Friday, March 21, 2008

Hormones and Guilt

I was blessed to get a great price on a weekend cruise from San Diego to Cabo San Lucas. I decided to take my daughter, who is a single mother of three and under a lot of stress, and went with two other friends. We had a great time, so good, in fact, that at times I felt guilty that I hadn't been able to bring all of my children on the cruise. No matter that I couldn't have afforded it, no matter that they were all busy and it probably wasn't a good time for them anyway, no matter that they were all happy I was able to have a good time and that I was able to share it with Tina. The guilt was there anyway.

Yesterday my son invited me to his son's pack meeting that evening to see him receive an award. I got out of work late and was exhausted. It took at least 40 minutes to get to their house if there was no traffic. It takes me an hour and a half to get home from their house. I decided to go home and take care of myself, but immediately felt guilty. No matter that I would probably be late and miss the awards anyway. No matter that I had that same grandson over the weekend before to spend two nights for his birthday. I felt the guilt anyway.

Many of us women, and some men, though studies show it is much higher in women, tend to feel that we have to be all things to all people, that we have to do everything well, that we should sacrifice ourself for the benefit of others. And we feel guilty when we can't do it all, which is almost all of the time.

One of the things many women are feeling guilty about right now is the use of hormone replacement therapy (HRT) for their menopausal symptoms. For years women have been told that taking estrogen after menopause will help them, not only with relieving hot flashes and other menopausal symptoms, but that it will reduce osteoporosis, heart disease, and even help them keep their youth. They did discover that using only estrogen (in the form of horse estrogens) increased the incidence of uterine cancer, so they invented progestins (a man-made chemical that attaches to progesterone receptors) which, when taken with the estrogen, stopped that risk. Though some women had unpleasant side effects, most women felt much better on hormones, especially in relation to stopping hot flashes, reducing vaginal dryness, and especially assisting in regulating mood swings.

As discussed in the previous blog, in the last few years new studies have come out that show that taking estrogens (in the form of horse estrogen) and progestins increases the risk of breast cancer, heart disease, blood clots, dementia and stroke. Many doctors stopped prescribing hormones, and women were left to go through their menopausal symptoms without relief, feeling guilty that they had risked their health by taking them so long, but secretly wishing they could go back on. Others, who continued to take the hormones "because I would rather die of breast cancer than go crazy" now feel guilty for taking them.

These studies have been heavily scrutinized over the last 5 or so years, and at the American Society of Reproductive Medicine in Jan. 2008, guidelines were given on the use of HRT. According to this algorithm, HRT should primarily be offered to treat hot flashes. HRT should be recommended for those who are at low risk for cardiovascular disease and are within 5 years after menopause. HRT should not be the first choice when someone is 10 or more years past menopause. Transdermal estrogen (no first-pass effect, therefore less clotting effect) is the preferred delivery route. Treatment should be started with the lowest effective dose and preferably should last less than 5 years.

The problem with this is that this is just putting off the agony. It has been shown in studies that when HRT is discontinued, the symptoms return. So a woman may use HRT to reduce her symptoms for up to 5 years after menopause starts, but then she'll have to suffer with them.

There are other options to assist with the symptoms of menopause other than horse estrogens and progestins. Bioidentical hormones have been hugely promoted since Suzanne Summers recommended them in a recent book. Bioidentical hormones are natural hormonal preparations extracted from plants (for example, soy, or wild or Mexican Yam). They are called bioidentical because the molecules are identical to the molecules found in the human body, unlike the horse estrogens. They can be customized; women can tailor the dose to the severity of their symptoms. Bioidentical estradiol, estrone, estiol, progesterone, testosterone, DHEA and pregnenolone are all available and can be delivered by various routes such as tablet, cream, transdermal, sublingual, etc. They are often made into custom compounds by compounding pharmacists as prescribed by a physician. Many women have had great symptomatic improvement using bioidentical hormones.

However, these compounds have recently been criticized by the FDA and the medical community. Their complaints are that they do not have government approval because individually mixed formulations have not been tested to prove that they are absorbed appropriately or provide predictable levels in blood and tissue. Moreover, there is little scientific evidence concerning the effects of these hormones, and as the preparation methods vary from one pharmacist to another, and from one pharmacy to another, patients may not receive consistent amounts of medication.

The FDA admitted that no adverse event involving bioidentical estriol, the estrogen that is most prevalent in the commonly prescribed "Tri-Est," has ever been reported. In fact, a research study involving 15,000 women found that women who produced the most estriol during their first pregnancy had 58% less breast cancer over the next 40 years.

There have been studies on bioidentical hormones which show that they seem to have protective effects in that they do not increase cancer or cardiovascular risk, but the large studies which were done on the horse estrogens (Premarin), and progestins (Provera) or their mixture (Prempro), have not been done on the bioidentical hormones, so there is not unequivical proof that these compounds are safer.

Also, transdermal progesterone alone, without estrogen, long touted as protective against osteoporosis, has been shown in recent studies that, although it slightly slows the reduction in bone mass after menopause, it does not stop it.

However, if your menopausal symptoms are severe, and you are considering using HRT anyway, I believe that the use of hormones that are identical to your own is likely safer than using horse estrogens which are up to 1,000 stronger, or synthetic hormone-like substances that are unfamiliar to the body. Maybe this will help reduce your guilt :-) However, it is important to find a physician who is knowledgable in the testing and use of these products.

To read the compounding pharmacists concerns related to the new FDA rulings on bioidentical hormones go to

There are also special tests that can test the metabolites of estrogen in your body. There are some metabolites that increase the risk of cancer and others that decrease the risk. This test will show how you break down the estrogen and if you're at higher risk. Even if you don't get the test, some of the things you can do to change your metabolites to the healthier type are: eat more cruciferous vegetables (broccoli, cauliflower, cabbage, brussel sprouts, etc.), take fish oil, eat ground flax seed, lose weight, exercise, eat soy. One study showed that mice who were bred to always get breast cancer didn't get breast cancer when they were fed fish or flax oil.

Other methods that may reduce your symptoms include plant based phytohormones. Soy is especially high in phytohormones, which attach to the hormone receptors in the body and help reduce symptoms. However, be aware that there is some evidence that soy may reduce thyroid function in some people if used over a long period of time. The herbs black cohosh, dong quai (Angelica sinensis), chaste berry (Vitex agnus-castus) and red raspberry leaves can also have hormonal effects. Acupuncture and Chinese herbs can be quite effective for some women. Homeopathic medicines can be useful. Though there is not one medicine to one disease in homeopathy, the most common menopausal remedies for hot flashes are Sepia and Lachesis. Supplements that have been shown to help are Vitamin E, Evening Primrose Oil, and Omega 3 oils. I will have another blog discussing osteoporosis later.

This is the end of my menopausal blogging at this time. Make sure, if you have any questions, to click on comments below and ask them!

"Finding Joy"

Assignment Four: Use remorse and let go of guilt. Remorse is a godly sorrow that brings us to strive to change ourselves and make amends. It lifts us, and allows us to feel better. Guilt is causes us to continually punish and belittle ourselves, but does not bring about change. Many people believe they have to hold onto guilt or they won't ever be better, but in reality it is BECAUSE they hold onto guilt that they don't ever get better. Holding guilt causes us constantly focus on the negative. What we focus on is what we attract to ourselves. It causes us to lose faith in ourselves, in others, and in God. Remorse allows us to build faith.

  1. If you really have done something that has wronged someone, remorse assists in correcting it. There is often a feeling of "I feel badly that I did this. How can I make it better?" Ask yourself why you did it. If you can't figure that out, talk to someone or get professional assistance to discover your hidden motives for that type of behavior. Then make amends--to that person or people, to God, to yourself. Acknowledge what you have learned. Then LET IT GO! If you continue to hold onto the pain of what you have done, it becomes guilt. If you do it again, go through the same process again, and then LET IT GO!
  2. Recognize the need to please. My guilt concerning my grandson was my need to please all people at all times. However, I am only human, and this simply is not possible.
  3. Recognize your own needs. Often we sacrifice our own needs to the needs of others so often that we fail to even realize when we are going beyond our capabilities. Then we crash, either emotionally or physically.
  4. Find time to nurture yourself. We are not required to run faster than we are able. It is important for us to recognize our limitations and take care of ourselves.
  5. Create a win-win. Recognize when you truly need to nurture yourself. If you are like most of us, there will be demands on your time which may tempt you to sacrifice your needs for someone else. Often you can create an alternative which will satisfy both needs, though maybe not in the expected way. In this case, I will be seeing this grandson in a few days. I will have him tell me all about his experience in receiving this award, and be a part of it in that way. There may be other times when you choose to do this other thing. Then make it a point to make another time to nurture yourself, and KEEP YOUR PROMISES TO YOURSELF!
  6. Be kind to yourself. We often treat ourselves more harshly that we do others. We call ourselves names and punish ourselves for little things. Our thoughts about ourselves are constantly negative, and we often don't feel that we deserve to do anything to nurture ourselves. Treat yourself as kindly as you treat others, and you will find yourself treating others even better!
  7. Recognize the difference between selfishness and being self-loving. They are not the same thing! Selfishness is not wanting to give to others, or giving to self without any thought or care about the effect on others. Being self-loving is taking care of yourself so that you have the energy and ability to give to others. WE CANNOT GIVE WHAT WE DO NOT HAVE!
Until we meet again,
Dr. Judi