The Decline of Hormones with Aging
For more than 50 years women have been receiving estrogen replacement therapy for the abrupt cessation of hormone production known as menopause. Researchers looking for the clues to aging have documented the decline of other important hormones, though such decline is less abrupt and universal than menopause. In the next few sections we will discuss these hormones, their effects, and the rationale behind their use as anti-aging therapies.
Bio-identical Hormones: Estrogen and Progesterone Replacement
It is an important decision to choose to replace estrogen and progesterone, when to start and which preparations to use. In addition, the recent results of the Women's Health Initiative Trial (WHI) have caused some anxiety and concern. Doctors are refusing to start HRT on women experiencing the symptoms of menopause, and even worse, many women's medications have been discontinued even though they have been doing so well on it for years. Importantly, despite headlines critical of HRT, physicians who understand the results of the WHI have spoken out against the generalization of the results to woman considering HRT. The WHI results only apply to the two drugs that were studied, Premarin and Provera and the majority of the women in the trial were 65 years old and had not been treated for the first 10 to 15 years of their menopause. As described in Susan Somers' book The Sexy Years, the state of the art in HRT therapy is the transdermal administration of "bio-identical" estradiol and progesterone with a safe and convenient daily cream. In addition, patients on HRT previously received a variety of doses, preparation and regimens, often raising their hormone levels to concentrations far in excess of normal physiologic levels and without regular monitoring of levels. Here at LAAI, our program includes the individual tailoring of doses to restore youthful, physiologic, early adult levels of estrogen and progesterone, the current "state of the art" in BHRT.
What are Menopause, Premenopause, Perimenopause and Postmenopause?
These are the terms describing a woman's transition from having regular periods to none at all. Premenopausal refers to the years before any menstrual irregularities occur. Menopausal and Postmenopausal respectively refer to the time when periods have recently stopped for good and the years after this transition and through the rest of a woman's life.
A Review of the Menstrual Cycle…
In order to best understand what happens to a woman's reproductive system as she grows older and the rationale behind optimal bio-identical hormone replacement, it is necessary to review the normal menstrual cycle. The purpose of the menstrual cycle is to prepare the lining of the uterus for implantation of a fertilized egg, the beginning of pregnancy. To accomplish this, the pituitary gland starts to release follicle stimulating hormone (FSH) to stimulate the ovaries to start producing estradiol (the principal estrogen of the menstrual cycle). FSH also stimulates a follicle in an ovary to become a mature egg. Among other things, Estradiol stimulates the cells lining the uterus to proliferate and cause thickening of the uterine wall in preparation for a possible fertilized egg. In addition, as estradiol continues to be produced for the next 14 days, it causes a surge in the pituitary hormone called luteinizing hormone (LH) which causes the release of the matured egg or “ovulation”. The egg travels down the fallopian tube to the uterine cavity in anticipation of being fertilized. Meanwhile, the part of the ovary from which the egg left (the corpus luteum) starts to produce progesterone which stabilizes the lining of the uterus and readies it for implantation after fertilization. If it is not fertilized, it does not implant. The corpus luteum stops producing progesterone after about two weeks and without this support, the lining of the uterus sheds. The cycle ends and the period starts a new cycle.
A Woman's Cycle Over Her Lifetime…
This normal cycle does not continue unchanged from a woman’s first period to her last. As a woman enters her thirties, and especially after her mid-thirties, her reproductive capacity (her ability to get pregnant and subsequently deliver) starts to decline. Her production of estrogen may decrease slightly and her progesterone production in the second half of the cycle can decrease. During this time she usually continues to ovulate and her menstrual cycle generally remains regular and normal even though her reproductive capacity has decreased. Over the next five to ten years, however, her menstrual cycle can become very disrupted and estrogen levels can swing from very high to very low. This can result in alternating sensations of enlarged and tender breasts with bloating and irritability when estrogen is dominant; and hot flashes, confused thinking or lack of concentration, memory difficulties and vaginal dryness when the estrogen level plummets. Along with this are cycles in which no ovulation occurs and therefore no progesterone is produced to counteract the effects of the estrogen and to regularize periods. This leads to times with no bleeding (often leading to worry that pregnancy has occurred or menopause has started), and can then be followed by heavy bleeding accompanied by severe cramps.
In the past few years, the term "perimenopause" has been adopted to denote these symptoms that occur in the 5 to 10 years prior to menopause. Menopause, is traditionally defined after a woman has gone twelve months without having a period. Estrogen levels are low and can cause hot flashes, difficulty concentrating and memory problems. In addition, the loss of bone accelerates at this point and in the first five years after menopause a woman loses bone at a faster rate than at any time in her life. Other symptoms such as vaginal dryness, decreased libido, dry skin, and decreased mood and energy intensify. After five years, the period referred to as post menopause, a woman's body settles into a lower estrogen state. Cardiovascular disease rates increase; osteoporosis and fracture rates increase; diabetes rates increase; Alzheimer's disease rates increase.
Advanced Preventative or Anti-Aging/Age Management medicine intervenes before the actual menopause to treat the symptoms and long term consequences that result from less-than-optimal hormone levels.
What are the Side Effects and Cancer Risks?
Some women have been reluctant to start HRT even when they are aware of all the benefits because of concerns about side-effects and breast cancer risk. As mentioned previously, side effects are virtually eliminated by dosing to achieve youthful physiologic levels, transdermal administration, the use of only bio-identical estradiol and progesterone and by monitoring blood levels closely. Importantly, the increased incidence of breast cancer reported in recent studies was found in groups of women taking oral, non bio-identical estrogen replacement therapy without proper blood level monitoring to achieve youthful physiologic levels of estrogen.
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