Menopause: HRT and Alternatives

by Nicolas Kats ND, LAc.

Hormonal Replacement Therapy

HRT is the use of hormones to address various symptoms and concerns associated with menopause. HRT can help, often dramatically, with menopausal problems such as hot flashes, loss of energy, vaginal wall atrophy with consequent vaginal and urinary tract infections and discomfort during sexual intercourse, depression and mood swings, and osteoporosis.

But there are side effects. Hormones are extremely potent. Human estrogen and progesterone have precise biochemical structures. These are not exactly reproduced in HRT. These slight differences mean that HRT hormones will not lock into human hormone receptors in precisely the same way that human hormones do. These differences help account for the side effects of HRT.

HRT consists of the estrins and the progestins. These hormones are similar to, but not identical to, human progesterone and estrogens. Equine estrogen is, for human purposes, an estrin.

A commonly used estrin, Premarin, comes from horse urine. The name is derived from pregnant mare’s urine. A sad story lies here. Mares are constantly kept pregnant, and immobilized in stalls 6 months/yr with urine collectors attached 24 hours/day. To concentrate the urine the mares get insufficient water. Living conditions are miserable. Nearly all mares and most foals end up slaughtered for human and dog food. Non-equine estrins are available.

Chemical analysis of Premarin shows over 200 compounds, including estrins and progestins. This complexity raises the question of whether premarin as a drug can ever be understood.

Estrin-based HRT was standard until the 1970s, when it was discovered that it caused uterine cancer. This side effect was predictable given the knowledge that estrogen builds up the intrauterine lining. Estrin-based HRT also increased the risk of breast cancer, but not by much.

The side effect of uterine cancer drove the shift to combined HRT – estrins and progestins – in an effort to better mimic women’s hormones. Combined HRT reduces uterine cancer. But a new problem arose. Combined HRT is more aggressive than estrin-based HRT in causing breast cancer. This happens when HRT is taken long term, eg over 5 years. Short term HRT is far less of a concern on this issue.

HRT was once thought to reduce cardiovascular disease. This belief is now proven wrong. Studies in the last 5 years show that HRT increases cardiovascular risk and thrombophebitis. (This is partly accounted for by the fact that HRT depletes B6, B12 and folic acid, all necessary to keep down homocysteine levels. Increased homocysteine is a factor in heart disease.) HRT is now contraindicated if heart disease is present.

On the positive side, combined HRT reduces colon cancer and osteoporosis (hip fractures in the elderly are often fatal).

We have, at this point in time, the complicated equation of whether HRT saves more lives than it kills (lives saved by decreased uterine cancer and osteoporosis vs lives lost due to increased breast cancer and cardiovascular events).

The big picture is that the knowledge and use of HRT is in a state of ongoing fluctuation. What was known about it 30 or 10 years ago is very different from what is now known. This will continue. In general, for those who opt to use HRT, the following should be observed:

Alternatives to HRT.

Menopause can bring on a wide range of symptoms or concerns. These need to be looked at individually.

Dysmenorrhea/irregular cycles. Take herbs to tonify the uterus (yarrow, Lady’s mantle). Other herbs rich in phytosteroids help even out hormonal fluctuations. Phytosteroids are plant compounds that modulate hormonal extremes, either excess or deficiency. Two categories are those that modulate the FSH phase (red clover, alfalfa), and those that modulate the LH phase (chaste tree, Dioscorrea, Smilax). The herbalist will provide the appropriate mix based on the picture.

Eat plants rich in phytosteroids such as legumes. (There is a big controversy about soy beans and its products, so eat in moderation and avoid highly processed soy products).

Fiber is effective at grabbing toxins and unwanted products in the alimentary canal. In the days before onset of menses (PMT phase), estrogen and progesterone drop dramatically. This is because the liver conjugates and secretes them into the intestines for excretion. Fiber grabs these unwanted hormones and pulls them out of the body. If dietary fiber is low, these hormones tend to be reabsorbed back into the body, adding to the liver’s burden, and raising the levels of hormones at a time that the liver is actively getting rid of them. For these reasons a fiber rich diet is important when on HRT.

Essential fatty acids are useful. A fine source is flaxseed (or linseed, same thing), freshly ground in a coffee grinder. This provides fresh omega-3 EFAs and lignan, a fibre and beneficial phytosteroid. Flax seeds are appropriate if the diet is mainly processed food (which is severely deficient in EFAs, particularly omega-3). When the diet is primarily whole food, hemp seeds may be more suitable for their broad range of EFAs.

Hot flashes. Easy on the hot stuff! Hot foods and liquids, hot spices, hot clothes, hot rooms, hot emotions!

Avoid sugars and refined/simple carbohydrates and alcohol.

Herbs can help with hot flashes. Motherwort is a specific herb for hot flashes and palpitations, and can be included in an herb mix formulated to tonify the uterus and moderate the hormones.

Acupuncture is useful – hot flashes can be diagnosed in different ways, and points accordingly selected and needled.

Vitamin E can help. Use the d- form (this is the natural form: avoid the synthetic l-form). Use the liquid form, not the solid.

Cardiovascular. There are many ways to reduce heart disease. The best of all is preventative.

Minimize refined carbohydrates and sugars. Avoid fried oils, margarines and other processed polyunsaturated fatty acids. All of these are directly involved with heart disease.

People think animal fats cause heart disease. But there was no heart disease with the traditional Eskimo diet, so rich in animal fats. Per capita consumption of animal fat and cholesterol in Ireland and the USA has dropped in the last 100 years, yet in the same period the incidence of cardiovascular problems and hypercholesterolemia has shot up from rare to extremely common. This means that dietary cholesterol and the fat of healthy animals are not the problem.

Think quality foods. This means whole foods rather than refined, fresh rather than old.

Ginger and garlic are great for reducing cholesterol and clots. Use in cooking often.

Exercise is essential!

Vitamin E nourishes the lining of arteries and veins. An antioxidant, it inhibits the oxidation of cholesterol, which is the form associated with clogged arteries (atherosclerosis). Vitamin E is abundant in whole grains, and absent in refined grain products, so think whole grain foods.

Heart disease is very much reversible using diet and exercise, with herbs and supplements as useful adjuncts. Natural medicine offers effective alternatives to statins (cholesterol-lowering drugs), aspirin and surgery, except in emergencies.

HRT is contraindicated if cardiovascular disease is present

Genitourinary. With declining estrogen the mucosal layer of the vagina can atrophy, leading to vaginal and urinary tract infections, and dryness leading to pain during sexual intercourse. Ways to help:

Emotional and Fatigue. For depression and fatigue, the herbalist uses herbs supportive of neurotransmitter and adrenal function. Homeopathy and acupuncture are useful.

Minimize sugars and refined carbohydrates to moderate blood sugar. Large fluctuations in blood sugar increases the stress hormones, which leads to reduced peace of mind and increased fatigue. (If a chocoholic, switch to black chocolate – it has half the sugar of milk chocolate, and is more satisfying. Some great brands are Cote D’Or, Toblerone, Lindt, Droste.)

Accept and embrace the change of menopause. What is the alternative?

Osteoporosis. Minerals come from two sources – diet and bone. When the diet is deficient in minerals the body turns to bone. Bone is a bank for minerals, to be drawn on for the physiological needs of the moment. Eat a mineral-rich diet! This means fruit, vegetables and whole grains. All seafoods are rich in minerals. Organic, home-grown and wild vegetables have perhaps 20x more minerals than supermarket vegetables.

Minerals depletion occurs with severe stress, illness, digestive deficiency, hypothyroidism, toxins and refined/processed foods. These must be addressed.

Protein, caffeine and common table salt increase the loss of calcium in urine. Eat small portions of protein. Be moderate with caffeine (coffee, black tea). A superior alternative to commercial salt is sticky grey sea salt, such as the brand Le Guerandais, or unprocessed rock salt quarried from ancient sea beds. These unprocessed salts are rich in minerals, whereas commercial salt is just sodium, chloride and an anticaking agent.

Alcohol inhibits bone growth: go easy.

Exercise is very important. Regular exercise stimulates bone growth and can increase bone density. Conversely, inactivity accelerates bone loss. This is because the bones are not being stressed. Osteoporosis is a major problem for astronauts living long-term in the weightlessness of space. They become severely osteoporotic and, on return, will, with appropriate diet, exercise and the stress of earth’s gravity, regain bone mass in a few months. This shows that osteoporosis is reversible.

Herbs offer phytosteroids to amplify the estrogen effect on bone, and minerals. A multivitamin should include Vitamin D, boron, calcium and magnesium. Winter has far less sunlight to convert Vitamin D in the skin – increase dosage during winter months and get out more often in the winter. The ratio of Ca to Mg should be 3:2 or so: calcium without magnesium may be counterproductive.

Appropriate changes of habit (diet, exercise) are far more appropriate than long term use of supplements, herbs, drugs, etc. There simply is no substitute for good dietary and exercise habits.

For osteoporosis the GP may prefer alendronate (Fosamax, or other biphosphonates) to long term HRT with its side effects. The problem with alendronate is that it works by inhibiting the release of minerals from bone. This can interfere with the essential function of bone of providing minerals to the body as needed. Also, alendronate commonly causes digestive upset, inhibiting absorption of minerals from food. Reduced mineral absorption forces the body to turn to bone for minerals.These limitations of alendronate suggest that natural therapies are preferable.

The GP is aware of the shifting understanding of HRT, eg, the need to use HRT short-term. For long term issues he may prefer other drugs (eg, alendronate for osteoporosis). Short term use of HRT is now standard practice. Though expert in the use of drugs, the GP has little or no training in the use of herbs, diet and supplements, acupuncture, etc. He does not have the expertise to advise on these therapies, especially for something as variable and complex as menopause.

Over-the-counter remedies for menopause are of limited value since they offer a broad shotgun approach to cover some of the commoner symptoms. Specific therapies fitted to the specific symptoms are far more effective. This means either educating oneself to select an appropriate therapy, or seeing a health practitioner adept in the use of natural therapies, preferably one who understands modern medicine.

Natural approaches can be integrated with HRT and other drugs.