Sooner or later, every woman goes through menopause. Menopause usually begins in the later 40s and can last around 4 years or so. Menopause begins when our estrogen levels begin to fall. As our ovaries stops producing estradiol and progesterone, ovulation ceases.  A decrease in estrogen and progesterone can mean troubling symptoms for some; hot flashes, night sweats, vaginal symptoms and trouble sleeping. Not all women react the same to menopause. As such, not all women will need hormone therapy to treat menopause symptoms. Hormone therapy is indicated for women who experience moderate to more severe symptoms.1

What are my choices?

As discussed in our other article, ‘Bioidentical Hormones; An Alternative to Premarin’, there are perhaps 3 types of medicinal treatments available for menopause symptoms. The first being traditional, prescription conjugated estrogens or ‘synthetic’ hormones. These hormone products are typically made from the urine of pregnant mares or from plant sources. Examples of these products include Premarin and Enjuvia.

The second type of product is referred to as ‘bioidentical hormones’. These are hormones that are 'identical' to human estrogen on a molecular basis. These hormones are typically isolated from natural sources such as soy beans and yams, but are modified so that they are just like the human hormone. There are a couple of commercially available bioidentical products available by prescription including Ogen, Estrace and Estraderm. It is also possible to have custom doses of these hormones compounded by a specialty pharmacy. The Wiley Protocol, made famous by Suzanne Somers, may utilize this type of compounding. The Wiley Protocol calls for dosing bioidentical hormones to mimic the ups and downs of a woman’s cycle.

The third type of therapy is referred to as ‘natural’ hormone products. The term ‘natural’ is very misleading and is not a scientific term. Typically, natural is used to describe products that are derived from plants, also called ‘phytoestrogens’. Phytoestrogens are not the same as human hormones.

There are two new estrogen products. Elestrin (estradiol gel) and Angeliq (drospirenone and estradiol tablets). Elestrin is a new, commercially available, bioidentical estradiol gel. Angeliq is a synthetic, commercially available tablet. It has an advantage in that not only can it be used to treat symptoms like hot flashes and night sweats, it is also indicated to treat vulvar and vaginal problems as well.

Controversy

Which therapy does one choose? There are advantages and disadvantages to all of these. Bioidentical hormones offer flexible dosing and have the option of having a dose tailored to you. However, the FDA has not regulated the compounding of bioidentical hormones. This has caused a bit of controversy in the medical community regarding the potency and consistency of dosing for these products. This may change though. Currently, there is talk about the FDA beginning to regulate the compounding of these hormones. The concern among pharmacies is that this push for legislation seems to be heavily backed by pharmaceutical companies that make synthetic hormones such as Premarin who may see bioidentical hormones as a threat to their financial livelihood. These manufacturers are even calling for the FDA to award the use the term ‘bioidentical’ solely to those products who are manufacture red by a drug company and recognized as an FDA approved hormone product.

What the experts do agree on
 
Although there is no clear-cut evidence that states one treatment (synthetic, bioidentical or natural) is superior, the experts do agree on a couple of things.2-5 First, that women with moderate to severe symptoms should use oral or transdermal (cream, patch) hormone therapy. They also agree that one should start the dose low and increase slowly until the symptoms are relived. Finally, for women who suffer from vulvar and vaginal symptoms but no other symptoms, topical remedies that are applied just to that area are recommended first.

Author: Christi Larson, Pharm. D.

Dr. Larson is a Clinical Infusion Pharmacist, author of Empowered Medicine; A Guide for Consumers and creator of www.empoweredmedicine.com. You can read more about her by visiting www.EmpoweredMedicine.com and clicking on the 'About Us' tab.  EmpoweredMedicine.com is committed to providing evidence-based medical information.

References

1. Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med 2006;355:2338-47
2. The American College of Obstetricians and Gynecologists. Frequently asked questions about hormone therapy. October 2004. http://www.acog.org/from_home/publications/press_releases/nr10-01-04.cfm. (Accessed May 17, 2007).
3. Belisle S, Blake J, Basson R, et al. Canadian Consensus Conference on Menopause, 2006 update. J Obstet Gynaecol Can 2006;28(2 Suppl 1):S7-S94.
4. U.S. Food and Drug Administration. FDA plans to evaluate results of Women's Health Initiative Study for estrogen-alone therapy. March 2, 2004. http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01281.html. (Accessed May 17, 2007).
5. Recommendations for estrogen and progestogen use in peri- and postmenopausal women: October 2004 position statement of The North American Menopause Society. Menopause 2004;11:589-600