The truth about estrogen, hormone, and testosterone replacement therapies.

A newly published study reveals that estrogen does NOT cause breast cancer in women.

Progestin is the link with breast cancer. A woman on estrogen replacement therapy for menopause should not be concerned about breast cancer unless she is on progestin. The previous study from 2002 (Women’s Health Initiative) did not differentiate between progestin and estrogen.

If your spouse/gf is having issues with menopause and low estrogen levels, they should talk with their physicians or be seen by Dr. Washington at our Bellevue clinic. Do not be surprised if your primary care physician still believes that estrogen replacement therapy is linked with breast cancer. Like testosterone replacement therapy [TRT], most doctors are not current in hormone replacement therapy and understand the benefits of HRT.

Benefits of Estrogen Hormone Replacement Therapy (HRT) include:

• Reduced risk of coronary artery disease and reduced risk of heart attacks
• Reduced risk of all-cause mortality with improved survival numbers in the hormone treated group.
• Reduced incidence of hip fractures due to osteoporosis.
• Reduced risk and mortality from breast cancer compared to non-estrogen users.
• We advise women to avoid PremPro (the combined HRT pill) which adds in a synthetic progestin. The synthetic progestin IS associated with increased breast cancer.

DISPELLING THE MYTHS

MYTH: Estrogen causes breast cancer.
FACTS: The best data indicates that not only does estrogen not cause breast cancer; estrogen supplementation after menopause might have a slight protective effect.

Estrogen induces breast development in our species, so of course there is a strong relationship with breast disease and the hormone that regulates breast growth—but balance is the key. Persistently high levels of estrogen, such as in obese or pregnant women, can promote growth of abnormal cells that might otherwise have been plucked out by the immune system. This is not causation but facilitation after the fact. Stating that estrogen causes breast cancer is like saying fertilizer causes weeds. In a garden, even weeds need some soil nutrients and if these are completely removed, the weeds can’t grow...but neither can the desired plants. The fact is, the positive metabolic effects of ideal amounts of estrogen may help the body defend itself from breast cancer before it starts.

MYTH: If you are deficient in estrogen, taking bioidentical estrogen is safe.
FACT: Bioidentical or not, estrogen does have risks.

Estrogen is nature’s gift to incite feminine differentiation. It is also loaded with a few bells and whistles to help protect some feminine liabilities. Women have a very unique reproductive cycle that results in more blood loss than any species on Earth. Menstruation is not unique to humans, but the amount of blood loss is. Surgery residents are known to gasp at the amount of blood lost during a routine C-section (when they are invited to observe), yet the pregnant woman clots like no other...an advantage, and a risk. This tendency to lose enormous amounts of blood with reproduction probably explains why estrogen receptors in the human have evolved to increase clotting in the presence of the hormone. In other words, bioidentical or not, estrogen increases blood clot formation and that may increase the risk of deep clots, pulmonary embolism (blood clots in the lung), and stroke. This risk must be weighed against the benefits of estrogen HRT. There are many things one can do to keep that risk low such as topical estrogen HRT (see below), low dose aspirin (80mg) daily, staying well hydrated, and avoid sitting for long periods without moving such as on airplane flights (we suggest getting up and walk around if permitted). For women over 50 years of age, most will benefit from low dose ASA which has little or no side effects or risks.

MYTH: Estrogen makes you gain weight.
FACT: Estrogen makes carbohydrate metabolism more efficient, helping to create the attractive waistline so closely associated with the fertile woman.

How many chubby-tummy little girls suddenly develop a carved-out waistline by about age 15? Ask any menopausal woman if she feels skinnier without her estrogen? The truth is that estrogen has a very positive effect on metabolism by increasing the body’s sensitivity to insulin to promote a smaller waist-to-hip ratio. It’s easy to understand that features we humans see as “attractive” usually reflect fertility. In fact, the best current data about metabolism and hormone replacement therapy in menopause demonstrates a positive effect for women taking HRT. The confusing factor is the association of estrogen with progesterone. Progesterone, the “other” female hormone, has its name because it is “pro-gestation”. In other words, progesterone’s job is to protect the assumed pregnancy and that means pumping up blood sugar (hence the susceptibility to gestational diabetes), and weight gain with birth control high in progestins (synthetic progesterone). Progesterone also protects the uterine lining. Many of the effects associated with progesterone are mistakenly assumed to be due to estrogen. Most women feel their best when progesterone is not in the picture, during what is sometimes called the “Venus Week”, the week after a woman’s period.

MYTH: Estrogen makes you stupid.
FACT: Estrogen enhances verbal memory.

The scary part about the “stupid” myth is that everyone knows it’s not true, but the reverse is often only whispered about. My patients are horrified by the loss of verbal memory that often accompanies declining estrogen levels in menopause. I must admit it scares me to death, as my livelihood is deeply dependent on verbal skills. Many neurologists are now giving serious consideration to encouraging hormone replacement therapy for menopausal women who have a strong family history of Alzheimer’s disease. Parkinson’s disease, another potential cause of dementia, is far less common in women who take HRT and while stroke risk complicates the risk/benefit profile, some women are very willing to take that risk to reduce their chances of verbal decline. To borrow a concept from Harvard gynecologist Dr. Alan Altman, it appears that estrogen is not a “repairer”, per se, of verbal memory, but perhaps a preserver.

MYTH: Men do fine without estrogen, so women don’t really need it.
FACT: Men actually do have estrogen, and have health consequences without it.

Men do not have ovaries, but they do have estrogen— and the best evidence is that for the rare man that cannot convert testosterone to estrogen, there are serious health consequences. A rare enzyme deficiency, known as aromatase deficiency, prevents a few men in the world from having any significant estrogen. These men not only have abnormal bone development, a high percentage suffer from what is known as metabolic syndrome, a deadly combination of high triglycerides, abdominal fat, and elevated blood pressure. Cognitive effects are not well researched, but there is concern that even drugs that prevent the conversion of testosterone to estrogen (such as some used to prevent breast cancer recurrence in women) may have negative effects on the aging brain.

Ultimately, we all must accept that nature endows us with estrogen as one way to promote reproductive vitality—it can’t be all bad. This gift has benefits and risks. Remaining “vital” is highly desirable, perhaps even negotiable, but fair negotiation is not possible if the stakes are not understood. There is still much unknown but investigators are working hard as many are baby boomers on the brink of gonadal retirement themselves, whether they are men or women. One thing about baby boomers, we like being vital, so stay informed and stay posted.

Extended Notes

The Premarin pill caused increased clotting (hypercoagulable state) resulting in increased stroke and pulmonary embolus in the Premarin Pill users. This is one reason why topical estrogen is preferable to pill form estrogen. Topical delivery of estradiol (bioidentical estrogen) does not cause increased coagulability, does not increase the risk for CVA or stroke, thereby safer, and is the preferred delivery route.

For patients that do need progesterone with their estrogen

A much better hormone replacement therapy utilizes a combination of human bioidentical estrogen (available as Bi-Est (Estradiol and Estriol)), with or without the addition of progesterone (a human bioidentical hormone). If you have had a hysterectomy and no longer have ovaries, the risk of ovarian and uterine cancer goes away. You do not need to cycle progesterone with estrogen any longer.