Hormone Therapy for Women: References
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|This paper reports a 12 plus months follow up on 189 patients who were administered natural estrogen plus progesterone with or without DHEA or testosterone according to a rationalized protocol. Ninety-seven percent of the patients experienced varying degrees of symptom control. Complications described with traditional HRT did not develop in this group of patients.|
Hormone Therapy for Women: Bioidentical Hormone Restoration Therapy (BHRT)
- Estrogens [Show]Estrogens actually refers to a group of related hormones, each with a unique profile of activity. Under normal circumstances, a woman's circulating estrogen levels fluctuate based on her menstrual cycle. For Hormone Replacement Therapy, these hormones are often prescribed in combination to re-establish a normal physiologic balance. The three main estrogens produced in female humans are:
- E1 (Estrone; 10-20% of circulating estrogens) is the primary estrogen produced after menopause.
- E2 (Estradiol; 10-30% of circulating estrogens) is the most potent and major secretory product of the ovary, and the predominant estrogen produced before menopause.
- E3 (Estriol; 60-80% of circulating estrogens)
- Progesterone [Show]Progesterone is a term that is incorrectly used interchangeably to describe both progesterone which is "chemically identical" to what the body naturally produces, and synthetic derivatives. Synthetic progestins are analogues of progesterone, and have been developed because they are patentable, more potent, and have a longer duration. Medroxyprogesterone acetate, the most commonly used synthetic progestin, was shown in a large study to cause significant lowering of HDL "good" cholesterol, thereby decreasing the cardioprotective benefit of estrogen therapy. Side effects are a frequent cause for discontinuation of HRT. Only about 20% of women who start synthetic HRT remain on it two years later.
- is commonly prescribed for perimenopausal women to counteract "estrogen dominance" which occurs when a woman produces smaller amounts of progesterone than normal relative to estrogen levels.
- alone, or combined with estrogen, may improve Bone Mineral Density.
- minimizes the risk of endometrial cancer in women who are receiving estrogen.
- is preferred by women who had previously taken synthetic progestins.
The benefits of progesterone are not limited to prevention of endometrial cancer in women who are receiving estrogen replacement. Progesterone therapy is not only needed by women who have an "intact uterus", but is also valuable for women who have had a hysterectomy. Vasomotor flushing is the most bothersome complaint of menopause, and is the most common reason women seek HRT and remain compliant. For over 40 years, estrogens have been the mainstay of treatment of hot flashes, but progesterone may be effective as well.
- Androgens (Testosterone, DHEA) [Show]Androgens are hormones that are important to the integrity of skin, muscle, and bone in both males and females, and have an important role in maintaining libido. Declines in serum testosterone are associated with hysterectomy, menopause, and age-related gender-independent decreases in DHEA and DHEA-sulfate. DHEA (dehydroepiandrosterone) is an androgen precursor from which the body can derive testosterone. After menopause, a woman's ovaries continue to produce androgens; however, the majority of the androgens produced in the female body, even before menopause, come from peripheral conversion of DHEA. As the body ages, production of DHEA declines so that by the time a woman goes through menopause, the production of DHEA is often inadequate. Additionally, ERT may cause relative ovarian and adrenal androgen deficiency, creating a rationale for concurrent physiologic androgen replacement. Recently, attention has turned to the addition of the androgens to a woman's HRT regimen in order to alleviate recalcitrant menopausal symptoms and further protect against osteoporosis, loss of immune function, obesity, and diabetes.
Androgens, such as testosterone and DHEA:
• enhance libido.
• enhance bone building (increase calcium retention).
• provide cardiovascular protection (lower cholesterol).
• improve energy level and mental alertness.
- Research [Show]The findings of numerous studies on hormone replacement therapy (HRT) conflict and, as a result, have raised serious questions regarding the appropriateness of HRT. Hormone replacement is an approved therapy for relief from moderate to severe hot flashes and symptoms of vulvar and vaginal atrophy. Numerous studies have confirmed that estrogen replacement decreases the risk of colon cancer, estrogen and progesterone decrease fracture risk, and various hormones increase energy levels and enhance libido. Reputable sources offer conflicting reports regarding issues such as memory, Alzheimer's disease, and stroke.
With the exception of the Postmenopausal Estrogen/Progestin Intervention (PEPI) study, major studies have either failed to distinguish among types and dosages of HRT used in the study, or examined only the use of synthetic HRT preparations (as in the case of the Women's Health Initiative). The Women's Health Initiative (WHI) study was designed to identify the potential risks and benefits of HRT. The estrogen-progestin portion of the clinical trial was stopped in 2002 after results showed that a synthetic hormone combination containing conjugated equine estrogens (CEE) plus medroxyprogesterone acetate (MPA) increased the women's risks of developing invasive breast cancer, heart disease, stroke, and pulmonary embolism. The data and safety monitoring board concluded that the risks outweighed the evidence of benefit for fractures and colon cancer. Utilizing data from the WHI, researchers later concluded that synthetic CEE plus MPA does not improve mental functioning and may increase the risk of dementia in women over age 65. They suggest these hormones increase the risk of stroke, which is known to increase the risk of dementia. With regard to the risk of dementia, typical HRT users are in their 50s and the WHI study focused on women aged 65 and over, who have a higher risk for dementia. The "estrogen-only" portion of the WHI study was halted in March 2004 after analysis of data suggested that synthetic CEE alone had no impact either way on heart disease (the main focus of the study), but may increase the risk of stroke.
Many patients and medical professionals are unaware of the availability of alternatives. In reality, women's experiences and clinical outcomes of HRT differ vastly depending on the dose, dosage form, and route of administration, and also the type of hormone that is used. As a result of concerns and doubts generated by studies that use synthetic hormones, many women who could substantially benefit from customized hormone replacement may never have the opportunity.
Published research delineating the differences between natural and synthetic HRT is now more abundant, but studies of natural HRT will probably never be as plentiful as those dealing with patented synthetic hormones. Our pharmacy welcomes your questions.
- References [Show]
Select a Topic Below for More Information:
This paper reports a 12 plus months follow up on 189 patients who were administered natural estrogen plus progesterone with or without DHEA or testosterone according to a rationalized protocol. Ninety-seven percent of the patients experienced varying degrees of symptom control. Complications described with traditional HRT did not develop in this group of patients. Gynecol Endocrinol. 2009 Aug 19:1-5. [Epub ahead of print] Natural hormone therapy for menopause. Mahmud K. Click here to access the PubMed abstract of this article. This study compared the effects of lower doses of HRT (L-HRT) and conventional doses of HRT (C-HRT) on a variety of relevant cardiovascular parameters and found that "L-HRT has comparable effects on lipoproteins, flow-mediated dilation, and PAI-1 antigen levels. However, L-HRT did not increase hsCRP or F1+2 levels, and it decreased antithrombin III less than C-HRT."
Arterioscler Thromb Vasc Biol. 2004 Aug;24(8):1516-21. Epub 2004 May 27.
Effects of conventional or lower doses of hormone replacement therapy in postmenopausal women. Koh KK et al. Click here to access the PubMed abstract of this article.
Reviewers conclude that the choice of transdermal route of administration of estradiol and the use of natural progesterone might offer significant benefits and added safety.
Maturitas. 2008 Jul-Aug;60(3-4):185-201. Epub 2008 Sep 5.
Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review. L'hermite M, Simoncini T, Fuller S, Genazzani AR. Click here to access the PubMed abstract of this article. Literature reviewers conclude that oral postmenopausal estrogen replacement is associated with an increased risk for venous thromboembolism. The review did not address transdermal estrogen therapy. Ann Intern Med. 2002 May 7;136(9):680-90. Postmenopausal estrogen replacement and risk for venous thromboembolism: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Miller J, Chan BK, Nelson HD. C lick here to access the PubMed abstract of this article. The use of oral estrogen plus progestin hormone therapy in postmenopausal women was associated with doubling the risk of development of venous thrombosis. JAMA. 2004 Oct 6;292(13):1573-80. Estrogen plus progestin and risk of venous thrombosis. Cushman M, Kuller LH, Prentice R, Rodabough RJ, Psaty BM, Stafford RS, Sidney S, Rosendaal FR; Women's Health Initiative Investigators. Click here to access the PubMed abstract of this article. According to this study's findings, oral postmenopausal estrogen/progesterone replacement may increase the risk of venous thromboembolism, but the risk of developing deep vein thrombosis (DVT) or pulmonary thromboembolism (TE) with transdermal estrogen therapy is negligible in comparison. Arterioscler Thromb Vasc Biol. 1997 Nov;17(11):3071-8. Effects of oral and transdermal estrogen/progesterone regimens on blood coagulation and fibrinolysis in postmenopausal women. A randomized controlled trial. Scarabin PY, Alhenc-Gelas M, Plu-Bureau G, Taisne P, Agher R, Aiach M. Click here to access the PubMed abstract of this article. The PEPI trial demonstrated that micronized progesterone is as effective as the synthetic progestin medroxyprogesterone acetate (MPA) in preventing endometrial hyperplasia. JAMA. 1995 Jan 18;273(3):199-208. Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial.
The Writing Group for the PEPI Trial.
Click here to access the PubMed abstract of this article. Mark E. Johnson et al of Massachusetts Institute of Technology finds that: “Steroids are an important class of pharmacologically active drugs which have been found to be well suited for transdermal delivery.” Steroid hormones, including (in increasing order of permability) estriol, estradiol, testosterone, pregnenolone, progesterone, and estrone, are low molecular weight, highly lipophyllic molecules, therefore, good candidates for absorption across the skin. J Pharm Sci. 1995 Sep;84(9):1144-6. Permeation of steroids through human skin. Johnson ME, Blankschtein D, Langer R. Click here to access the PubMed abstract of this article. Stanczyk et al. of Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, report: "antiproliferative effects on the endometrium have been demonstrated with progesterone creams when circulating levels of progesterone are low. Thus, effects of topical progesterone creams on the endometrium should not be based on serum progesterone levels, but on histologic examination of the endometrium. Despite the low serum progesterone levels achieved with the creams, salivary progesterone levels are very high, indicating that progesterone levels in serum do not necessarily reflect those in tissues" Menopause. 2005 Mar;12(2):232-7. Percutaneous administration of progesterone: blood levels and endometrial protection. Stanczyk FZ, Paulson RJ, Roy S. Click here to access the PubMed abstract of this article. “These findings suggest that the choice of the progestagen component in combined HRT is of importance regarding breast cancer risk; it could be preferable to use progesterone.” Breast Cancer Res Treat. 2008 Jan;107(1):103-11. Epub 2007 Feb 27. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Fournier A, Berrino F, Clavel-Chapelon F. Click here to access the PubMed abstract of this article. Ovarian androgens normally protect mammary epithelial cells and the addition of testosterone (not METHYLtestosterone) to conventional hormone therapy for postmenopausal women does not increase and may indeed reduce the hormone therapy-associated breast cancer risk-thereby returning the incidence to the normal rates observed in the general, untreated population. Menopause. 2004 Sep-Oct;11(5):531-5. Breast cancer incidence in postmenopausal women using testosterone in addition to usual hormone therapy. Dimitrakakis C, Jones RA, Liu A, Bondy CA. Developmental Endocrinology Branch, National Institutes of Health Click here to access the PubMed abstract of this article. Chang et al. studied influences of percutaneous administration of estradiol and progesterone on human breast epithelial cell cycle in vivo and reported that progesterone decreases estrogen-induced breast cell proliferation by 400%. Fertil Steril. 1995 Apr;63(4):785-91. Influences of percutaneous administration of estradiol and progesterone on human breast epithelial cell cycle in vivo. Chang KJ, Lee TT, Linares-Cruz G, Fournier S, de Ligniéres B. Click here to access the PubMed abstract of this article. According to Fitzpatrick et al "A micronized progesterone-containing HRT regimen offers the potential for improved QOL as measured by improvement of menopause-associated symptoms." J Womens Health Gend Based Med. 2000 May;9(4):381-7. Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey. Fitzpatrick LA, Pace C, Wiita B. Click here to access the PubMed abstract of this article. While none of the hormone treatments used in this study had a detectable effect on mood, Cummings et al conclude "the lesser side effects of the micronized progesterone-containing regimen suggest that some women may prefer it to an MPA-containing regimen."
Menopause. 2002 Jul-Aug;9(4):253-63.
Comparison of physical and emotional side effects of progesterone or medroxyprogesterone in early postmenopausal women. Cummings JA, Brizendine L. Click here to access the PubMed abstract of this article. “This study demonstrates that the daily administration of a combination of micronized E2 and progesterone results in symptomatic improvement, minimal side effects, an improved lipid profile, and amenorrhea without endometrial proliferation or hyperplasia in menopausal women." Obstet Gynecol. 1989 Apr;73(4):606-12. Menopausal hormone replacement therapy with continuous daily oral micronized estradiol and progesterone. Hargrove JT, Maxson WS, Wentz AC, Burnett LS. Click here to access the PubMed abstract of this article. This trial indicates that the use of natural progesterone does not increase the risk of breast cancer, as opposed to synthetic progestins. Fertil Steril. 1998 May;69(5):963-9. Estradiol and progesterone regulate the proliferation of human breast epithelial cells. Foidart JM, Colin C, Denoo X, Desreux J, Béliard A, Fournier S, de Lignières B. Click here to access the PubMed abstract of this article. A growing body of medical literature suggests that various progestogens are not equivalent. Furthermore, trials indicate that the use of natural progesterone alone or combined with estradiol does not increase the risk of breast cancer while use of medroxyprogesterone acetate or norethisterone acetate stimulate proliferation of breast cancer cells. Maturitas. 2003 Dec 10;46 Suppl 1:S55-8. Differential effects of progestogens on breast cancer cell lines. Franke HR, Vermes I. Click here to access the PubMed abstract of this article. Estrogen deficiency during menopause contributes to the development of abdominal obesity and insulin resistance, and could represent a major step in the development of diabetes in women. In a 2006 meta-analysis of 107 trials, Salpeter et al. concluded that appropriate HRT reduces abdominal obesity, insulin resistance, new-onset diabetes, lipids, pro-inflammatory adhesion molecules and pro-coagulant factors in women without diabetes. Diab Obes Metab 2006;8:538–54. Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women. Salpeter SR, Walsh JME, Ormiston TM, Greyber E, Buckley NS, Salpeter EE. Click here to access the PubMed abstract of this article. Glucose metabolism and insulin sensitivity can be improved by estrogen replacement therapy but the addition of an androgenic progestin, such as MPA or NETA, may reduce the beneficial effect of estrogens. While MPA is known to increase insulin resistance and impair glucose tolerance, natural progesterone does not. Maturitas 2008;59:249–58. Effects of estradiol and norethisterone on lipids, insulin resistance and carotid flow. Fernandes CE, Pompei LM, Machado RB, Ferreira JA, Melo NR, Peixoto S. Click here to access the PubMed abstract of this article. Neuroprotective effects of progesterone include prevention and reversal of age-dependent changes and dysfunction. Some of these actions, particularly those mediated by conversion to neurosteroids such as allopregnanolone, may not be shared by synthetic progestins since progesterone behaves differently in the brain than synthetic progestins (particularly MPA), through direct effects, as well as indirectly through effects on the vascular endothelium. This may have important implications for the effective use of HRT in the maintenance of neuronal function during menopause and aging and for protection against neurodegenerative diseases. Endocr Rev. 2007 Jun;28(4):387-439. Epub 2007 Apr 12. Novel perspectives for progesterone in hormone replacement therapy, with special reference to the nervous system. Schumacher M, Guennoun R, Ghoumari A, Massaad C, Robert F, El-Etr M, Akwa Y, Rajkowski K, Baulieu EE. Click here to access the PubMed abstract of this article. This study of the aftermath of the Women’s Health Initiative (WHI) found that 70% of women who were taking hormone therapy (conjugated equine estrogens and medroxyprogesterone acetate) discontinued it, and 26% of women lost confidence in medical recommendations in general. Many women have sought alternatives in the form of compounded bio-identical hormones. Womens Health Issues. 2005 Jul-Aug;15(4):187-95. After the Women's Health Initiative: decision making and trust of women taking hormone therapy. Schonberg MA, Davis RB, Wee CC. Click here to access the PubMed abstract of this article.
As women age and estrogen levels decline, cutaneous changes such as dryness, atrophy, fine wrinkling and poor healing occur. This article reviews the effects of declining estrogen levels on the skin and the effects of estrogen supplementation.
J Am Acad Dermatol. 2005 Oct;53(4):555-68
Estrogen and skin: the effects of estrogen, menopause, and hormone replacement therapy on the skin. Hall G, Phillips TJ. Click here to access the PubMed abstract of this article. Ninety-seven percent of the 189 women participating in this study experienced varying degrees of symptom control, but complications described with traditional HRT did not develop in these patients using bio-identical hormones. The findings of this study point out a need for larger controlled trials of bio-identical hormones in the management of menopause.
Gynecol Endocrinol. 2009 Aug 19:1-5. [Epub ahead of print]
Natural Hormone Therapy for Menopause Click here to access the PubMed abstract of this article.
Transdermal estradiol was similarly effective as raloxifene in preventing bone loss at the lumbar spine, was well tolerated, and had no clinically significant effect on endometrium or breast density.
Menopause. 2009 May-Jun;16(3):559-65.
Effect of microdose transdermal 17beta-estradiol compared with raloxifene in the prevention of bone loss in healthy postmenopausal women: a 2-year, randomized, double-blind trial. Schaefers M, Muysers C, Alexandersen P, Christiansen C. Click here to access the PubMed abstract of this article. The objective of this analysis was to determine the effects of conjugated equine estrogens/medroxyprogesterone acetate on breast cancer mortality after a total mean follow-up of 11.0 years, through August 14, 2009. The analysis did not track or review patients taking bio-identical estrogens (estriol, estradiol) or progesterone. JAMA. 2010 Oct 20;304(15):1684-92. Estrogen plus progestin and breast cancer incidence and mortality in postmenopausal women. Chlebowski RT et al; WHI Investigators. Click here to access the PubMed abstract of this article. Breast cancer incidence and mortality is increased in women using conjugated equine estrogens and medroxyprogesterone acetate (a synthetic progestin). Lancet. 2003 Aug 9;362(9382):419-27. Breast cancer and hormone-replacement therapy in the Million Women Study. Beral V; Million Women Study Collaborators. Click here to access the PubMed abstract of this article. In this 2005 review of clinical studies comparing synthetic progestins to natural progesterone, Campagnoli et al concluded: "The balance of the in vivo evidence is that progesterone does not have a cancer-promoting effect on breast tissue. ...We therefore suggest that when HRT is indicated, preparations containing progesterone and not a synthetic progestin should be used, according to a sequential or cyclic-combined regimen. In this way the risk of endometrial cancer is minimized without increasing the risk of BC [breast cancer]." J Steroid Biochem Mol Biol. 2005 Jul;96(2):95-108. Progestins and progesterone in hormone replacement therapy and the risk of breast cancer. Campagnoli C, Clavel-Chapelon F, Kaaks R, Peris C, Berrino F. Click here to access the PubMed abstract of this article. In this 2005 clinical trial, Fournier et al compared synthetic progestins to the natural progesterone and reported: "The risk was significantly greater… with HRT containing synthetic progestins than with HRT containing micronized progesterone, the relative risk being 1.4 and 0.9, respectively." Int J Cancer. 2005 Apr 10;114(3):448-54. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Fournier A, Berrino F, Riboli E, Avenel V, Clavel-Chapelon F. Click here to access the PubMed abstract of this article. This large French study raises the possibility that micronized progesterone, when combined with human estrogens such as estradiol or estriol, may have less impact on breast cancer mortality. J Clin Oncol. 2008 Mar 10;26(8):1260-8. Use of different postmenopausal hormone therapies and risk of histology- and hormone receptor-defined invasive breast cancer. Fournier A, Fabre A, Mesrine S, Boutron-Ruault MC, Berrino F, Clavel-Chapelon F. Click here to access the PubMed abstract of this article. Studies of women using HRT, including either micronized progesterone or synthetic medroxyprogesterone acetate (MPA), compared efficacy, patient satisfaction and quality of life. Women reported greater satisfaction, fewer side effects and improved quality of life when they were switched from synthetic progestins to micronized progesterone. J Womens Health Gend Based Med. 2000 May;9(4):381-7. Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey. Fitzpatrick LA, Pace C, Wiita B. Click here to access the PubMed abstract of this article. Transdermal Progesterone and Estrogen Improve Blood Pressure in Menopausal Women with High Stress Dr. Kenna Stephenson of the University of Texas Health Science Center has shown luteal phase levels of progesterone and estrogen administered via transdermal delivery improve blood pressure in perimenopausal and menopausal women with prehypertension and stress related to work or home. http://sanjay-kapur.blogspot.com/2009_09_01_archive.html Progesterone vs Synthetic Progestins: Clinical Options James A. Simon, MD, Clinical Professor, George Washington University, Washington, DC, notes: “Clinicians have numerous options in selecting a progestogen for the individual patient. The specific properties of progesterone or synthetic progestins may result in differing side-effect profiles for individual patients. Route of administration also offers differing systemic or local effects that should be considered for some uses and specific patients.” Differences exist among the exogenous progestogens, which include both natural progesterone and synthetic and semi-synthetic progestins, drugs which are “structurally related - but are not identical - to either progesterone or testosterone... Progesterone and progestins differ not only in their structure, but also in their potency, as determined by standard bioassays... Additionally, studies often do not evaluate the effects of progestogens on specific organs or compare the side-effect profiles of individual agents. These characteristics constitute an important, although rarely discussed, aspect of the differences among progestogens.”
The Journal of Family Practice 2007 Feb; 2(7):S3-S5
Comparison of Different Routes of Progesterone Administration for Luteal Phase Support in Infertility Treatment Different routes of natural progesterone supplementation have been tried as luteal phase support in infertility treatments. Orally administered progesterone is rapidly metabolized in the gastrointestinal tract and oral administration has proven to be inferior to intramuscular (IM) and vaginal routes. Progesterone IM achieves serum progesterone values that are within the range of luteal phase and results in sufficient secretory transformation of the endometrium and satisfactory pregnancy rates. The comparison between IM and vaginal progesterone has led to controversial results as regards the superiority of one or the other in inducing secretory endometrial transformation. However, there is increasing evidence in the literature to favor the use of vaginal progesterone. Vaginally administered progesterone achieves adequate endometrial secretory transformation but its pharmacokinetic properties are greatly dependent on the formulation used. After vaginal progesterone application, discrepancies have been detected between serum progesterone values and histological endometrial features. Vaginally administered progesterone results in adequate secretory endometrial transformation, despite serum progesterone values lower than those observed after IM administration, even if they are lower than those observed during the luteal phase of the natural cycle. This discrepancy is indicative of the first uterine pass effect and therefore of a better bioavailability of progesterone in the uterus, with minimal systematic undesirable effects. Hum Reprod Update. 2000 Mar-Apr;6(2):139-48. Comparison between different routes of progesterone administration as luteal phase support in infertility treatments. Click here to access the PubMed abstract of this article. Uses of Progesterone in Clinical Practice Progesterone is the natural progestogen produced by the corpus luteum during the luteal phase. It is absorbed when administered orally, but is greater than 90% metabolized during the first hepatic pass. This greatly limits the efficacy of once-daily administration and also results in “unphysiologically” high levels of progesterone metabolites which can cause dizziness and drowsiness to the point of preventing the operation of a motor vehicle. Synthetic progestins, such as medroxyprogesterone acetate and norethindrone acetate, have been specifically designed to resist enzymatic degradation and remain active after oral administration. However, according to Drs. Warren and Shantha of the Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, these synthetic progestins exert undesirable effects on the liver and often cause severe psychological side effects. Transvaginal administration of progesterone is a practical non-oral route available for administering progesterone. Early experience was gained with vaginal suppositories. The clinical acceptance of progesterone administered as a vaginal gel was enhanced by the characteristics of a polycarbophil-based gel, which conveys controlled and sustained-released properties. Investigations have shown that because of local direct vagina-to-uterus transport, which results in a preferential uterine uptake of progesterone, progesterone vaginal gel given in conjunction with physiological amounts of estradiol produces endometrial changes similar to those seen in the luteal phase, despite plasma progesterone levels that remain subphysiologic. Studies in infertility show that vaginal progesterone in this form allows secretory transformation of the endometrium and the development of pregnancy despite providing low systemic progesterone concentrations. Fewer side effects occur when vaginal progesterone is used for hormone replacement than are typically encountered with progestins and oral progesterone. Int J Fertil Womens Med. 1999 Mar-Apr;44(2):96-103 Uses of progesterone in clinical practice. Click here to access the PubMed abstract of this article. Pregnenolone – The Parent Hormone Affecting Memory, Sleep, Anxiety, and Mood • Pregnenolone is at the top of the hormone cascade, the “parent hormone” from which neurosteroids and sex hormones are formed, and gives rise to important “neurohormones” that affect learning, memory, mood, sleep, and many other functions. • Pregnenolone may relieve anxiety, help to fight depression, and reduce symptoms of withdrawal from nicotine and alcohol addiction. • Hormone levels naturally decline with advancing age. People with lower pregnenolone levels are more likely to suffer from memory deficits, mood disorders, and even some mental illnesses. • Pregnenolone and other neuroactive steroids can protect brain cells against the long-term damage that can lead to Alzheimer’s disease and other forms of dementia. The conversion of cholesterol to pregnenolone constitutes the first of many steps in the synthesis of some of the body’s key hormones, including dehydroepiandrosterone (DHEA), testosterone, progesterone, estrogen, and cortisol. Pregnenolone’s metabolites fulfill a myriad of essential roles in the body, from stimulating memory via excitatory pathways to easing anxiety through inhibitory mechanisms.1,2 Pregnenolone has vast potential for maintaining healthy cognitive function and may be “the most potent memory enhancer yet reported.”3 Alzheimer’s disease patients have lower levels of pregnenolone, allopregnanolone (a pregnenolone metabolite) and DHEA-sulfate (DHEAS) in all the main memory-related areas of their brains, compared with control patients. Furthermore, the brains of patients with the highest neurosteroid levels display the lowest collections of the destructive amyloid-beta proteins. 4,5,6 Researchers have also shown that pregnenolone increases brain levels of acetylcholine, a key neurotransmitter required for optimal brain function, which is deficient in patients with Alzheimer’s disease. 7 Acetylcholine is not only vital for thought and memory, it is also involved in controlling sleep cycles, especially the phase of sleep that is associated with memory (called paradoxical sleep or the random eye movement [REM] phase). Neurosteroids are known to affect anxiety in humans.8 Researchers from the University of California in San Francisco performed two studies of pregnenolone and anti-anxiety medications and concluded that pregnenolone, taken as a supplement while using an anti-anxiety medication, could reduce many adverse effects of the medication, such as sedation and memory impairment. 9 There is increasing evidence that lower levels of pregnenolone are associated with a variety of mental health conditions beyond anxiety, including depression, phobias, and even schizophrenia.10,11,12,13 One study revealed that schizophrenic patients with the lowest levels of pregnenolone were also most likely to have high levels of anxiety.14 Pregnenolone and other neurosteroids have also been shown to counteract the anxiety-like behavior that is associated with nicotine or morphine withdrawal, due to their potent effects on sigma receptors, and may offer relief to individuals seeking to overcome these addictions. 15,16
Please click on the links below for more information.
http://www.lef.org/magazine/mag2007/nov2007_report_pregnenolone_01.htm 1 Pharmacol Biochem Behav. 2006 Aug;84(4):555-67. 2 Jpn J Pharmacol. 1999 Oct;81(2):125-55. 3 Proc Natl Acad Sci USA. 1995 Nov 7;92(23):10806-10. 4 Prog Neurobiol. 2003 Sep;71(1):3-29. 5 J Clin Endocrinol Metab. 2002 Nov;87(11):5138-43. 6 Biol Psychiatry. 2006 Dec 15;60(12):1287-94. 7 Prog Neurobiol. 2003 Sep;71(1):43-8. 8 Neuropsychobiology. 2004;50(1):6-9. 9 Psychoneuroendocrinology. 2004 May;29(4):486-500. 10 Prog Neuropsychopharmacol Biol Psychiatry. 2005 Feb;29(2):169-92. 11 Neuropsychopharmacology. 2005 Jun;30(6):1181-6. 12 Pharmacol Biochem Behav. 2006 Aug;84(4):644-55. 13 Am J Psychiatry. 2002 Jan;159(1):145-7. 14 Eur Neuropsychopharmacol. 2007 Apr;17(5):358-65. 15 J Pharmacol Sci. 2006 Feb;100(2):93-118 . 16 Brain Res Brain Res Rev. 2001 Nov;37(1-3):116-32. Researchers at The University of Texas at Tyler, led by Kenna Stephenson, M.D., showed that use of progesterone in a topical cream (20 mg per day) relieved menopausal symptoms. In addition, in a subpopulation of hypercortisolemic women, nocturnal cortisol levels were reduced to normal range while they were using the progesterone cream as compared to placebo. Stress activates cortisol, and an abnormal cortisol pattern has been associated with an increased risk of heart attacks, cancer, obesity and other diseases.
Blood 2004 Nov; 104(11):16
Progesterone Relieves Menopausal Symptoms and Normalizes Nocturnal Cortisol Levels The French E3N-EPIC cohort study assessed the risk of breast cancer associated with HRT use in 54,548 postmenopausal women. Breast Cancer Res Treat. 2008 Jan;107(1):103-11 Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Click here to access the PubMed abstract of this article. The neuroprotective and promyelinating effects of progesterone are promising not only for preventing, but also for reversing, age-dependent changes and dysfunctions. Endocr Rev. 2007 Jun;28(4):387-439. Novel perspectives for progesterone in hormone replacement therapy, with special reference to the nervous system. Click here to access the PubMed abstract of this article.
Clinical evidence shows that, during menopause, estrogen withdrawal gives rise to modifications in mood, behavior and cognition and that estrogen administration is able to improve mood and cognitive efficiency in post-menopause. There may be a critical period of time for HRT-related neuroprotection, and early initiation of estrogen therapy may be necessary for cognitive benefit.
Hum Reprod Update. 2007 Mar-Apr;13(2):175-87 Estrogen, cognition and female ageing. Click here to access the PubMed abstract of this article.
J Clin Endocrinol Metab. 2006 Jan;91(1):136-44.
Pharmacokinetics of Testosterone Gel in Healthy Postmenopausal Women C lick here to access the PubMed abstract of this article. Absorption and Efficacy of Multiple Hormones Delivered in a Single Cream This study is the first documenting systemic absorption of multiple hormones by both saliva and blood as well as improvement of health-related quality of life.
Gynecol Obstet Invest. 2008 Apr 29;66(2):111-118.
Click here to access the PubMed abstract of this article.
New research from the Women's Health Initiative Memory Study (WHIMS) links the use of hormone replacement therapy (HRT) before the age of 65 years to a reduced risk of all-cause dementia and Alzheimer's disease (AD) in women. At the American Academy of Neurology’s 59th Annual Meeting, researchers presented an analysis that showed early HRT use was associated with a 46% overall reduction in dementia risk and a 64% reduction in AD. WHIMS also included 2 studies that looked at cognitive outcomes and HRT in women over 65 years old. At an average 5-year follow-up, both the conjugated equine estrogens plus medroxyprogesterone acetate (CEE + MPA) and the CEE-alone trials showed conjugated estrogens, with or without MPA, increased dementia risk when therapy was initiated after age 65 years. In the CEE + MPA trial the risk doubled, while in the CEE-alone trial there was about a 50% increased risk. There is evidence from animal models suggesting estrogen at an earlier age may be beneficial, and these results are intriguing because they seem to support that evidence.
While studies describe the therapies used in the WHI as “estrogen with or without progesterone”, the WHI actually used only synthetic CEE and MPA (which is chemically different than progesterone). HRT Before Age 65 May Decrease Risk of Dementia and Alzheimer’s Disease American Academy of Neurology 59th Annual Meeting: Abstract S31.004. April 28 – May 5, 2007 Click here to access the Medscape article. (accessed April 4, 2008) Progesterone Therapy for Catamenial Epilepsy Catamenial epilepsy refers to seizures that occur or worsen around menstruation. Researchers at North Carolina State University evaluated the hypothesis that neurosteroid "replacement" is an effective and a rational therapy for catamenial epilepsy. It is well known that progesterone possesses anticonvulsant properties. The clustering of seizures around the beginning of menstruation corresponds with a significant drop in the levels of progesterone circulating in the body and an increase in the estrogen:progesterone ratio. Recent studies have shown that progesterone is metabolized to the neurosteroid allopregnanolone which plays a crucial role in seizure protection. Declining levels of allopregnanolone, which occur during the menstrual cycle, can provoke seizures.
“Cyclic natural progesterone use has been demonstrated as an effective treatment for catamenial and non-catamenial seizures in women. Progesterone is efficiently absorbed after oral administration as lozenges, and rectal administration as suppositories.” Progesterone was given at 100 to 200 mg, t.i.d. on days 15 to 28 of the menstrual cycle. In a 3 month investigation of cyclic natural progesterone therapy, 23 of 25 (92%) women continued on the same AED and progesterone protocol and continued to have a very substantial (62% to 74%) reduction in seizure frequency.
Epilepsy Behav. 2008 Mar 16 [Epub ahead of print]
Click here to access the PubMed abstract of this article. Seizure. 2008 Mar;17(2):176-80. Click here to access the PubMed abstract of this article. Indian Journal of Pharmacology 2005; 37(5):288-293 Click here to access this article. Neurology 1995;45:1660-2 Click here to access the PubMed abstract of this article. Neurology 1999;52:1917-8 Click here to access the PubMed abstract of this article . The Women's Health Initiative Memory Study (WHIMS) links the use of hormone replacement therapy (HRT) before the age of 65 years to a reduced risk of all-cause dementia and Alzheimer's disease (AD) in women. American Academy of Neurology 59th Annual Meeting: Abstract S31.004. April 28 - May 5, 2007 Click here to read a Medscape article on this topic. The following finding that conjugated equine estrogen was associated with venous thrombotic risk may have implications for the choice of hormones in perimenopausal and postmenopausal women.
JAMA. 2004 Oct 6;292(13):1581-7
Esterified estrogens and conjugated equine estrogens and the risk of venous thrombosis. Click here to access the PubMed abstract of this article.
These observations suggest that the addition of testosterone to conventional hormone therapy for postmenopausal women does not increase and may indeed reduce the hormone therapy-associated breast cancer risk-thereby returning the incidence to the normal rates observed in the general, untreated population.
Menopause. 2004 Sep-Oct;11(5):531-5
Breast cancer incidence in postmenopausal women using testosterone in addition to usual hormone therapy. Click here to access the PubMed abstract of this article. The pharmacodynamic differences of testosterone and methyltestosterone are briefly reviewed in the context of choice for individualized clinical use.
Mayo Clin Proc. 2004 Apr;79(4 Suppl):S8-13
Hot flashes and androgens: a biological rationale for clinical practice. Click here to access the PubMed abstract of this article. The results of this study suggest a significant reduction in the incidence of type 2 diabetes in our population of non-obese, healthy postmenopausal women who used transdermal 17-beta-estradiol. This could suggest that, in some women, the estrogen deficiency that occurs after menopause could represent a fundamental step in the process of diabetogenesis.
Diabetes Care. 2004 Mar;27(3):645-9
Transdermal 17-beta-estradiol and risk of developing type 2 diabetes in a population of healthy, nonobese postmenopausal women. The full text article is available FREE online: http://care.diabetesjournals.org/cgi/content/full/27/3/645 Mayo Clinic researchers surveyed 176 women taking natural micronized progesterone who had previously taken synthetic progestins. After one to six months, the women reported an overall 34% increase in satisfaction on micronized progesterone compared to their previous HRT, reporting these improvements: 50% in hot flashes, 42% in depression, and 47% in anxiety. Micronized progesterone was also more effective in controlling breakthrough bleeding.
J Womens Health Gend Based Med 2000 May;9(4):381-7
Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey. Click here to access the PubMed abstract of this article.
Fertil Steril 1999 Sep;72(3):389-97
Micronized progesterone: clinical indications and comparison with current treatments. Click here to access the PubMed abstract of this article. J Am Coll Cardiol 2000 Dec;36(7):2154-9 Natural progesterone, but not medroxyprogesterone acetate, enhances the beneficial effect of estrogen on exercise-induced myocardial ischemia in postmenopausal women. (This is not a "claim", it is the title of the article.) Click here to access the PubMed abstract of this article.
An extensive federally sponsored double-blind study was conducted at 19 academic
medica l centers that comprise the Maternal-Fetal Medicine Units Network under the National Institutes of Health and found that 17-alpha-hydroxyprogesterone caproate (17P) provides substantial benefit for decreasing the risk of pre-term birth at less than 37 weeks gestation.
N Engl J Med 2003;348:2379-85
Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate . Click here to access the PubMed abstract of this article. Am J Obstet Gynecol 2007;196:224.e1-224.e4. Increased recurrence of preterm delivery with early cessation of 17-alpha-hydroxyprogesterone caproate. Click here to access the PubMed abstract of this article.
Vaginal progesterone suppositories have also been shown to decrease the rate of preterm birth in patients at increased risk. Da Fonseca
et al noted that among 142 women who had one prior preterm birth, prophylactic cerclage, or uterine malformation, daily use of a 100-mg vaginal progesterone suppository compared with placebo significantly decreased the likelihood of delivery prior to 37 weeks.
Am J Obstet Gynecol. 2003; 188(2):419-424.
Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased risk: a randomized placebo-controlled double-blind study. Click here to access the PubMed abstract of this article.
Other related articles:
Obstet Gynecol 2005 May;105(5 Pt 1):1128-35 Am J Obstet Gynecol. 2007 May;196(5):453.e1-4
The PEPI Trial, a 3-year multicenter, randomized, double-blind, placebo-controlled study of 875 healthy postmenopausal women, stated that synthetic progestins partially negate the beneficial effects on cholesterol levels that result from taking estrogen. Natural progesterone maintained the benefits of estrogen on cholesterol without side effects.
JAMA 1995 Jan 18;273(3):199-208
Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in postmenopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. The Writing Group for the PEPI Trial. Click here to access the PubMed abstract of this article. Certain progestogens, such as micronized progesterone, can be administered concurrently with estrogen replacement therapy, providing protection against endometrial hyperplasia without significantly affecting the beneficial effects of estrogen on lipid profiles, atherosclerosis and vascular reactivity.
J Reprod Med 2000 Mar;45(3 Suppl):245-58
Rationale for hormone replacement therapy in atherosclerosis prevention. Click here to access the PubMed abstract of this article.
J Clin Endocrinol Metab 2002;87:1062-1067
Estrogen status correlates with the calcium content of coronary atherosclerotic plaques in women. Click here to access the PubMed abstract of this article.
J Neurosci. 2003 Dec 10;23(36):11420-6
Estradiol attenuates programmed cell death after stroke-like injury. Click here to access the PubMed abstract of this article.
Endocrinology 2001 Mar 1;142(3):969-973
Minireview: Neuroprotective Effects of Estrogen-New Insights into Mechanisms of Action. Click here to access the PubMed abstract of this article. The use of conjugated equine estrogen plus medroxyprogesterone acetate in a double-blind, randomized, controlled trial of 16,608 postmenopausal women between the ages of 50 and 79 years doubled the risk of venous thrombosis. This estrogen, which is derived from pregnant mares' urine, plus synthetic progestin therapy increased the risks associated with age, overweight or obesity, and factor V Leiden.
JAMA. 2004 Oct 6;292(13):1573-80
Estrogen plus progestin and risk of venous thrombosis. Click here to access the PubMed abstract of this article.
Chem Res Toxicol 1998 Sep;11(9):1105-11
The equine estrogen metabolite 4-hydroxyequilenin causes DNA single-strand breaks and oxidation of DNA bases in vitro. Click here to access the PubMed abstract of this article. The following study concluded that in non-human primates, medroxyprogesterone increases the risk of coronary vasospasm. Progesterone plus estradiol protected against vasospasm.
Nat Med 1997 Mar;3(3):324-7
Medroxyprogesterone interferes with ovarian steroid protection against coronary vasospasm. Click here to access the PubMed abstract of this article. MPA reduces the dilatory effect of estrogens on coronary arteries, increases the progression of coronary artery atherosclerosis, accelerates low-density lipoprotein uptake in plaque, increases the thrombogenic potential of atherosclerotic plaques and promotes insulin resistance and its consequent hyperglycemia. These effects may be largely limited to MPA and not shared with other progestogens.
J Reprod Med 1999 Feb;44(2 Suppl):180-4
Progestogens and cardiovascular disease. A critical review. Click here to access the PubMed abstract of this article. Significant bone loss occurs during the 10 to 15 years before menopause when estrogen levels are still normal. Progesterone can stimulate new bone formation in women with osteoporosis. Dr. Prior measured estrogen and progesterone levels in female marathon runners who had osteoporosis. Although their estrogen levels were still high, they had stopped ovulating (common in female athletes) and progesterone levels had fallen, triggering the onset of osteoporosis. This can indicate a role for progesterone use, alone or combined with estrogen which reduces bone loss, in improving Bone Mineral Density.
Endocr Rev 1990 May;11(2):386-98
Progesterone as a bone-trophic hormone . Click here to access the PubMed abstract of this article. The WHI assessed the major health benefits and risks of the most commonly used combined hormone preparation in the United States, the synthetic combination of conjugated equine estrogens and medroxyprogesterone acetate. Absolute excess risks per 10,000 person-years attributable to this synthetic hormone combination were 7 more CHD events, 8 more strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers, while absolute risk reductions per 10,000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures.
JAMA. 2002 Jul 17;288(3):321-33
Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. Click here to access the PubMed abstract of this article. Among postmenopausal women aged 65 years or older, synthetic estrogen plus progestin did not improve cognitive function when compared with placebo. However, typical HRT users are in their 50s and this study focused on women aged 65 and over, who have a higher risk for dementia.
JAMA 2003 May 28;289(20):2663-72
Effect of estrogen plus progestin on global cognitive function in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled trial. Click here to access the PubMed abstract of this article. In the following study, estrogen plus progestin increased the risk of ischemic stroke in generally healthy postmenopausal women.
JAMA 2003 May 28;289(20):2673-84
Effect of estrogen plus progestin on stroke in postmenopausal women: the Women's Health Initiative: a randomized trial. Click here to access the PubMed abstract of this article.
Androgens (Testosterone, DHEA)