Many women are reluctant to start HRT —even when they are aware of all the benefits—because they are worried about side-effects and breast cancer risk. Side effects can be managed by breaking from traditional HRT and maintaining physiological levels of estradiol and progesterone, by administering them transdermally, and by monitoring blood levels closely.
Two of the basic tenets of our hormone replacement program are to put into the body only the same hormones it produces on its own, and only at levels the body has known before (physiological levels). Furthermore, commercially available blood tests cannot accurately measure blood levels of horse hormones in humans. This becomes important when one considers what recent studies by Dr. Elizabeth Ginsberg show us about what happens to estrogen blood levels when estrogens are taken orally and even a small amount of alcohol is consumed: the level can be increased by 300%--considerably above even the peak levels experienced during the menstrual cycle of a normal young woman. This may account for the excessive vaginal bleeding and breast tenderness that women often experience on standard dose oral ERT (estrogen replacement therapy).
Whereas extensive large-scale clinical trials of transdermal bioidentical HRT have not yet been completed, we can say that since 1997, having treated more than 1,800 patients, the side effects are minimal, manageable, and reversible. The most commonly reported side effects from ERT are breast tenderness and vaginal bleeding; these are often dose-related and can be eliminated or mitigated by reducing the dose. If a woman has a tendency to have hair growth in unwanted areas or acne as a teenager, this can be worsened with testosterone replacement therapy. Prolonged exposure to high levels of testosterone can cause enlargement of the clitoris and a deepening of the voice, both of which decrease with reduction of the levels. In summary, when hormone levels are restored back to youthful levels but not above them (what doctors call supraphysiological levels), side effects are easily managed.
The main impediment that long-term HRT presents to the majority of women is the fear of breast cancer. Let us be very clear on our position: the lay press has overstated the risk of breast cancer. The oft quoted “one in eight women” figure is understood by women to mean that a woman has greater than a twelve percent chance of getting breast cancer at any age; in reality this is only true if she reaches the age of 85. The increased risk of breast cancer for a 65 year old woman who has been on ERT for 10 years increases from approximately 4.5 percent to 5.6 percent—a small increase in comparison to the benefits. But even this increase may be avoidable by taking bioidentical ERT in the transdermal form as mentioned above.
The same research that demonstrated a tripling of a woman’s estradiol level when her ERT is taken orally and she consumes even one glass of wine a day may explain an intriguing finding by Dr. Susan Gapstur and her colleagues regarding ERT and breast cancer risk. When she analyzed the data from the Iowa Women’s Health Initiative she found that the preponderance of the increase in breast cancer risk was in the group of women taking estrogen (virtually all taking it orally) and drinking the equivalent of at least a glass of wine a day. This probably results from the higher that normal levels of estrogen found in the Ginsberg study of the effect of alcohol intake on blood levels of estradiol in women taking oral ERT. This does not, however, mean that a woman needs to completely abstain from alcohol. With bioidentical transdermal estradiol, the increase in estradiol level with alcohol consumption is only about 30 percent; this small increase can be adjusted for when dosing transdermal creams which allow for an infinite number of individualized doses.
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