If the plan involves going off or stopping hormones, then typically this should be a gradual process over a period of time. My most common recommendation is as follows:
1. reduce estrogen daily dosage to next lower level every 2-4 weeks until the lowest dosage is reached
2. if symptoms of lower estrogen become significant, then maintain current dosage for several weeks and, if necessary, increase to next highest dosage for 2-4 weeks
3. once the lowest dosage is reached, then alternate days on treatment and off treatment
4. for patch wearers, the last patch at lowest available dose can be followed by no treatment
5. while weaning or stopping, use Progesterone Cream or non-hormonal alternatives if possible…these may include vitamin E and soy protein foods and, if necessary, herbal supplements such as Promensil, or Remifemin
6. discuss other options for bone health, cardiovascular health and non-estrogen hormones such as progesterone and androgens for a customized plan of hormone health.
Various Options of Hormone Support Treatment
The Classic Step-wise Approach to any treatment involves trying the simplest and often safest therapy before moving to stronger and often a more intensive strategy. Still, some patients may opt for an aggressive strategy if symptoms are creating major disruptions. For most patients, a carefully chosen prescription hormone supplement used over a relative short term has a high benefit and low risk profile. Once severe symptoms have been stabilized over a period of time, patients may want to try a lower dosage program or slowly stop prescription hormones completely. Some research studies have suggested higher risks for certain types of cancers and cardiovascular events in certain patient groups. Whether there really are any newly identified increased risks or not, caution should be exercised with the use of any prescription (and non-prescription) medication or products.
First Step for Hormonal Support:
1) Increase supplemental Vitamin E to 800-1000 units daily. This is generally safe and effective (Check blood pressure periodically). Despite some reports, there are generally believed to be vitamin E benefits for cardiovascular and breast problems as well.
2) Increase nutritional Soy-based foods and even consider Soy protein supplements if absolutely necessary (see food source list under phytohormones).
Second Step:
Choose a scientifically, research-backed, natural progesterone supplement and/or a Vitamin/Nutritional and Herbal combination:
1) Natural progesterone cream 20-40 mg daily applied to the skin. We offer a prescription strength bio-identical progesterone cream. This is USP pharmaceutical grade natural progesterone for the best quality available.
See our patient handout or go to our products page on this website for a full description of this highly successful formula.
2) Promensil 500 mg. daily or Remifemin herbal combination…over the counter.
3) Estroven herbal combination…over the counter.
The key is comparing ingredients and trusting a manufacturer for quality and consistency. Key ingredients are Black Cohosh, Dong Quai, Isoflavinoids and Evening Primrose Oil.
Third Step:
Consultation regarding compounded or prescription formulary hormone replacement products. Some patients should consider hormone replacement in light of specific medical benefits that may outweigh potential risks. These conditions may include severe menopausal symptoms, osteoporosis, significant sexual dysfunction, Alzheimer’s family history, or vaginal and bladder issues. Women with a history of breast cancer, uterine cancer or significant risks for any female cancer or blood clots, should generally not use certain estrogen products (at least not on an ongoing basis). Natural Progesterone products are generally safe for these patients.
On hormone treatment for menopause/ perimenopause, our office policy is as follows: We believe that recent studies and the media have exaggerated the risks of hormone therapy. The pharmaceutical companies and overzealous doctors have perhaps exaggerated the benefits of hormones. The real facts are that for some women, some kind of hormone therapy is essential for quality of life, and for other women, certain hormones are dangerous and should be avoided. For the majority of women, an individualized approach should be taken with a careful analysis of that patient’s needs, risks and experience.
Also, this should be re-analyzed regularly (yearly) because options, needs, situations and alternatives change too. Some hormones carry a potential risk of accelerating breast cancer growth, increasing thromboembolic risks, gall bladder risks and may increase EXISTING cardiovascular disease (synthetic progestins, especially Provera are believed by many to be the culprit in lipid change and CVD risk). Hormones definitely help bone strength, bladder and vaginal tissues and probably healthy vascular systems. Most researchers believe there is a benefit in cognitive (brain) function.
If vasomotor symptoms, such as hot flashes, night sweats and heart palpitations are a significant issue, then consideration should be given to using hormones for that alone. If a woman has a uterus, then estrogen should be balanced with progesterone in some way. When low dose topical estrogen is used, such as Estriol, Estrace cream, Estring or Vagifem, the risks associated with using estrogen are very low. These products can be used at least on a temporary basis in virtually all women, even those with usual contraindications to estrogen use.
Generally, we like non-oral routes if the patient agrees, such as patches, creams, drops and rings. Avoiding the oral route, will avoid the “first pass via liver effect”. This means that a lower dosage can be used because the hormone does not have to be digested to get to the bloodstream. Topical routes allow the hormone to be absorbed directly into the bloodstream.
Here are some vitamins, herbal and nutritional and general health tips:
Remember basics
Good diet Fiber Low fat High calcium (use a high quality supplement if food sources are inadequate)
For Hot Flashes/Night Sweats:
Natural Progesterone Cream
Evening primrose oil
Black Cohosh (10-60 drops)
Dong Quai (2 capsules)
Vitex (Chastberry, Chaste Tree) 2 capsules 3 times per day)
For Sleep Disturbances:
Natural Progesterone Cream
Valerian (2 gm capsules)
melatonin 2 mg
For Fatigue, Mood Swings and Low Libido:
Natural Progesterone Cream
Siberian Ginseng (200 mg-1000 mg 3 times/day)
Garden Sage (up to 3 cups tea daily)
Passionflower (14-15drops in liquid)
Vitex (Chastberry, Chaste Tree) 2 capsules
Regular Exercise or Fitness Program
Possible benefit from herbal combinations, such as Avlimil
For Vaginal Dryness:
Use a good quality water-based lubricant as needed
Estriol Moisturizing Cream for improved vaginal strength, elasticity and lubrication
*this excellent natural estrogen vaginal cream is available in our office…
Borage Oil (2-8 capsules)
Dong Quai (2 capsules)
Vitex (Chastberry, Chaste Tree) 2 capsules
For Vaginal Lubrication:
Many new vaginal lubricants are available commercially now. These include Astroglide, Slippery Stuff, Gynemoistrin, Replens, and new versions of KY Jelly. We have two high quality products available in the office for discreet purchase. Any product chosen should be water-based. For more difficult cases of vaginal sensitivity, a short course of vaginal cream or similar product (Estrace Cream, Vagifem tablets, Estring) can offer rapid and lasting improvement.
Dietary Recommendations For Menopause:
1. Consume smaller, more frequent meals or snacks.
2. Reduce consumption of simple sugars and refined carbohydrates.
3. Increase intake of foods high in phytohormones, especially soy protein-based foods. (see list)
4. Increase foods rich in calcium. (Milk, yogurt, cheese, Total cereal, etc – see list)
5. Increase water intake, 1 to 2 quarts daily.
6. Eat at least one boron-rich food daily. (See list)
7. Reduce or eliminate caffeine.
8. Reduce or eliminate alcohol.
9. Reduce salt intake.
10. Reduce intake of animal protein.
Hot Flash Trigger Foods: (Keep a hot flash diary to track patterns in flashes)
Acidic foods like oranges, tomatoes, berries
Garlic and Onions Alcohol
Ginger
Caffeine
Hot Drinks
Cayenne
Salt
Chocolate
Spicy Foods
Fat
Sugar
Large meals
Meals eaten too quickly
Foods High In Phytohormones:
Phytohormones closely resemble our human hormones, providing Estrogen and Progesterone effects and may have less risks and side effects than are associated with prescription hormones.
Soy-based Foods and Products – Tofu, soy nuts, tempeh, soymilk, soy-fortified foods
Special fortified source products – Nutlettes cereal 1- 800-233-3668
Beef (not) protein granules 1- 800-233-3668
Take Care High Protein Beverage 1-800-445-3350
Alfalfa, apples, barley, carrots, cherries, date palms, fennel, garlic, green beans, oats, parsley, pomegranates, potatoes, red beans, rice, rye, sage, sesame, tomatoes, wheat, yams.
Boron Rich Foods:
Apples, broccoli, carrots, pears, other fruits and vegetables
Calcium Rich Foods:
Yogurt, milk, sesame seeds, blackstrap molasses, spinach, mustard greens, okra, almonds, rainbow trout, tofu BEST TIP – Total ™cereal for an excellent source of vitamins, fiber, and a full day’s calcium requirement.
