treatment of endometriosis-associated pelvic pain: LEAP study. Eur J Obstet Gynecol Reprod Biol. 2018 Sep;228:221-224. doi: 10.1016/j.ejogrb.2018.07.002. Epub 2018 Jul 6. PMID: 30007250.
Morales-Prieto DM, Herrmann J, Osterwald H, Kochhar PS, Schleussner E, Markert UR, Oettel M. Comparison of dienogest effects upon 3,3′-diindolylmethane supplementation in models of endometriosis and clinical cases. Reprod Biol. 2018 Sep;18(3):252-258. doi: 10.1016/j.repbio.2018.07.002. Epub 2018 Jul 9. PMID: 30001982.
Cuevas M, Cruz ML, Ramirez AE, Flores I, Thompson KJ, Bayona M, Vernon MW, Appleyard CB. Stress During Development of Experimental Endometriosis Influences Nerve Growth and Disease Progression. Reprod Sci. 2018 Mar;25(3):347-357. doi: 10.1177/1933719117737846. Epub 2017 Nov 6. PMID: 29108503; PMCID: PMC6343219.
Introduction Menopause is a natural phase in a woman’s life, but it often comes with a variety of challenging symptoms, such as hot flashes, mood swings, and sleep disturbances. Bioidentical Hormone Replacement Therapy (BHRT) is one option that has gained popularity in recent years for managing these symptoms. In this blog post, we’ll review the benefits and risks of BHRT, the different forms of hormones, and the importance of safely monitoring hormone use based on the July 2023 American Family Physician’s article on “Managing Menopausal Symptoms.”
What is Bioidentical Hormone Replacement Therapy BHRT means using hormones that are molecularly identical to the forms we naturally make in our ovaries before menopause. This is in comparison to conventional hormone replacement therapy that used conjugated equine estrogens that are molecularly identical to pregnant horse hormones and progestin, which is a synthetic but binds somewhat effectively in our naturally occurring progesterone receptors. The bioidentical hormones are estradiol, estriol, progesterone, DHEA and testosterone.
Benefits of Bioidentical Hormone Replacement Therapy BHRT involves the use of hormones that are structurally identical to those produced naturally by the body. This fundamental similarity makes BHRT an appealing option for many women experiencing menopausal symptoms. Some of the potential benefits of BHRT include: 1. Relief from Hot Flashes and Night Sweats: Bioidentical hormones can effectively alleviate these bothersome symptoms, improving sleep and overall comfort. 2. Mood Stabilization: BHRT may help regulate mood swings and reduce irritability, anxiety, and sleep disorders commonly associated with menopause. 3. Bone Health: Hormone therapy can help maintain bone density and reduce the risk of osteoporosis. 4. Improved Vaginal Health: BHRT can alleviate vaginal dryness and discomfort, making sexual intercourse more enjoyable. It also protects against urinary incontinence and overall genitourinary symptoms. Libido often improves as well.
5. Enhanced Cognitive Function: Some studies suggest that BHRT may have a positive impact on cognitive function and memory. 6. Enhanced Vitality: BHRT users report higher quality of life, feeling younger and stronger, and enjoying overall anti-aging benefits. 7. Improved Skin Integrity, collagen production, and facial tone and prevention of muscle laxity. 8. Prevention of chronic diseases including diabetes, colorectal cancer, and cardiovascular disease. In fact, all-cause mortality is lower among women using BHRT, and premature menopause/hypogonadism is a known risk factor for early mortality due to the increase risk women with low lifetime hormone exposure have of these conditions, as well as frailty, and fractures.
Risks of Bioidentical Hormone Replacement Therapy While BHRT offers many potential benefits, it’s essential to consider the associated risks and limitations: 1. Blood Clot Risk: Hormone therapy may elevate the risk of blood clots, thromboembolism, which can lead to serious health complications. 2. Increased Risk of Gall Bladder Disease: It’s unclear why, and there are many ways to improve and manage gall bladder health with diet and lifestyle strategies. 3. Uterine Cancer Risk: Women who have not had a hysterectomy and take estrogen without progesterone may face an increased risk of uterine cancer. 4. Increased Risk of Breast Cancer: Hormone replacement therapy has been linked to a slightly increased risk of breast cancer, although the extent of this risk remains a subject of debate. A recent review of 25 clinical trials that looked for associations between breast cancer and hormone replacement therapy found that only 1 of those 25 trials found an increased rate of breast cancer recurrence in women who had previously had breast cancer and used HRT. The subgroup analysis demonstrated that this was true for women with hormone receptor positive (HR+) cancers, but not for HR- ones Another trial has shown a lower rate of breast cancer among women taking estrogen-only HRT (women who have had hysterectomies and don’t need progesterone for endometrial protection). (references at the end of this blog). It is also important to put the degree of risk in context with other risk factors. For example, obesity incurs a 60% increased risk of breast cancer which is much greater than BHRT.
5. Individual Variability: The effectiveness and safety of BHRT can vary from person to person, making personalized treatment plans crucial.
Forms of Bioidentical Hormones Bioidentical hormones can be administered in several forms, tailored to individual preferences and needs. These forms include: 1. Oral: Pills or capsules are a common method, but suboptimal option. Because of gastric metabolism, taking hormones orally requires very high doses to get a small percentage of what is taken into circulation. Further, the liver has to process and detoxify all the excess and some of the metabolites created by the liver are considered more toxic and higher risk than estradiol alone. I rarely use oral estradiol for these reasons. While the same holds true for progesterone, some of the metabolites of progesterone are actually beneficial for improved sleep and relaxation. 2. Transdermal: Patches, gels, creams, and oils, applied to the skin offer a steady release of hormones into the bloodstream. Transdermals are the best method to allow for fine-tuning of doses by the prescriber and patient. And because we can control the base cream, gel, or oil, we can control exposure to unwanted additives like parabens or phthalates and chemicals that are common in low-quality personal care products. There is an organic oil base that most prescribers are unfamiliar with. If you care about chemical exposures, this option is the cleanest one available. 3. Pellets: Tiny hormone pellets implanted under the skin release hormones gradually over several months. Convenient, but if the dose isn’t right, there’s no way to take them out! 4. Injections: Intramuscular or subcutaneous injections provide rapid delivery of hormones but require weekly appointments.
Monitoring Hormone Use Monitoring BHRT is crucial for ensuring safety and efficacy. This involves regular check-ups and various tests, including: 1. Lab Testing: Hormone levels should be regularly assessed to ensure they are within the desired range, not excessively high, and that hormone metabolites are being appropriately processed and metabolized. Blood tests can only give a glimpse of circulating hormone levels at the moment of testing. Urinary hormone testing is superior and is the only way to accurately measure metabolites. Read more in the references at the bottom. 2. Mammograms: Regular breast cancer screening through mammograms is vital for early detection and treatment. In March of 2023, guidelines for reporting mammograms changed and now comment on the density of the tissue. Dense tissue can obscure small masses and may also increase the risk of breast cancer. If you have dense breasts, it is probably wise to use a
more sensitive method of screening. While there is no consensus on this, 3D mammography (digital breast tomosyntesis), ultrasounds, and MRIs can show things that are not visible on mammogram. But those may not be covered by insurance. 3. Pelvic Ultrasounds: If unusual bleeding or spotting occurs, a pelvic ultrasound can help identify any abnormalities in the uterine or ovarian tissues. 4. Hormone Metabolite Testing: Tests such as the DUTCH urinary hormone panel or similar panels provide a comprehensive view of hormone metabolites. This data helps understand how well the body is metabolizing or processing the hormones, aiding in treatment adjustments.
Non-hormonal Strategies for Menopausal Symptoms There are other options beside BHRT for women who for whatever reason prefer to try non- hormonal methods to manage symptoms and address prevention and healthy aging. In fact, in most of my patients, I employee some of these strategies along with BHRT. For vasomotor symptoms, some women find relief with high dose vitamin E and soy isoflavones. Isoflavones are particularly useful because they also reduce the risk of cardiovascular disease, breast & uterine cancer, dementia, osteoporosis, and many of the same conditions we seek to address with BHRT. Urogenital symptoms often respond to non-hormonal therapies like hyaluronic acid and homeopathic suppositories that can moisturize vaginal tissue and maintain pH balance. For more information on lifestyle factors, see my previous blog post on Hormone Harmony (link below).
Conclusion Bioidentical Hormone Replacement Therapy can be a valuable tool in managing menopausal symptoms and planning for a healthy, vital second half of a woman’s life, but it is essential to weigh the benefits and risks carefully and tailor treatment to individual needs. Regular monitoring, using methods like hormone level testing and advanced metabolite analysis, ensures the safety and efficacy of BHRT. Choosing the right dose and right delivery method are also critical. As one of California’s only doctors certified by the Institute of Bioidentical Medicine and Dr. Rosensweet’s Menopause Method, you will find no one more experienced in BHRT than Dr. Oberg. If you are curious of hormones might provide relief from menopausal symptoms and enhance your quality of life during this significant life transition, consider scheduling a complimentary 15 minute exploratory call with Dr. Oberg to see if working with her would be a good fit.
References:
AAFP menopause management: https://www.aafp.org/pubs/afp/issues/2023/0700/menopausal-symptoms.html
Soy isoflavones: https://pubmed.ncbi.nlm.nih.gov/33809928/
HRT in breast cancer survivors: https://pubmed.ncbi.nlm.nih.gov/34731351/ 1. https://pubmed.ncbi.nlm.nih.gov/35594465/ 2. https://pubmed.ncbi.nlm.nih.gov/35854422/
HRT and all-cause mortality/CVD: https://pubmed.ncbi.nlm.nih.gov/35594469/
Mammography guidelines: https://www.cancer.org/cancer/types/breast-cancer/screening-tests-and-early-detection/mammograms/breast-density-and-your-mammogram-report.html
BHRT and osteoporosis blog: hormones-osteoporosis-are-bioidentical-hormones-right-for-me
Hormone Harmony blog: hormone-balance
