Michael Janson, M.D.: Biography

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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 balance.

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 currant oil).

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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