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Hormone Replacement Therapy in Women with PCOS

By: Nancy Dunne Boggs, N.D. and Bill Slater, Medical Researcher.

Dr. Dunne Boggs and Mr. Slater publish www.ovarian-cysts-pcos.com and are completing a book on natural therapies for PCOS, due to be released in October, 2002.

For further information about Hormone Replacement Therapy, please refer to an additional article, which will be featured in our upcoming membership publication, the PCOS Bulletin. If you are not a member and would like to join click here.

On July 9, 2002 the National Institute of Health (NIH) aborted the most thorough study ever conducted on hormone replacement therapy (HRT). This startling event was front-page news for several days and has caused a firestorm of controversy and confusion.

Many of you are wondering if this development is relevant to you. In this issue, we'll talk about hormones and the study that was cancelled.

WHAT DO HORMONES DO? WHAT ARE THEIR SIDE EFFECTS?

Hormones are essentially chemical messengers that tell your cells what to do. Most hormones are created in various glands and tissues in your body and are carried in your bloodstream. Once a hormone gets into your bloodstream, it will encounter a cell or an enzyme.

CELL RECEPTORS. When a hormone encounters a target cell, a specific interaction occurs. The desired interaction depends on the presence of a receptor site on the cell wall, and a corresponding, unique shape of the hormone. The interaction is similar to a lock- and-key relationship. If the hormone "key" fits the cell receptor "lock", the hormone delivers its message to the cell and the cell carries out the instruction given to it by the hormone.

However, dietary deficiencies or high demands for nutrients caused by chronic stress can prevent the cell from creating a proper receptor site. The hormone can arrive at the cell, but no receptor doorway appears. Even if you have enough hormones, they may not communicate properly with your cells if you have a poor diet and are under chronic stress.

Some chemical compounds, either natural or synthetic, can fit into a cell receptor designed for a hormone - just like the wrong key can sometimes fit into a lock. When a compound is similar in shape to a certain hormone, it may be able to lock into the cell receptor for that hormone. But since it has a slightly different structure than the hormone, it will deliver a different instruction to your cell and your cell will function in a different way. Or a compound may simply occupy the receptor, thus preventing the ideal hormone from locking into that receptor.

Whether the chemical is good, bad or neutral depends on the specific compound. The problem is that there are tens of thousands of chemical compounds in our foods and water, in our environment, and in pharmaceuticals that may compete for the same cell hormone receptor sites. Each of these may deliver a message to your cells that is different from your own hormone, or they may prevent your hormone from docking into the cell.

ENZYMES. Another thing that can happen with a hormone circulating in your bloodstream is that it may encounter an enzyme. There are many hundreds of different enzymes in your body, each having a specialized function. An enzyme is something that causes a chemical reaction to occur.

When an enzyme and hormone meet, another lock-and-key situation occurs. If the hormone-key fits into the enzyme-lock, the enzyme changes (metabolizes) the hormone into something else. The hormone may be changed into a slightly different hormone, or converted into a substance that is to be excreted from the body. Keep in mind that hormones need to be broken down and excreted. If not, they can build up and eventually cause serious health problems. Enzymatic action is a crucial part of the removal process. Nutritional deficiencies may prevent you from forming the enzymes necessary for properly managing your hormones.

The enzyme picture is also clouded by the introduction of numerous environmental chemicals and pharmaceuticals into your body. One example of many is ethinyl estradial, a synthetic estrogen derivative found in most birth control pills. It is structurally similar to but different from the estrogens you produce inside your body. It is able to compete for estrogen receptor sites on cells in your body and thus exert an estrogen-like effect.

However, your body has never seen ethinyl estradiol before. You were not born with enzymes to optimally metabolize this chemical. When you have a foreign, synthetic chemical floating around in your body, there's a risk it may not be metabolized in an optimal way. The result is that your body becomes hormonally and metabolically unbalanced. You would then probably experience "side effects" or potential long-term adverse health consequences.

BOTTOM LINE: Many pharmaceutical products, including hormone derivatives, offer relief of symptoms, which is an obvious benefit. However, unintended, unforeseen and undesirable long- term metabolic consequences can occur because your body is not optimally equipped to handle these foreign compounds.

HORMONE REPLACEMENT BOMBSHELL - SHOULD YOU BE CONCERNED?

After reviewing the data collected thus far, the researchers realized that the women who had been on HRT longer than five years developed a small but significant increase in invasive breast cancer, heart attacks, strokes and blood clots as compared to the women on placebo. Therefore they stopped the study because, on balance, the HRT was not benefiting the long-term health of the study participants, even though it relieved menopausal symptoms in many cases.

The results of this study have relevance for women with PCOS because many are taking birth control pills on a long-term basis, in an effort to have regular monthly cycles of bleeding. Birth control pills are a form of HRT. Birth control pills are similar to the medication (Prempro) used in the WHI study in that they both contain an estrogen derivative and a progesterone derivative. Although the two products are certainly not identical, they have similarities.

Even though the WHI was studying menopausal women on HRT, all women who are on long-term HRT should take notice. Until there is a similar long-term study of large numbers of younger women taking the compounds found in birth control pills, and comparing them to matched controls taking a placebo, one should carefully assess the risks and benefits of any hormone treatment. And, consider other therapies that may achieve similar results.

WOMEN'S HEALTH INITIATIVE STUDY: WHAT WENT WRONG?

Apparently the problem was Prempro, the medication used in the WHI study. It's commonly prescribed for the relief of menopausal symptoms, and for prevention of osteoporosis and heart disease in women. Of course, you're probably not taking Prempro or a similar product for these problems. But read on and to see how Prempro may be relevant to you.

Prempro is a combination of conjugated estrogens (Premarin) and medroxyprogesterone (Provera).

PREMARIN. Premarin is a combination of human and horse estrogens. "Estrogen" is a term used to describe a family of three related hormones found in your body: estriol, estrone, and estradiol. Premarin is predominantly estrone and a smaller amount of estradiol. It has no estriol.

Premarin also contains a horse estrogen called equilin. This horse estrogen is extracted from the urine of pregnant mares. Horse estrogen does not naturally exist in the human body, although it has a powerful estrogen-like effect.

Therefore a woman might raise two questions about Premarin. First, why is estriol not included? Estriol is one of three essential estrogens in the human body. Medical studies indicate estriol reduces symptoms of menopause, and may have a cancer- preventive effect as well as other health benefits. With Premarin, you end up receiving an unbalanced ratio of estrogens.

Second, what are the consequences of introducing a horse estrogen into your body? Horse estrogens are structurally different from human estrogens; your body is not able to metabolize a horse estrogen the same way a horse does. Therefore, metabolic problems, i.e., "side effects", are the probable result.

PROVERA. The other drug found in Prempro is Provera, which is a synthetic progestin called medroxyprogesterone acetate. A progestin is a synthetic substitute that is similar to, but structurally different from progesterone Medroxyprogesterone acetate was created in the lab and, like horse estrogen, does not naturally occur in your body.

Progesterone is the sex hormone that naturally occurs in your body. Provera is not progesterone. A progestin is not progesterone. When you take Provera, you are not getting progesterone; you are taking an artificial compound that is foreign to your body. So it's not surprising that Provera has become associated with health risks.

Progestins are associated with side effects so unpleasant that some women simply quit taking their prescriptions. On the other hand, progesterone, taken appropriately, has an excellent compliance record, in large part because of the minimal side effects.

Another question a woman might ask is this: Why should I take a synthetic, artificial substance like medroxyprogesterone? Why not take progesterone itself? We'll answer these questions later in this article.

BOTTOM LINE: First of all, Prempro has a number of possible side effects, including headaches, irritability, restlessness, mood changes, nausea, increase in uterine fibroids, changes in vaginal bleeding, weight changes, changes in sleep patterns, fatigue, upset stomach, bloating, acne, breast tenderness, and changes in sex drive. Secondly, according to the WHI study, a woman is ultimately better off taking a placebo than Prempro hence the reason why they ended the study. So what, then, is the compelling reason to take Prempro or similar products on a long-term basis?

BIRTH CONTROL PILLS AND PCOS Now let's turn our attention to the birth control pills you may be taking.

Prior to menopause, most women naturally produce estrogen and progesterone in a rhythmic fashion in order to regulate ovulation and menstruation. In women with PCOS, this natural hormonal rhythm is disturbed. Birth control pills are commonly prescribed in an attempt to restore this rhythm because they contain a combination of drugs that have estrogen-like and progesterone-like activity.

The Pill causes a monthly bleed in most women, which seems like a "normal" period. Although the shedding of the lining of the uterus is an important health benefit of birth control pills, many women do not actually ovulate while taking them, and therefore are not experiencing all of the complex hormonal interactions that occur with a natural cycle. Continuation of this activity on a long-term basis could have unintended consequences.

Let's take a look at the estrogen part of the Pill. Nearly all birth control pills contain a synthetic estrogen called ethinyl estradiol, which is structurally different from any of the estrogens you have in your body (estrone, estradiol, and estriol).

However, because it's a foreign molecule to your body, ethinyl estradiol is not metabolized in your liver the same way as your own estrogens are. Therefore, ethinyl estradiol remains longer in your body and has more time to exert its estrogen-like effects. The long-term health effects of consuming ethinyl estradiol are open to question. But it does appear to have a more potent effect than your own estrogens.

While ethinyl estradiol is in nearly every birth control pill, the progestin part of the pill is different in most cases. Why do birth control pills have so many different types of progestins? The reason you are likely to hear is that one type produces better results than another. However, it is more likely that the various brands use different progestins to differentiate their products.

There are many pros and cons of the various progestins, in fact, too many to completely cover it in this article. Our main point is that they are all synthetic derivatives of progesterone. Progesterone is a sex hormone your body produces. Progestins are not progesterone.

BOTTOM LINE: Synthetic hormone derivatives do not work the same in your body as your own hormones do because they are structurally and biochemically different from your own hormones. Long-term consumption of synthetic derivatives can result in negative health consequences.

NATURAL VS. SYNTHETIC HORMONES There's a lot of talk - and confusion - about "natural" vs. "synthetic" hormones. We don't use this classification because it doesn't clarify the important issue.

Instead, we place all hormones into two basic categories: "native" and "foreign".

NATIVE HORMONES. A native hormone is a hormone that your body produces, i.e., it is "native" to your body. However, a number of native hormones can be created in the laboratory. They are structurally and biochemically IDENTICAL to the hormone you produce in your body.

For example, progesterone can be developed in a laboratory, as well as in your body. The laboratory version is identical to the one in your body and when you take the laboratory progesterone, it behaves exactly the same as your own progesterone.

FOREIGN HORMONES. A foreign hormone is a chemical compound that is not naturally found in your body. Foreign hormones are structurally and biochemically distinct from the native hormones that they seek to imitate.

A foreign hormone can be either natural or synthetic. For example, equilin is natural horse estrogen that many women take. An example of a synthetic hormone is ethinyl estradial, found in most birth control pills. Whether natural or synthetic, they are foreign hormones because they are not the same as your own hormones.

NATIVE VS. FOREIGN. So which hormone should you take - a native hormone or a foreign one?

Many would suggest that taking a native hormone is healthier for you than taking a foreign hormone.

But as a practical matter, your medical doctor will probably steer you in the direction of foreign hormones. This usually occurs for several reasons -- there have been no large scale studies done on native hormone therapy because these studies are expensive and are usually funded by pharmaceutical companies and most physicians do not study native hormone therapy in medical school.

WHAT ARE YOUR HORMONE REPLACEMENT OPTIONS?

Before discussing options, we want to make one thing clear: we are NOT recommending that you abandon your current hormone therapy, whatever it may be. Your current therapy MAY be the best option for you.

We DO recommend that you educate yourself and consider all of the available options.

There's no "right" or "wrong" answer to HRT. There is only the "best" answer for you, according to your unique health needs and goals.

Here are some options to consider:

1. Consult with a physician who is knowledgeable about "native" hormone therapy. If you're unsatisfied with your physician's insistence on using conventional hormone replacement therapy with foreign hormones, you may want to get a second opinion.

We suggest you find a naturopathic physician, a holistic-oriented medical doctor, or an osteopathic physician. They are the most likely to be knowledgeable about native hormone therapies. You can visit these websites for directories of doctors in your area.

Naturopathic physicians

Medical doctors - members of the American College for Advancement of Medicine

Osteopathic physicians

2. Use native hormones. Hormone therapy using native hormones such as progesterone, estriol, estradiol and estrone allows the physician to customize hormone therapy according to your specific lab results and medical condition. There is no "one size fits all" approach.

Your prescription can be filled by a compounding pharmacy that will create a customized medication just for you. There are about 1,500 compounding pharmacies scattered around the country.

WARNING: It is foolish and risky for you to experiment on your own with progesterone creams. Progesterone is a powerful hormone and we urge you consult with a knowledgeable physician first about its proper use.

Progesterone from creams is starting to show up in abnormally high levels in women's diagnostic lab assessments. It can take months to clear this excess progesterone out of the body.

Read labels of all cosmetic creams. Some contain progesterone and you may be exposed without knowing it.

3. Improve your diet. Diet profoundly affects your hormonal balance. One striking example is Japanese women who consume a traditional diet. These women seldom experience unpleasant menopausal symptoms. In fact, hot flushes are so rare in Japan that there is not even a word in the Japanese language to describe them. Plus, Japanese women have a much lower rate of breast cancer. There are dozens of ways that food can help you maintain healthy hormonal balance throughout your life.

4. Modify your lifestyle and environment. How you behave can reduce hormonal problems. Regular exercise, stress management, low alcohol consumption, and smoking cessation all help to normalize your hormones.

There are numerous estrogen mimics or hormone disrupting chemicals in your environment, which can disturb your hormonal balance. It's to your advantage to reduce your exposure to chemicals such as herbicides, pesticides, solvents and artificial food additives.

5. Consider special herbs and supplements. There are vitamins, minerals and herbs that can help you to better manage your hormones. Some of them also tonify and nourish your reproductive and glandular systems. A licensed naturopathic physician can be a good source of information on the safe and effective use of herbal medicines and nutritional supplements.

CAUTION: Some herbs and specialty nutrients will influence your hormonal balance, which may necessitate a review or modification of your hormonal medication by a knowledgeable physician. Also be aware that there is significant variability in the quality of any particular nutrient. Therefore selection of a trustworthy brand is an important factor.

6. Make sure your liver is healthy. One of the primary functions of your liver is to metabolize or detoxify hormones and other substances that accumulate in your body, and to prepare them for removal. This function is important for maintaining proper hormonal balance; if your liver did not do this job, hormones would simply build up in your body until they became toxic, creating serious symptoms.

All of these hormone replacement options will be further reviewed in complete detail in our forthcoming book.

This article is the opinion of the writers and is not intended to replace medical treatment. We strongly urge you to consult with a physician before starting or stopping any treatment.

For further information about Hormone Replacement Therapy, please refer to an additional article, which will be featured in our upcoming membership publication, the PCOS Bulletin. If you are not a member and would like to join click here.