Ask Dr. J. a question
Do I need Premarin(R) after
or during menopause, and what are the alternatives?
After menopause (the cessation of the menstrual
cycles) women do often benefit from estrogen replacement therapy.
Menopause is associated with hot flashes, vaginal atrophy,
and loss of bone density (osteoporosis). Estrogen is used
to treat hot flashes, and it reduces the rate of bone loss
for a few years after menopause. Recent evidence suggests
a role in lessening the risk of heart disease and helping
to maintain brain function. Although Premarin(R) is the most
common prescription for hormone replacement therapy for post-menopausal
women, it is not an ideal medication. With Premarin(R) there
are a number of risks. However, there are alternatives using
natural, human hormone replacement, and other nutritional
and botanical remedies.
Premarin(R) is a mixture of estrogens derived
from pregnant mares' urine (thus the name), which is not the
same as that found in humans. The estrogens in horse urine
(including estrone, equilin, and equilenin). These are stronger
than the balance of human estrogens, which consists mainly
of estriol, estrone, and estradiol, in approximately an 8:1:1
ratio. Stronger estrogens pose more of a risk of side effects
and long term health problems than the proper human estrogen
Among the potential problems with Premarin(R)
are an increased risk of gallstones, breast tenderness or
enlargement, fluid retention, migraines, depression, and excessive
blood clotting in the veins (thrombophlebitis). There is also
a reported increased rate of endometrial and breast cancers
in women who take Premarin. When we do prescribe hormone replacement,
I and many of my colleagues use estrogens derived from soybeans,
in a ratio that mimics what is naturally present in women.
This has the benefits of estrogen but the presence of estriol,
a relatively weaker estrogen, and absence of the horse estrogens
appears to reduce the risks.
Supplements of natural progesterone (not Provera(R),
which is a synthetic analogue of progesterone) helps to balance
the estrogen. This further reduces risks, and provides some
of its own benefits. Progesterone appears to increase bone
density, as opposed to simply slowing the loss. Even at 72
years old, natural progesterone may help you to build bone
density. As your body can make estrogens from progesterone,
sometimes it provides all the benefits you need without taking
the additional estrogens.
Increased soy products in the diet (such as
tofu, tempeh, miso and soy milk) appear to help as a mild
estrogen source to reduce hot flashes and breast cancer. Cultures
with a high soy intake have low incidence of these problems,
presumably because of the estrogenic isoflavones such as genistein
that they contain.. Exercise and diet also help to maintain
bone density. Elimination of sugar, sodas, animal protein,
caffeine and alcohol will reduce the urinary excretion of
calcium. Dietary supplements of the mineral boron (3 mg daily)
also appear to help maintain bone density.
Essential fatty acids, vitamin E and bioflavonoid
supplements can help to treat or prevent hot flashes. I often
recommend 1000 mg of mixed bioflavonoids twice a day, 400-800
IU of vitamin E, and supplements of 240 mg gamma-linolenic
acid (GLA, found in evening primrose oil, borage oil or black
Black cohosh is an herb that has been well studied
and shown to be helpful with many of the symptoms of menopause.
A standardized extract of black cohosh has mild estrogenic
activity, and has been shown to help with hot flashes, vaginal
atrophy, and other symptoms of menopause. Whether it helps
with osteoporosis is not as clear, but it is very likely considering
its biochemistry. Vitex agnus-castus is another herb that
is effective for the symptoms of menopause.
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